Baseline School WASH and Nutrition Survey

SUBMITED BY: KALEAB BAYE (PHD)

Center for Food Science and Nutrition, AAU

1

Contents Table of contents

1. Background ....................................................................................................................................... 2

2. Objectives ......................................................................................................................................... 3

3. Methods ................................................................................................................................................ 3

3.1 Study Design and Approach .............................................................................................................. 3

3.2 Sampling ............................................................................................................................................ 3

3.3 Ethics .................................................................................................................................................. 3

3.4 Data collection ................................................................................................................................... 4

3.5 Data collection tools ........................................................................................................................... 4

3.5.1 WASH practices .............................................................................................................................. 4

3.5.2 Nutrition and school food environment .......................................................................................... 4

3.5.3 Menstrual Hygiene .......................................................................................................................... 4

4. RESULT ........................................................................................................................................... 5

4.1 School participants information ......................................................................................................... 5

4.2 Wash ............................................................................................................................................. 6

4.2.1 Drinking water availability and quality ........................................................................................... 6

4.2.2 Sanitation facility access and conditions................................................................................... 8

4.3 Menstrual hygiene ..................................................................................................................... 9

4.4 Hand-washing facility access, hygiene education and promotion ................................................... 10

4.5 Food availability, access, and nutrition ....................................................................................... 11

4.5.1 Last semester related information ................................................................................................. 11

4.5.2 Yesterday’s food consumption (24 h recall) ........................................................................... 12

5. Observation of school facilities ....................................................................................................... 13

6. School specific recommendation .................................................................................................... 14

6.1 Toilet related ............................................................................................................................... 14

6.2 Water related ............................................................................................................................... 14

6.3 Food related ................................................................................................................................ 14

7. Conclusion and recommendation .................................................................................................... 15

Annex ..................................................................................................................................................... 16

2

Background

Many low-resource communities in cities have a high prevalence of diseases related to

inadequate water supply, sanitation and hygiene (WASH), such as diarrhea, parasitic worm

infections and skin and eye diseases. Schools, particularly those in slums, often have inadequate

water, hygiene and sanitation facilities. Communities themselves are at risk when schoolchildren

are exposed to disease because of inadequate water supply, sanitation and hygiene at school.

Families bear the burden of their children’s illness due to suboptimal conditions at school,

further depriving them from economic opportunities.

Conversely, students who have adequate WASH conditions at school are more able to integrate

hygiene education into their daily lives and can be effective messengers and agents for change in

their families and the wider community. Girls and boys, including those with disabilities, are

likely to be affected in different ways by inadequate WASH conditions in schools, and this may

contribute to unequal learning opportunities. Besides, poor nutrition can affect learning in

school, lead to increased susceptibility to diseases, and thus may further widen inequalities.

The onset of menstruation and puberty bring several challenges to schoolgirls in low-resource

settings. Challenges include biologically inaccurate beliefs and harmful practices around

menstruation that are often linked to stigmatizing beliefs regarding menstruation. The water,

sanitation and hygiene facilities in schools are often deficient or lacking, preventing girls from

accessing a safe, private and hygienic space to manage menstruation at school. This may increase

school absenteeism during menstruation, or can lead girls to dropping out of school altogether.

To minimize disease transmission, improvements in water and sanitation facilities should be

accompanied by hygiene behavior change interventions and nutrition education. Hygiene

interventions can focus on hand washing behavior at key times (before eating and after using the

toilet), whereas proper nutrition would contribute to increased school performance and overall

health.

3

1. Objectives

The overall objective of this study to rapidly assess the nutrition, food environment, water,

sanitation and hygiene of selected schools in Addis Ababa city to inform the design of an

effective school health demonstration project.

Specific objectives

- Assess WASH related knowledge, attitude, and practices of school children

- Assess the nutritional situation of school children

- Assess the school environment for accessibility of essential goods like nutrient-dense foods,

pads, etc.

- Identify barriers and enablers to improve overall school WASH system

3. Methods 3.1 Study Design and Approach

The methodology adopted in undertaking this baseline combined quantitative and qualitative

methods. The mixed approach was adopted for purposes of complementarily, triangulation, and

validation of responses. While the greater part was quantitative using a structured questionnaire,

the qualitative aspect focused on direct observations of WASH facilities with regard to presence

of handing washing facilities and practices, cleanliness of toilet facilities, and other observable

phenomena.

