evaluating water, sanitation and hygiene (wash) affecting...
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Faculty of Environment and Natural Resources
Albert-Ludwigs-Universität Freiburg
Evaluating Water, Sanitation and Hygiene
(WASH) affecting school children performance
in Lahore and Islamabad, Pakistan
Master thesis submitted in partial fulfillment of the requirements for the
Degree of Master of Science in Environmental Governance
By
Nisa Butt
3550830
Supervisor: Prof. Dr. Rüdiger Glaser
Second examiner: Dr. Sajjad Haider Sheikh
Freiburg im Breisgau, Germany
03.11.2014
i
Name of Supervisor: Prof. Dr. Rüdiger Glaser
Name of Second Examiner: Dr. Sajjad Haider Sheikh
Prof. Dr. Rüdiger Glaser: _______________________________
Dr. Sajjad Haider Sheikh: ______________________________________
ii
DECLARATION
“I hereby declare that this submission is my own work and that, to the best of my knowledge
and belief, it contains no material previously published or written by another person nor
material which to a substantial extent has been accepted for the award of any other degree
or diploma of the university or other institute of higher learning, except where due
acknowledgment has been made in the text”.
Nisa Butt
3550830
03.11.2014
Freiburg im Breisgau, Germany
iii
Table of Contents Summary ............................................................................................................................................. 1
Chapter 1: Introduction ...................................................................................................................... 2
a) Problem Statement ................................................................................................................. 2
b) Literature review: ................................................................................................................... 3
c) Research Objectives .................................................................................................................. 16
d) Area of Study: ........................................................................................................................... 16
e) Research Questions .................................................................................................................. 17
Chapter 2: Conceptual Framework ................................................................................................... 17
a) WHELL (Water, Health and Livelihood) Framework: ............................................................ 18
b) Proceed Precede theoretical framework .............................................................................. 19
c) Improving Environmental Sanitation, Health, and Well-Being ............................................. 20
Chapter 3: Methodology ................................................................................................................... 24
a) Plan of work (research design) ............................................................................................. 24
b) Sampling Site ......................................................................................................................... 25
c) Sampling Procedure .............................................................................................................. 27
d) Data collection methods and tools ....................................................................................... 28
e) Parameters Measured .......................................................................................................... 32
f) Result Interpretation ............................................................................................................ 37
g) Ethical Considerations .......................................................................................................... 38
Chapter 4: Results ............................................................................................................................. 39
Chapter 5: Discussion, Conclusion & Recommendations ................................................................. 63
a) Water and Sanitation Hygiene (WASH) conditions inside Schools ...................................... 63
b) Occurrence of Absenteeism and Diarrhea ............................................................................ 65
c) Sanitation Education and Awareness ................................................................................... 67
d) Conclusion ............................................................................................................................. 69
e) Recommendations ................................................................................................................ 71
References ........................................................................................................................................ 73
Annexures ......................................................................................................................................... 78
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Table of Figures
