ANEXOS

The studies further found out that the state of ordinary pit latrines and urinals in schools were not in a commendable condition. The state of VIP and flush toilets in the schools were in good condition.

In terms of the institutional factors related to WASH morbidity in primary schools, the study found out that health clubs can be formed complementary to academic learning to teach pupils about disease causation and transmission, demonstrate proper hand washing and hygiene practices, and provide incentives for good hygiene. School-based hygiene education is vital in order to decrease the rates of transmissible diseases. Children are more receptive to learning and are very likely to adopt healthy behaviours at a younger age. They can also be agents of change by spreading what they have learned in school to their family and community members. Enhanced, comprehensive knowledge about these issues should be used to improve low-cost but highly effective programs that will meaningfully attenuate the burden of transmissible disease among students in rural settings.

Soap, water, and latrines are essential for proper hygiene practice in schools. A study conducted among Colombian school children reported that only 7% of students

reported having clean water and soap regularly available at school (Lopez-Quintero, Freeman & Neumark, 2009). Those that had water and soap were three times more likely to wash their hands before eating or after using the toilet. Even if knowledge of hygiene exists, lack of appropriate resources may negatively affect proper hand washing practices. A UNICEF study conducted in Ethiopia found that less than one- third of schools had water points and only 5% had hand-washing facilities, none of which had soap (UNICEF, 2009).

Education has the potential to significantly alter the behaviour patterns of students and can thereby lead to improved outlooks on hygiene. Second, much of hygiene practices are contingent upon availability of sufficient resources. Well-designed and well- located hand washing facilities and latrines that include adequate amounts of soap and water, are essential in promoting hygiene. This study results corroborates with the findings of Doods (2004) who stated that the merit of integrated services is their ability to residents residing in the slums in a comprehensive manner, provide greater service accessibility, co-ordination, continuity, quality, achieve early intervention and prevention and reduce morbidity, inefficiency and costs of curing. The latrine (pit toilet) to pupil ratio is 1:64 compared with the recommended public health standards of 1:25 for boys and 1:30 for girls (AMREF, 2009). Assessments conducted by the School Sanitation and Hygiene Education Working Group in public schools found an average of 64 students sharing one toilet in the study of schools in Nairobi, Machakos, Kajiado and Kiambu districts The situation was worse in Arid and semi-Arid areas, and an average of 104 students sharing one toilet was found in north-eastern province (Keidar, Berry, Ezeh & Donchin, 2008).

This findings are similar with a study done in Malawi by (Borrazzo, 2009) which found that the duty of the institutions health clubs is to restore hygiene in schools and in the community at large in order to enable the society understand the importance of washing hands with soap so as to eliminate or reduce the infection and transmission of diseases. This means that the pupils are able to understand their feelings, attitudes and emotional disposition. Thus, the student is able to better understand him or herself in relating to his present and future decision in matters related to WASH.

The teacher is instrumental in shaping the attitudes of a community. In many cases he/she is the only adult role model that children can identify with especially in families where parents are absent. The teacher is very much a part of the community and as such understands the problems of the people. He is therefore in a good position to steer the community towards development if only he/she is empowered with the right resources and skills. These findings differ with the study done in Tanzania (Steadman Group, 2007) which revealed that it is the role of the government and public health officers to educate the public as well as educational institutions on the importance of WASH programmes.

NETWAS, UNICEF, and AMREF in partnership with other stakeholders such as the Ministry of Health have established initiatives in schools. These initiatives are, however, not specific to hand washing but to hygiene in general, and have been implemented through the formation of WASH and Hygiene clubs in schools. However, hand washing with soap (HWWS) has not been emphasized (GoK, UNICEF, & WSP, 2008).

A number of studies have been done in Kenya looking at hygiene and sanitation in school. A survey looking at schools in Nairobi, Mombasa and Kwale looking at access to toilets, maintenance, cleanliness, and use of facilities by children revealed that only about 50% of the schools provided children with water for washing hands. Problems encountered in the schools include periodic or seasonal interruptions in the supply, too few working water taps, broken taps and inappropriate locations. In the same study more than half of the pupils reported washing their hands in school on the previous day although observation revealed that less than one-fourth were observed to actually wash their hands after doing so (Njuguna et al., 2008).

Assessments conducted by the School Sanitation and Hygiene Education Working Group in public schools found an average of 64 students sharing one toilet in the study of schools in Nairobi, Machakos, Kajiado and andKiambu districts The situation was worse in Arid and semi-Arid areas, and an average of 104 students sharing one toilet was found in north-eastern province (Keidar, Berry, Ezeh & Donchin, 2008).The Sanitation and Hygiene working group found in their assessment that one of the reasons for not washing hands in schools is lack of water facilities. Ninety percent of schools in rural Kenya do not have a source of safe water and lack even the simplest hand washing facilities. The insufficient number of water points, lack of soap and sometimes complete lack of water are pronounced in the slums, but pose a big challenge in general making it impossible for the school community to maintain basic hygiene standards (Keidar, Berry, Ezeh & Donchin, 2008).

Barriers to hand washing included: Non-placement of the hand washing facilities in schools. Size of hand washing facilities; overcrowding at the hand washing facilities;

soap disappearance and wastage; poor or lack of water drainage of hand washing facilities leading to accumulation of dirty water, in the trough and spilling around the hand washing site; and lack of support from the teachers. In some schools WASH interventions are perceived as an addition to the workload for teachers who feel they are already overworked (GoK, UNICEF & WSP, 2008). Much of hygiene practices are contingent upon availability of sufficient resources. Well-designed and well- located hand washing facilities and latrines that include adequate amounts of soap and water, are essential in promoting hygiene and consequently lowering WASH prevalence. School supported health Clubs have been identified as an ideal platform with unharnessed potential to address HWWS in particular and WASH issues in general. Their presence was also positively and significantly linked to WASH morbidity in Mathare schools.

The Ministry of Education would be greatly useful in enhancing WASH related resource gaps in schools. They also need key stakeholders to coordinate and step up resource mobilization, possibly under MoH to avoid duplication and use of available resources in the most effective fashion. The emphasis of these partners and stakeholders should be on developing school-club based activities with children playing a central role. The stakeholders need to ensure that these activities are supported by making adequate facilities available, especially soap and water, and ensure that technological choices such as taps and toilets are hygienic, efficient and effective.