3.2 Sampling Elementary schools (n=4) and highschool (n=2) were selected from Mekanisa, Nifas-silk Lafto

Sub-city. The choice of the district is made for convenience reasons. We will be using a cluster

randomized design. Each school will be considered as a cluster from which 70-75 students were

selected using stratified random sampling. A total of 434 students were interviewed.

3.3 Ethics Prior to interviewing consent forms were obtained from students and the school administration.

Formal authorization and support letters were obtained from the City Administration. The

personal information like names were kept confidential.

4

3.4 Data collection The main method of data collection was a quantitative survey using a structured questionnaire,

direct observations and spot checks. The questionnaires were interviewer-administered. Direct

observations and spot checks were used to observe the students’ hygiene practices such as hand

washing with soap and cleanliness of sanitation facilities.

Using qualitative methods like Focused Group discussion (FGDs) and Key Informant Interviews

(KIIs), information related to curriculum, school’s administration, the feasibility of doing things

differently to improve the WASH, nutrition and overall school health was assessed. The aim was

to identify potential enablers and barriers to inform the design of the intervention.

The overall data collection was conducted in July 2017. A team composed of 10 data collectors

and 2 supervisors were responsible for the data collection.

3.5 Data collection tools

3.5.1 WASH practices The WASH questionnaire covered standard questions related to access, education, and WASH

behaviors.Hand washing practices, availability of facilities for proper hand-washing (soap, basin,

etc.) was assessed. Overall, the knowledge, attitude and practice towards WASH was assessed.

The adequacy of the WASH education was assessed by looking for WASH related topics in the

textbooks/curriculum.

3.5.2 Nutrition and school food environment Understanding that poor nutrition leads to frequent absenteeism, low school performance and

poor health and wellbeing, it will be important to improve the nutrition of school children. To

this end, key questions regarding meal frequency and type of foods consumed was assessed. The

food environment around and in the school was also accessed through in depth observations.

3.5.3 Menstrual Hygiene The determinants of challenges related to menstrual hygiene will be identified and their impacts

and potential risks will be explored in view of proposing solutions that are adapted to the

schools. To this end, questionnaires were used to assess menstrual hygiene from different

perspectives including:

- School policy, tradition, and cultural beliefs

5

- Water, sanitation and resource availability

4. RESULT

4.1 School participants information

A total of 434 students from six schools participated in the survey. Among the six schools, four

of them were elementary, one secondary, and one preparatory. An equivalent number of

participants, around 17%,were taken from each school (Figure 1).

Figure 1 Schools and their respective percentage of participants participated in the survey, Addis Ababa, Ethiopia, 2017

The mean (+SD) age of all participants was 14.54 (+2.2) years. Among of the total study

participants, 8 (1.8%) of them were disabled. Out of these disabled participants, 5 (62.5%) were

from elementary schools. The majority (66.6%) of the participants were selected from

elementary schools (Table 1).

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Table 1Educational and background related information ofthe study participants in selected

schools of Addis Ababa, Ethiopia, 2017

Variables (n =434) Frequency Percent (%) Educational level Elementary 289 66.6 Secondary

Preparatory 75 70

17.3 16.1

Shift Morning 0 0 Afternoon 0 0 All the day 434 100 Night 0 0 Sex Female 216 49.8 Male 218 50.2 Disability Yes 8 1.8 No 426 98.2

4.2 Wash

4.2.1 Drinking water availability and quality

Regarding availability of water, 161 (38.2%) students reported that the water is always available.

Three hundred fourteen (98.1%) participantssaid they get drinking water at a limited time

interval and most of the time at lunch and, or break time (Table 2). The majority 262 (97.4%) of

the elementary students reported thatthey are capable of drinking water by themselves. Only 2

study participants responded that the pipeline is above their height.

7

Table 2 Water related information of the study participants in selected schools of Addis Ababa,

Ethiopia, 2017

Variables Percent (%) All time availability of drinking water

Yes No

38.2 61.8

Drinking water interruption

Yes No

71.8 28.2

Drinking water in limited time

Yes No

98.1 1.9

Time of availability Lunch time 41.0 Break time 7.0 Lunch and break time

Sometimes Not known

44.6 4.4 3.0

About 38% responded that water is available all the time in their schools. But, out of these

students, the majority (63.7%) could not drink water whenever they wanted to drink (Figure 2).