Figure 1: Relationship b/w WASH & MDGs 5
Figure 2: Whell framework 18
Figure 3: Proceed Precede theoretical 19
Figure 4: Framework for Improving Environmental Sanitation, Health & Well-Being 20
Figure 5: Conceptual Framework 23
Figure 6: A map of City District Lahore and Islamabad 26
Figure 7: CDGL showing the UC’s & Locations from where the samples were obtained 27
Figure 8: An overview of Sampling Procedure 28
Figure 9 : Centrifuge tubes containing water 30
Figure 10: Incubator for media growth and Autoclave for decontaminating 32
Figure 11: Classroom in Gov. Middle School, Lahore 33
Figure 12: Pearson's chi-squared test 34
Figure 13: Overview of the Assessment of student performance 36
Figure 14: Types of Toilet in Government Secondary Schools, Lahore 41
Figure 15: Comparison between Toilet in Gov. and WASH Secondary Schools, Lahore 42
Figure 16: Usage of Latrines in Gov. Secondary Schools, Lahore 43
Figure 17: Usage of Latrines in WASH Secondary Schools, Islamabad 43
Figure 18: Comparison of toilet conditions inside Gov. Lahore & WASH Schools 44
Figure 19: Non-operational latrine & Open drainage present in Gov. Sec Schools, Lahore 45
Figure 20: Conditions inside Gov. Sec Schools, Lahore 45
Figure 21: Toilets present and required for students in Gov. Sec School, Lahore 46
Figure 22: Toilets present and required for students in WASH school, Islamabad 47
Figure 23: Comparison of Sanitation Facilities present and required in Schools 47
Figure 24: Overview of students waiting for the toilet facilities 48
Figure 25: Overview of students avoiding the usage of Toilet Facilities 49
Figure 26: Students toilets inside Gov. Secondary School, Lahore 49
Figure 27: An overview of relationship b/w requirement & avoidance from toilets 50
Figure 28: Toilet conditions inside WASH Sec Schools, Islamabad 51
Figure 29: Overview of assessment of decreased student performance based on assumptions
54
Figure 30: Detection of E. coli in drinking water of Schools 55
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Figure 31: Drinking Water sources present in Schools 56
Figure 32: Drinking water places situated inside schools 57
Figure 33: Comparison of awareness regarding school sanitation in Schools 58
Figure 34: Comparison of awareness regarding sanitation education in Schools 59
Figure 35: Comparison of awareness regarding sanitation policy among School Teachers 60
Figure 36: Gov. WASH School having soap for washing hands 65
Figure 37: Filters attach with drinking water coolers 67
Table of Tables
Table 1: Name of schools visited and their UC/Sectors 25
Table 2: An overview of the Research Methodology 31
Table 3: An overview of Questions and variables used for applying Chi-Squared Test 35
Table 4: An overview of coding done for Chi-Squared Analysis 37
Table 5: Differentiation of Improved and Not Improved Sanitation facilities 40
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Abbreviations and Acronyms
CDG City District Government
CDGL City District Government Lahore
CLTS Community Led Total Sanitation
E. coli Escherichia coli
FPL Flush pour latrine to somewhere else (street, yard, open
drainage, plot)
FPLPSS Flush pour latrine to piped sewer system
IEC Information Education Communication
MDGs Millennium Development Goals
MFM Membrane Filter Method
NA Not Applicable
NAR Net Attendance Ratio
NEQS National Environmental Quality Standards
SLTS School Led Total Sanitation
SPSS Statistical Package for the Social Sciences
SSHE School Sanitation and Hygiene Education
TMA Tehsil Municipal Officer
UC Union Council
UNICEF United Nations Children’s Fund
WASA Water and Sanitation Agency
WASH Water and Sanitation Hygiene
WHO World Health Organization
WSSCC Water supply and sanitation collaborative council
WSSCC Water supply and sanitation collaborative council
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ACKNOWLEDGEMENTS
It is a privilege to profoundly thank my respected first Supervisor, Prof. Dr. Rüdiger
Glaser, Managing Director of the Institute of Physical Geography, for guiding me choose
a topical theme which is a great relevance to human life and for being there from the
initial to the final level which enabled me to develop an understanding of my research.
I also express my sincere thanks to Dr. Sajjad H. Sheikh, Professor of Environmental
Engineering, University of Engineering and Technology for accepting to be my second
Supervisor in Pakistan and for his expert advice and sincere co-operation throughout
my field work which encouraged me to complete this research work.
Lastly, I offer my regards and blessings to my family and my friends for helping and
supporting me in any respect during the completion of my research.
NISA SHAHZAD BUTT.
1
Summary
Government Secondary School in Lahore and Islamabad, Pakistan consists of two
different scenarios when it comes to Water and Sanitation Hygiene (WASH) conditions
inside the schools. The present study in line with the objectives was undertaken to
assess, evaluate and compare the prevailing sanitation conditions along with practices
adopted by children and teachers for utilizing sanitation facilities inside both of these
schools.
