Diarrhea, Helminth Infection, Dehydration, and Malnutrition Associated with Water, Sanitation, and Hygiene Facilities and Poor Handwashing in Schools in Metro Manila, Philippines: A Cross-Sectional Study

Abstract

Diarrhea, soil-transmitted helminth (STH) infection, and malnutrition threaten the lives of millions of children globally but particularly in the Global South, where inadequate water, sanitation, and hygiene (WaSH) drive disease risk. The aim of our study was to identify environmental and behavioral risk factors of these diseases among schoolchildren in Metro Manila, Philippines. We analyzed data from a multistage cluster sample of grade 5-10 students to investigate WaSH facilities and hygiene practices. Outcomes were self-reported diarrhea and STH infection and observed malnutrition (stunting, undernutrition, over-nutrition); we used logistic regression models to explore correlates. We included 1,558 students from 15 schools in 3 cities. Over 14% (212) of students experienced diarrhea only, 29.7% (438) experienced STH infection only, and 14% (207) experienced both diarrhea and STH infection. Over 15% (227) of students were stunted, ∼6% (87) were undernourished, and 21% (306) were over-nourished. While diarrhea was associated with poor handwashing, avoiding school restrooms, and lack of a restroom cleaning policy, STH infection was associated with students’ dissatisfaction with school restrooms. Risk of having both diarrhea and STH infection increased when school restrooms lacked water or were unclean. Being only stunted was associated with diarrhea, while being both stunted and undernourished was associated with STH infection. These findings demonstrate that adequate water supply and cleanliness of school WaSH facilities must be achieved and maintained to prevent disease. Future school-based WaSH interventions are recommended to provide clean WaSH facilities that have water, promote handwashing, and discourage avoidance of school toilets.

Water, Sanitation and Hygiene in Schools in Low- and Middle-Income Countries: A Systematic Review and Implications for the COVID-19 Pandemic

“…Of the seven studies assessing water quality in schools, all detected contamination of water samples with microbial content [ 41 , 55 , 57 , 80 , 84 , 92 , 95 ]. According to the E. coli counts, 40% of schools (1142 out of 2861) across 15 countries had drinking water in non-conformity with the WHO guidelines (intermediate, high or very high risk) [ 57 , 80 , 84 ].…”

“…Students, especially girls, struggled with the lack of enough privacy in the sanitation facilities in the schools [ 28 , 54 , 92 , 95 ]. Use of shared facilities and urinals between students (boys and girls) and between students and teachers was mentioned in 34% (n = 22) and 5% (n = 3) of the studies, respectively.…”

“…The average number of handwashing facilities varied from two [ 43 ] to five and six [ 44 , 92 ], and the maximum from three [ 62 ] to ten [ 43 ]. In some schools, in the Sunsari district (Nepal) or Dhaka metropolitan and Manikganj district (Bangladesh), when soap was available it was only designated for teachers [ 70 , 90 ].…”

“…The location of handwashing stations varied from being near the classrooms [ 43 ], on the path from the latrines to the classrooms [ 80 ], inside or near the sanitation facilities [ 43 , 45 , 57 , 72 , 77 ], outside the toilet [ 82 ], and in the center of schools far away from the sanitation facilities [ 95 , 96 ]. Only one study informed the student-to-handwashing basin ratio as 562:1 [ 92 ].…”

Exploring Teaching Strategies and Challenges Towards a Holistic Context-Based Special Education Teaching Strategies Program

“…Although the education sector received the highest budget, the Philippines with an increasing population (Ballesteros, 2010) and as a developing country is still struggling to provide access to quality education for the students. Limited classrooms, lack of books, and restrooms are some of the common physical problems faced by the teachers and students (Sangalang et al, 2020). Meanwhile, most of the government programs were focused on the student development.…”