The majority of the respondents (61.4%) had to rely on the school water system as only one

student reported to buy water from the shop.

8

Figure 3Availability and accessibility of drinking water for students who participated in the school survey, Addis Ababa, Ethiopia, 2017

4.2.2 Sanitation facility access and conditions

Two hundred forty eight (57.8%) of the study participants responded that they use the school

toilet, while 46 (10.7%) reported to not use it. The students who reported not using the school

toilet mentioned the following reasons: 102 (61.1%) of them mentioned latrine dirtiness and

smell as their main reason for not using the latrine.Only a few (1.2%) of them mentioned the

case of privacy as their reason for not using the toilet. About nine female students (4.5%)

indicated that they get insulted by male students or adults whenever they go to use the toilet. The

majority of the study participants responded that the toilets cannot be locked from inside. All in

all, 61.6% of the students replied that they would love their schools more if the schools had a

better toilet facility.

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4.3 Menstrual hygiene

Amongfemale participants, 149 (76.8%) were already in their age of menarche. Among female

students who started menstruating, 32.7%responded that it is hard for them to go to school while

they are on their periods. The majority of menstruating students mentioned uninterrupted water

supply, hidden washing area,and toilets that can be locked as a positive factor that would

encourage them to come to school while on their periods (Table 3).

About 38% got some form of counseling or education from their teachers. While asked if they

were interested to receive menstruation-related education, 62.4% reported that they would be

interestedto receive such a training/education. Being afraid of the teachers and not getting any

additional useful information were the reasons mentioned by those who did not want to get

education/counseling from their teachers. When asked about the things that could motivate them

to go to school when they are having their periods, the following were mentioned: private

washing area near the toilet, toilet that allows privacy, toilets that can be locked and with a place

to throw used napkins (Table 3).

Table 3 Menstruation related information in selected schools of Addis Ababa, Ethiopia, 2017

Variables Percent (%) Menstruating Yes 76.8 No 23.2 Hard to go to the school while menstruating

Yes No

32.7 67.3

Things makes you to go to the school while menstruating

Hidden toilet Toilet with functional key Hidden washing area Washing area for my used sanitary napkins A place to through away used sanitary napkins Uninterrupted water supply

12.3 19.3 21.1 3.5

10.5

33.3

10

4.4 Hand-washing facility access, hygiene education and promotion

About 80.9% of the study participants reported to frequently wash their hands, of which about a

third reported not using soap. Those who reported not washing their hands, their main reason

was the interruption of the water supply in the school (Table 4).

Table 4 Personal hygiene related information of study participants in selected schools of Addis

Ababa, Ethiopia, 2017

Variables Percent (%) Personal hygiene communication

Yes No

80.9 19.1

Time of personal hygiene communication

While working home work

31.5

Because of school promotion

53.4

During family discussion about personal hygiene

15.1

Availability of water at school to wash hands

Yes there is enough water Sometimes it is not enough Most of the time it is not enough Always it is not enough

22.1 38.7 27.6

11.5

Washing hands always after visiting toilet or before eating

Yes No

83.6 16.4

When do you wash your hand at school

After using toilet Before eating After playing Before eating and after playing After using toilet, before eating and after playing I am not washing

15.2 44.3 0.9 0.5

35.8

3.2

Using soap to wash hands Yes

No There is no soap

13.3 29.5 57.2

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4.5 Food availability, access, and nutrition

4.5.1 Last semester related information

In most schools, school feeding or support was not widely available. Out of the total respondents

(377) who reported that the school was not supporting them with food, most of them (97.1%) did

not have difficulties attending school due to food shortage (Table 5). Nevertheless, about 18%

reported to have come to school without eating anything. About 5% of the students also indicated

that in the last semester there were days where they did not eat food the whole day, due to food

shortage.