An investigation was carried out in 21 Gov. Secondary Schools in Lahore and 05 WASH
nominated Gov. Secondary School in Islamabad from April till June 2014. Data was
gathered by filling in semi structured questionnaires, review of the exiting literature,
acquiring attendance registers for surveying absenteeism and collecting drinking water
samples for detecting E. coli.
The results demonstrated that the secondary schools in Lahore have more E. coli than
the WASH school, Islamabad. Whereas the overall conditions of sanitation in Lahore
schools were worse in terms of cleanliness and standard requirement. A significant
relationship (.000) showed that sanitation and student’s performance can be
dependent on each other or in other words poor sanitation practices can have an effect
on the students overall performance.
The results suggested that the Gov. Secondary WASH Schools, Islamabad could be taken
as a practical example by the Schools in Lahore. It cannot be ignored that the Gov.
Schools in Lahore has less budget than the private schools and due to this fact the
conditions in government schools in Pakistan were mostly not very appreciable. Lack
of interest by the school administration or teachers was mainly because of the financial
barriers due to which the sanitation conditions inside the schools were not maintained.
Government on the other hand is required to take urgent actions towards sanitation
inside school and ask the officials stated by the national sanitation policy to perform
their responsibilities.
2
Title: Evaluating Water and Sanitation Hygiene (WASH) affecting school children
performance in Lahore and Islamabad, Pakistan
Chapter 1: Introduction
One of the important factors to cause serious health impacts is lack of access to clean
water and poor sanitation (Murray and Lopez 1997). Different pathogens can affect the
body in many different ways likewise the ones for causing water borne diseases such
as cholera, diarrhea, shigellosos etc (Enger et al. 2013). Escherichia coli pathogen is one
of the most common pollutants in drinking water to act as pathogens. Unsafe hygiene
practices along with contaminated water and food is one of the main causes of child
mortality (Katukiza et al. 2012). People, community even countries can have major
economic and social impact triggered by lack of access to drinking water and basic
Water and Sanitation Hygiene (WASH) facilities. An example from 2007 found from
Indonesia can be quoted where the country lost approximately 6.3 US Billion because
poor sanitation practices (Hutton et al. 2008).
It has been estimated that 1.7 million children faces death each year due to unsafe
water, poor sanitary and hygiene conditions. Diarrhea is the primary cause of death in
9 out 10 children whereas one third out of 1.7 million deaths occur in South East Asia
having high child mortality rates (Suk et al. 2003). Therefore, provision of proper
Water and Sanitation Hygiene (WASH) facilities ensures improvement of wellbeing
specifically in regards to protection of body from various diarrheal vectors among
adolescent children.
a) Problem Statement
Geographically Pakistan is located in the south eastern part of Asia and is facing a lot of
problem in terms of WASH practices. According to the statistics of 2006, 58% of the
total population has an access to proper sanitation facilities out of which 40% of the
population lives in rural and 70% in urban areas (Moccia, Anthony, and UNICEF 2008).
In regards to drinking water only 65% of the whole population has an access to
improved source of save drinking water (Jabeen et al. 2011).
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Health status of children in Pakistan remains inadequately low as compared to other
low income countries mainly as a result of low level of literacy and poor sanitation
facilities (National Institute of Population Studies, Islamabad, Pakistan and Measure
DHS, ICF International, Calverton, Maryland, USA 2013). Approximately 70,000
children under the age of 5 die each year because of diarrhea which is normally
associated with poor water or sanitation and hygiene practices (Stephen Rahaim 2010).