Table 5 Food related information of study participants in the last semester in selected schools of

Addis Ababa, Ethiopia, 2017

Variables (434) Percent %) School food support Yes

Some times No

12.2 0.9 86.9

Difficulties to attend education due to food shortage

Yes Some times No

1.6 1.4 97.0

Came to school without eating any food

Yes Some times No

18.2 7.4 74.4

Times you did not eat food the whole day due to food shortage

Yes Some times No

5.3 3.5 91.2

Times you did not eat food the whole day and night due to food shortage

Yes Some times No

2.5 1.8 95.4

School absentee due to food shortage

Yes Some times No

1.4 1.4 97.2

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4.5.2 Yesterday’s food consumption (24 h recall)

The majority of the study participants ate their breakfast, lunch, and dinner on the day prior the

survey. However, about 16% did not eat their breakfast on the day before the survey (Table 6),

which was in line with the figures obtained for the semester.

Table 6 Food eaten yesterday by study participants of selected schools of Addis Ababa,

Ethiopia, 2017

Variables Percent (%) Breakfast Yes

No 84.1 15.9

Lunch Yes

No 91.9 8.1

Snack* Yes

No 42.4 57.6

Dinner Yes

No 89.9 10.1

4.6 Pocket money

About ¾ (76%) of the students did not have pocket money. The median (minimum- maximum)

pocket money per week was 20 (1 - 300) birr. Most of the students used their pocket money to

buy biscuit/cookies (37.8), mobile cards (11.2), and for transportation (23.5).

13

5. Observation of school facilities

All the schools have toilets separate for male and female. However, the number of toilets

available may not be enough for the school population. Besides, some are already broken and are

in extremely bad shape (Table 7). Even the toilets said to give service are very dirty and smelly.

This was the case for all the schools, and boys’ toilets tended to be worse. Open defecation was

observed in all the schools.

checklist Mekdela Tesfa Mekanisa Higher 23 Eweket Hiber

does the school have toilets yes yes yes yes yes yes are toilets separate for male/female yes yes yes yes yes yes How many toilets are available in the school for students

12 18 14 19 20 20

not working (broken) 4 3 4 0 7 20 How many toilets are available in the school for teachers

8 6 2 5 6 8

not working 4 0 0 1 0 0 are the toilets clean no no no yes ladies no no are the toilets smelly yes yes yes no yes yes are there signs of open defecation yes yes yes yes yes yes is there a place to wash hands yes yes yes yes yes no are the washing place near toilets no no yes no no no is there enough water yes NE NE yes NE NE is there soap no no no no no no is drinking water available yes,

same tap

yes, same tap

yes yes yes yes

is there enough drinking water NE NE yes yes NE NE does the drinking water come from a bucket/container

no don’t know

yes no yes no

would disabled children be able to use toilets

Don’t know

yes no yes no no

would disabled children be able to use hand-washing station

don’t know

yes yes yes yes yes

NE, not enough

Although there are places where they can wash their hands, this is physically not near the toilets

and thus discouraging hand-washing after toilet use. This along with the limited water available

and the absence of soaps hinder proper hygiene and sanitation in school, predisposing students to

poor health.

14

6. School specific recommendation

Six schools participated in this study: Hibir elementary, Mekanisa elementary, Mekdela

elementary, Tesfa elementary Ewket secondary, and Higher 23 preparatory schools. Participants

were asked toilet, water, and food related recommendations for the coming year. The results for

each category are presented as follows.

6.1 Toilet related

Most study participants from Tesfa elementary, Ewket secondary, and Higher 23 preparatory

school mentioned importance of toilet cleanliness and doors as well as availability of water

around the toilet. Almost the majority of students from each school suggested toilet sanitation

needs improvement and water should be available around the toilet with doors that have key.

Participants from Mekanisa elementary, and Ewket secondary school raised the importance of installing

electric lights and improvement of toilet sanitation.

6.2 Water related

All the study participants from each school recommended that water should be made available throughout

the time. Participants from Hibir elementary, and Ewket secondary schools also suggested that soaps and

washing space should be made available near the toilets.

6.3 Food related

Participants from Hibir elementary, Mekanisa elementary, and Higher 23 preparatory schools

recommended that access to affordable food is limited. A higher number of participants from Hibir, and

Mekanisa elementary school recommended that the school should provide lunch for those who did not

bring lunch.

15

7. Conclusion and recommendation

All together, the study found that the WASH conditions in the schools are suboptimal and would require a

major intervention. In most schools, the numbers of toilets are not enough for the number of students that

the schools have. More toilets would need to be built, and existing ones need to be repaired. Water is not

always available, and when it is available it does not have enough power. Most schools did not have

tankers, and thus this can be an alternative to bridge the gap in water supply. Behavioral change

interventions about hand-washing and proper toilet-use are also needed.

The schools are not disability friendly; this is particularly the case for toilets. The schools do not also

provide an enabling environment for girls, particularly during their periods. The toilets are not private

enough, doors cannot be locked, and there is no washing area. This discriminately affects girls and can

contribute to greater absenteeism. Teachers’ involvement in preparing girls with information related to

menstruation was limited. As most girls believe that they would love to be prepared and have open

discussion with their female teachers, sessions that cover this topic should be encouraged.

About 5-10 % of students are food insecure to the point that will affect their ability to attend or perform

well in school. School feeding for needy students or other forms of interventions (voucher) will be

needed. On the other hand, those who have pocket money tended to buy sugary products like biscuits.

Although this is a common choice at this age group, through nutrition education and by making fruits

available in the area, a shift towards fruits could be promoted.

16

Annex Table S1-Toilet, water, and food related information of study participants of selected schools of Addis Ababa, Ethiopia, 2017

Schools Hibir Elementary

Mekanisa Elementary

Mekdela Elementary

Tesfa Elementary

Ewket Secondary

Higher 23 Preparatory

Variable Freq. % Freq. % Freq. % Freq. % Freq. % Freq. % Toilet related (n=72) (n=73) (n=71) (n=70) (n=72) (n=68) Toilet need proper sanitation and it needs doors 4 5.6 2 2.7 1 1.4 7 10 8 11.1 9 13.2 Water should be available around the toilet 2 2.8 0 0 1 1.4 4 5.7 5 6.9 5 7.4 Water should be available around the toilet: doors with key and proper sanitation

31 43.1 30 41.1 25 35.2 26 37.1 15 20.8 12 17.6

Toilet sanitation needs improvement 35 48.6 38 52.1 41 57.7 33 47.1 41 56.9 39 57.4 Toilet sanitation needs improvement and electric lights should be installed

0 0 3 4.1 0 0 0 0 3 4.2 1 1.5

Water should be available around the toilet and it needs proper sanitation

0 0 0 0 3 4.2 0 0 0 0 2 2.9

Water availability related (n=71) (n=71) (n=60) (n=70) (n=64) (n=69) Water pipe lines should be available and open all the day

65 91.5 69 97.2 57 95 65 92.9 56 87.5 66 95.7

It should be continued like this 1 1.4 0 0 3 5 4 5.7 5 7.8 3 3.3 Soap should be placed near to the toilets 5 7 2 2.8 0 0 1 1.4 3 4.7 0 0 Food related (n=37) (n=22) (n=21) (n=33) (n=31) (n=10) Dining hall should be open 0 0 1 4.5 1 4.8 0 0 2 6.5 2 20 The cost of foods should be affordable 17 45.9 3 13.6 1 4.8 0 0 0 0 3 30 The school should provide lunch for those who did not bring

20 54.1 9 40.9 1 4.8 0 0 9 29 2 20

It does not matter 0 0 9 40.9 18 85.7 33 100 20 64.5 3 30

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Table S2-All variables and their respective descriptive statistics of study participants of selected schools of Addis Ababa, Ethiopia, 2017

Variables Frequency Percent (%) Educational level Elementary 289 66.6 Secondary

Preparatory 75 70

17.3 16.1

Shift Morning 0 0 Afternoon 0 0 All the day 434 100 Night 0 0 Sex Female 216 49.8 Male 218 50.2 Disability Yes 8 1.8 All time availability of drinking water Drinking water interruption Drinking water available whenever you want to drink Drinking water in limited time Time of availability Capable of drinking water by myself Not capable of drinking water by myself

No Yes No Yes No Yes No Yes No Lunch time Break time Lunch and break time Sometimes Not known Yes No The pipeline is above my head We are not allowed to drink by our self