Education plays an important role in upbringing of children while it can be used as a
tool for creating awareness regarding good sanitation practices (MO et al. 2013). The
secondary level of education in Pakistan is not up to mark as the overall percentage of
female enrolled in secondary schools is 18% whereas the males are 23% (Moccia,
Anthony, and UNICEF 2008). Keeping aside the question of access to safer sanitation
facilities, practices related to hygiene and sanitation are greatly influenced by student’s
behavior since they might not be aware what is and is not harmful for them (Vivas et al.
2010). According to one of the reports of World Bank if a girl misses her school 4 days
in every 4 weeks she will lose 10 to 20% of her school days (Oster and Thornton 2010).
Keeping in mind the above statistics and scenario it can be assumed that the children
getting sick affect their overall performance in schools therefore an in-depth evaluation
will be carried out for governmental schools of Pakistan and assessing how WASH
schools are better with the following statement:
Evaluating Water and Sanitation Hygiene (WASH) affecting school children
performance in Lahore and Islamabad, Pakistan
b) Literature review:
There are three main major causes of environmental damages which include air
pollution causing illness and premature mortality, reduced production in agriculture
and diarrheal diseases caused by improper sanitation, hygiene and water supply
induced via key factors such as lack of environmental awareness and education
(Farooqi and Fatimah 2010).
According to WHO sanitation is referred to a concept of provisioning facilities and
services for safe disposal of human excreta, maintenance of proper hygienic conditions
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by sustainable collection of solid waste and treatment of waste water (“WHO |
Sanitation” 2014) whereas in some other definitions the term sanitation also meant to
ensure public health by preventing the transmission of diseases via improper use of
toilet and open space defecation (Nadkarni 2004). “Improved Sanitation” or “Improved
Sanitation facilities” refers to those kind of facilities where the pupils do not come in
direct contact with human excreta and are maintained in a more sanitary conditions
(UNICEF 2006). Improved sanitation facilities includes Flush or pour to piped sewer
system/septic tank/pit larine, ventilated pit latrine, pit latrine with a slab or a
composting toilet (World Health Organization and WHO/UNICEF Joint Monitoring
Programme for Water Supply and Sanitation 2006).
Water and Sanitation has been given a lot of importance and is seen as one of the basic
component of Millennium Development Goals (MDGs) adopted by United Nations in
2000 (Kvarnström et al. 2011). Their aim is to decrease half of the proportion of people
who doesn’t have access to safe drinking water and basic sanitation facilities by 2015
(World Health Organization and WHO/UNICEF Joint Monitoring Programme for Water
Supply and Sanitation 2006). WASH is an abbreviation used for Water and Sanitation
Hygiene developed by Water supply and sanitation collaborative council (WSSCC). This
term was lobbied for MDGs targeting sanitation problems in order to develop advocacy
campaigns at a global level as shown in Figure 11. Their vision explains that proper
sanitation, safe water and adequate hygiene education can reduce diseases causing an
impact on poverty reduction as well as socio economic development. According to their
strategic plan of 2012 to 2016 their efforts are dedicated to improve the sanitation
conditions predominantly of Asia and Africa (Water supply and sanitation collaborative
council 2011). Sanitation is considered to be an important part of MDGs and amongst
others it is most commonly related with two targets i.e. to promote gender equality and
empower women (MDG 3) (Halcrow et al. 2010) and ensure environmental
sustainability (MDG 7) (Calow and Tucker 2013). However, literature can also be found
relating to other MDGs such as achieving universal primary education (MDG 2) and
reduce child mortality (MDG 4) as children getting affected by water related diseases
1 Source: (Micah Challenge 2011)
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can cost directly in being absent from school as well as improper sanitation and poor
quality of water is the direct cause of 85% of child death due to diarrheal diseases
worldwide (Halcrow et al. 2010).
Countries are making progress in
achieving these goals however;
there are still serious disparities
amongst many such as Pakistan
since MDGs provincial report of
Punjab, Pakistan forecasted that
an estimate of 55 percent of
population living in the province
decreased its use in the toilet
facilities (UNDP 2011). According to the WHO assessment 28% (approximately more
than two million) of the children can be prevented from death each year only if WASH
is addressed properly (Micah Challenge 2011). Most significant WASH related diseases
can be diarrhea, malnutrition, intestinal infections, trachoma and schistosomiasis
(Prüss et al. 2002) etc. causing death of 22,000 children per day where 98% of them are
in developing countries (Micah Challenge 2011). Pakistan economic survey of 2011-
2012 estimates specify that 38% of children under the age of five are under-weight
while 12% are severely under-weight (A. Khan 2012). The country is lacking behind in
achieving MDGs related to health however in terms of education, improvement has
been made. Children symbolizes a vulnerable part of the society and unfortunately
Pakistan is considered as having the highest mortality rate for children and women in
South Asia (Afzal and Yusuf 2013). In order to reach the MDGs it has been estimated
that the infant mortality rate should decline to about 40 deaths per 1000 live births
whereas for under-five the mortality rate should be not less than 52 deaths per 1000
births but so far the pace of improvement is not satisfactory due to lack of resources
and increasing population (A. Khan 2013). Countries similar to Pakistan in economic
development have made greater progress in child mortality rate such as Bangladesh
and Nepal (Afzal and Yusuf 2013).
Figure 1: Relationship b/w WASH & MDGs
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Taking into consideration seven indicators of MDG 7 (ensure environmental
sustainability) Pakistan is somehow on track by improving access to safe drinking
water with 89 percent as compared to the target of 93 percent whereas it lacks in
providing access to proper sanitation facilities with 72 percent as compared to the
target of 90 percent (Ministry of Planning, Development and Reform 2013). In another
report of UNICEF and WHO it has been explained that approximately 91 million people
live in Pakistan without improved sanitation facilities and around 40 million people still
practices open defecation (OD) (Fonds des Nations Unies pour l’enfance and
Organisation mondiale de la sante 2012). To meet the MDG demand for sanitation, it
alone requires substantial amount of economic as well as sustainable resources which
means to provide toilet facility to 2.1 billion people from 2002 till 2015 which also
entails a minimum amount of 44,300 installations per day while assuming one toilet for
every 10 persons (Moe and Rheingans 2006). In Pakistan 24% of sanitation facilities
have been improved amongst the whole population from 1995 till 2010 (Fonds des
Nations Unies pour l’enfance and Organisation mondiale de la sante 2012).
Women, children and infants suffers the most due to lack of proper WASH facilities such
as a small act of hand washing can have a huge impact on one’s health especially on
those of children eventually reducing the risk of illness related to diarrhea and other
infectious diseases (UNICEF 2006). It is evident from the above literature that WASH
plays an important role in our everyday lives and we see that the concept further
evolved into several different labels and terminologies with good or bad practices
(Chambers 2009) such as Community Led Total Sanitation (CLTS) approach and WASH
Schools following School Led Total Sanitation (SLTS) approach. Water and Sanitation
Hygiene (WASH) Schools refers to a concept of technical aka hardware and
development of human aka software component resulting in a healthy environment of
schools by developing and supporting health and hygiene behaviors where the
technical software’s includes hand washing, drinking water and toilet facilities whereas
the software components incorporates all the developmental activities and conditions
such as practices related to prevention of diseases from poor water and improper
sanitation amongst children (A. Mooijman et al. 2010).
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Further advancing (Shayamal et al. 2008), explains Community Led Total Sanitation
(CLTS) approach, which is becoming a water sanitation discourse amongst
practitioners and scholars where a certain community without any external subsidies,
participates to achieve areas with Open free defecation (OFD) across the whole village
or community as well as incorporates safe disposal of waste and access to safe water
for domestic purposes. Similar approach has been adopted in Mardan, Pakistan where
apart from OFD environment, attitude and behavior changes in the community were
also observed leading it to government recognition resulting in approving CLTS to be a
part of the National Sanitation Policy (Khisro et al. 2008). Two key prominent
assumptions of CLTS is to empower the community and to get rid of technocratic and
monetary backing while shifting to participatory approaches (Shayamal et al. 2008).