426

161 260

303 119

102 324

314 6

112 21

133 13 9

261 7

2

2

98.2

38.2 61.8

71.8 28.2

23.9 76.1

98.1 1.9

41.0 7.0

44.6 4.4 3.0

97.4 2.6

50

50

18

Variables Frequency Percent (%) From where getting the drinking water

From the school I am not drinking water from the school I am bringing from home using a bottle From the shop

266 15

151 1

61.4 3.5

34.9

0.2

Why not drinking water from the school

Problem with sanitation in the school Water is not available at any time in the school The drinking water is served from tanker

34

80

49

20.9

49.1

30.1

Using school latrine Yes 248 57.8 Some times 135 31.5 I am not using 46 10.7 Why not using the school latrine

Dirty Locked always/some times Very dirty and smell bad Far No time Longer lineup Expose privacy Very dirty and smell bad as well as expose privacy

22 13 102 6 4 8 2 10

13.2 7.8 61.1 3.6 2.4 4.8 1.2 6.0

Male students or teachers insult me when I am going to latrine

Yes Some times Never

9 3 18

4.5 1.5 93.9

Is the latrine has key inside Yes, but all are not working

Yes, only some of them are working No All doors have keys

44 50

101 2

22.3 25.4

51.3 1.0

Menstruating Yes

No 149 45

76.8 23.2

Hard to go to the school while menstruating

Yes No

50 103

32.7 67.3

19

Variables Frequency Percent (%) Things makes you to go to the school while menstruating

Hidden toilet Toilet with functional key Hidden washing area Washing area for my used sanitary napkins A place to through away used sanitary napkins Uninterrupted water supply

7 11 12 2 6

19

12.3 19.3 21.1 3.5

10.5

33.3

Availability of washing area or a place to through away menstruation sanitary napkin is good

Yes May be I do not think

146 6 1

95.4 3.9 0.7

Ever get counseling/education about menstruation from your teachers

Never Yes

95 58

62.1 37.9

Ok to get education from your teachers about menstruation

Yes May be I do not want

93 26 30

62.4 17.4 20.1

Personal hygiene communication

Yes No

351 83

80.9 19.1

Time of personal hygiene communication

While working home work

92 31.5

Because of school promotion

156 53.4

During family discussion about personal hygiene

44 15.1

Availability of water at school to wash hands

Yes there is enough water Sometimes it is not enough Most of the time it is not enough Always it is not enough

96 168 120

50

22.1 38.7 27.6

11.5

20

Variables Frequency Percent (%) Washing hands always after visiting toilet or before eating

Yes No

363 71

83.6 16.4

When do you wash your hand at school

After using toilet Before eating After playing Before eating and after playing After using toilet, before eating and after playing I am not washing

66 192 4 2

155

14

15.2 44.3 0.9 0.5

35.8

3.2

Wash your hands always after visiting toilet or before eating

Yes No

363 71

83.6 16.4

Enough water available at school to wash hands

Yes, enough Sometimes it is not enough Not enough, most of the time Not enough, always

96 168 120 50

2.1 38.7 27.6 1.5

Using soap to wash hands Yes No There is no soap

57 127 246

13.3 29.5 57.2

School food support Yes

Some times No

53 4

377

12.2 0.9 86.9

Difficulties to attend education due to food shortage

Yes Some times No

7 6

421

1.6 1.4 97.0

Came to school without eating any food

Yes Some times No

79 32 323

18.2 7.4 74.4

Times you did not eat food the whole day due to food shortage

Yes Some times No

23 15 396

5.3 3.5 91.2

21

Variables Frequency Percent (%) Times you did not eat food the whole day and night due to food shortage

Yes Some times No

11 8

414

2.5 1.8 95.4

School absentee due to food shortage

Yes Some times No

6 6

422

1.4 1.4 97.2

Breakfast Yes

No 365 69

84.1 15.9

Lunch Yes

No 399 35

91.9 8.1

Snack Yes

No 182 247

42.4 57.6

Dinner Yes

No 390 44

89.9 10.1

What do you buy using your pocket money

Candy Soft drinks Biscuit/cookies Fruits/corn Injera with sauce/pasta Educational materials and personal learning equipments Transportation Lollipop Mobile card I save it

6 4 37 3 7 3

23 2 11

6.1 4.1 37.8 3.1 7.1 3.1 23.5 2.0 11.5 2.0