The involvement of the community in planning and development of sanitation facilities
is important mainly because of two reasons; firstly since the decision is made by the
locals so there is a possibility of introducing a technology which is more cost effective,
and affordable for them and secondly as they understand the actual problems better
than the outsiders so it leads to more adequate facilities (Allen, Hofmann, and Griffiths
2008).
Various studies indicate that amongst other stakeholders in implementing the
approach of CLTS children specifically have played an important role such as in
monitoring hygiene behavior as well as helping in surveying types of latrines (Williams,
Lambongang, and Bundle 2011). Successful implementation of CLTS can be achieved by
using children as drivers to facilitate in the whole process of capacity building leading
it to aware their own parents and community of what they have learnt in schools
through School Led Total Sanitation (SLTS) approach (Chambers 2009). SLTS
combined with the School Sanitation and Hygiene Education (SSHE) follows the similar
approach as CLTS (F. Khan et al. 2008; A. Mooijman et al. 2010) but rather than focusing
on the whole community as CLTS, the emphasis is restricted to schools and more
towards children’s personal as well as household hygiene in coverage of improved
latrines and sanitation facilities, OD free areas, enhance behaviors, empowering them
in developmental actions and increase partnership approaches to sustain WASH
facilities (Adhikari and Shrestha 2008). Children are perceived as “agents of change” as
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they can help the parents and community to realize the dangerous effects of poor
sanitation and unsafe drinking water while helping them move towards adopting better
practices, in short SLTS has been developed as complete package comprising of all the
WASH Schools components as well as capacity and awareness building activities for the
community (A. Mooijman et al. 2010). Improvement in WASH sector can bring
favorable outcomes such as improvement in school attendance ratio, health and
behavior development, increased participation of female students, equality among
schools, teacher’s training and outreach to community members along with including
sanitation as a part of the school curriculum (UNICEF 2012; A. Mooijman et al. 2010).
Through several other studies it has been proved that school children play a significant
role in disseminating information regarding sanitation e.g. in Kenya children were
involved in making their own action plans, in Bangladesh they had been seen as taking
responsibilities for sanitation mobilization, Indian children were blowing whistles if
they found someone doing OD whereas in Indonesia they conducted out door
awareness activities etc. (Chambers 2009).
Apart from physical and emotional damages natural catastrophes causes a lot of
infrastructure damages resulting in chaotic situation causing fears of epidemic due to
poor WASH facilities. A case study regarding SLTS in 2009 from Pakistan shows that
during the time of earthquake considering teachers as the natural leaders (Chambers
2009) children were utilized as sanitation agents for societal change since they are
considered as the recipients for learning and behavioral change activities which in
other words also means that children not only improve their immediate school
environment but rather take the message home as well as to a certain community level
(F. Khan et al. 2008). Successful examples of implementing WASH facilities through
SLTS had been imagined mostly in South Asian or African countries assuming their
economic and developmental statues however, (Samwel and Gabizon 2009), describes
in her paper the problems children faced in schools in eastern Europe due to improper
sanitation and water facilities which later were overcome by Women in Europe for a
Common Future (WECF), an organization working in Western and Eastern Europe as
well as Caucasus for the better coverage of proper sanitation and water facilities for
children.
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As discussed earlier children are considered as a vulnerable part of the society which
directly links to the fact that they are more prone to diseases (Afzal and Yusuf 2013)
and this shows in eastern part of Europe as well where in 2009 lack of proper sanitation
facilities in schools were the main cause of child mortality due to either having no hand
washing/proper toilet facilities or those equipped were poorly maintained (Samwel
and Gabizon 2009). School sanitation or proper WASH facilities can be considered as
an influential aspect of children’s attendance in two ways; first, improved conditions at
school provide them a more appealing environment for education where they have
access to proper latrines as compared to their home and second due to poor WASH
facilities at home they might get illnesses or additional WASH related responsibilities
such as fetching water resulting in being absent from school (Dreibelbis et al. 2013).
Having an inaccessibility to latrines in school can cause problems for children specially
for female students causing an increase ratio of drop outs from school (Adhikari and
Shrestha 2008). In the industrial-production-based countries, the studies that observe
the deviation of routine and punctuality caused by gastrointestinal and respiratory-
related illness, show that the implementation of improved hand hygiene system in
schools – the deviation can reduce and the number of absenteeism can drop between
25% and 50% (UNICEF 2012).
Whereas in some societies children are seen as driving agents others expect them be
obedient and listen to what their elders tell them, e.g. in some African areas children
are not allowed to speak and are considered disrespectful for taking part in promoting
WASH activities (Williams, Lambongang, and Bundle 2011). Excreta and toilets are still
considered to be taboo and discussing sanitation related problem is strictly personal
(Nawab et al. 2006). Due to this kind of culturally embedded challenges, children’s risk
of facing health problems increases that is why in addition to different approaches,
School Sanitation and Hygiene Education (SSHE) such as hand washing, proper
utilization of sanitation facilities should be disseminated thoroughly (Afzal and Yusuf
2013). UNICEF estimates that still half of the world’s children lack the access to clean
water, proper sanitation and education related to hygiene and as a result it has highly
affected the health along with learning and teaching environment of the children at
school. Though it is not directly related to health, mental or social processes but,
10
ultimately cause damage to economic and political development (A. Mooijman et al.
2010). In regards to the developing countries two third of the region does not have
proper sanitation facilities and, wherever the facilities are present they are mostly
inadequate (Pynnönen et al. 2014). School-aged children accounts for approximately
578 million out of which 40% are reported to be infected by worms while 88 million
children under the age of 15 years are suffering from schistosomiasis, such diseases are
considered to be a burden for the children aging from 5 to 14 years which is a critical
period of physical and mental development resulting in having a negative impact on
school performance and overall growth (A. Mooijman et al. 2010).
Pakistan having a 6th largest population (ranking 145th on Human Development Index
out of 187 countries) in world faces a lot of challenges in SLTS approaches towards
achieving WASH in schools. Out of 180.8 million people living in 4 provinces (Punjab,
Sindh, Baluchistan and Khyber Pakhtunkhwa) of the country 43.6% are children having
an age less than 18 years whereas 28.6% are children aged between 5 to 14 years
(UNICEF et al. 2013). From another report UNICEF states the data regarding WASH in
Pakistan i.e., the net primary school enrollment ratio as of 2007 to 2009 is 66%,
population using improved drinking water as of 2010 accounts to a total of 92% where
urban population is approximately 96% and rural is 89%, improved sanitation facilities
used by the population in total is 48% out of which 72% is covered by urban and 34%
by rural and last but not the least since WASH plays an important role in promoting
education the total no. of governmental schools are 124,385 (UNICEF 2012). The above
mentioned literature supports the fact that education can be an important tool for an
improved WASH system in a country and supporting this argument (Annemarieke
Mooijman. 2009) describes in his paper that around 1.9 billion school days could be
attainted if WASH education is promoted in schools as this helps in fulfilling the rights
of children towards health, education and improved participation, ultimately leading in
achieving MDGs related to reducing child mortality, improved water and sanitation and
access to education.
It has been researched by several authors as discussed above that children studying in
school can have a major impact on their health by having School Sanitation and Hygiene
11
Education (SSHE) and promoting it to the community but it directly relates to the fact
that exactly how many children are getting education. Unfortunately in Pakistan apart
from the primary sector, education is lagging behind in middle/secondary/lower
secondary education with a percentage of total 30.1 children (2.7 million out of which
1.1 boys and 1.6 million girls) being out of schools i.e. not attending primary or
secondary level of education at all (UNICEF et al. 2013). According to the Pakistan
Health and Demographic Survey the net enrollment of girls and boys at
middle/secondary/lower secondary school is only 37% (National Institute of
Population Studies, Islamabad, Pakistan and Measure DHS, ICF International, Calverton,
Maryland, USA 2013). If we consider the provincial statuses of the country it is found
out that out of four provinces Sindhi children are at the top of not attending school
followed by Balochi, Pushto, Punjabi and Urdu speaking children because around
15.9% of children aged 10 to 14 years are involved in labor work while working an
average of 32.2 hours per week outside house whereas those involved in household
chores work with an average of 24.3 hours per week (National Institute of Population
Studies, Islamabad, Pakistan and Measure DHS, ICF International, Calverton, Maryland,
USA 2013). Similarly the reporting percentage of children (10 to 14 years) attendance
at school who are involved in child labor is only 9.9 percent (UNICEF et al. 2013).
Punjab, being the most populous province of the country has a population of about
98.223 million as of 2013, having a literacy rate of 60% (68% males and 51% females)
(Planning and Development Department, Punjab 2014). The status of
middle/secondary schools accounts to a total of 41% (51% urban and 31% rural) as
per the Net Attendance Ratio (NAR) which further divides with a female proportion of
39.8% and a male proportion of 42% (National Institute of Population Studies,
Islamabad, Pakistan and Measure DHS, ICF International, Calverton, Maryland, USA
2013). It is obvious from the above statement that rural children are at a higher rate of
being out of school than the urban children mainly due to one strong reason amongst
others is concerning their wealth quintile which means children from the poorest
wealth quintile are more likely to be out of school as compared to the those in urban
areas where the wealth quintile is higher (UNICEF et al. 2013). Apart from children
being affected due to work and missing from school there are some other important
12
factors to be taken into consideration such as children who are being affected because
of poor sanitation conditions prevailing inside the schools.
Though having 50% of the whole population, Punjab still remains far from satisfactory
in providing proper facilities at primary and middle level government schools where
33% schools do not have safe drinking water facility and 36% have no latrines
(Planning and Development Department, Punjab 2014). According to another report
around 670,000 children in Pakistan miss their school every day due to water borne
illnesses or not having adequate coverage to facilities up to standards i.e. 1 toilet for 25
girls, 1 toilet for 50 boys and 1 separate toilet for female and male teachers along with
considering 5 liters of water for every pupil per day and one water cooler/ container in
every class room (UNICEF 2012; JMP, UNICEF, and WHO 2011). Currently the biggest
challenge secondary/middle level schools faces is the problem of having no basic
facilities specially toilets and boundary walls along with poor drinking water quality
which also discourages the parents to send children, particularly their daughters to
schools (UNICEF et al. 2013). Physical environment of the school can enormously affect
children’s health and well-being as the diseases spread where the ventilation systems
are not proper, soaps or hand washing facilities are not present, toilets are either not
available or are mostly out of order (Annemarieke Mooijman. 2009).
Adequate and improved water supply is one of the major aspect of WASH facilities in
schools and a report from UNICEF states that in Pakistan out of 124,385
public/governmental schools 53,734 needs an extensive repair or new systems
whereas 82,349 schools requires a new functioning system (UNICEF 2012). In regards
to Punjab, access to improved water conditions are not that worse where 98.6% of the
population is using an improved source of drinking water which further break downs
to pipe into dwelling/yard/plot (29.8%), public tap/stand pipe (6.2%), tube well or
borehole/hand pump (55.5%), protected well (0.6%), protected spring/rainwater
(0.2%), bottled water (1.3%) and filtration plant (5.1%) whereas non improved water
sources accounts to total 0.6% where the source consists of unprotected well (0.2%),
unprotected spring (0.0%), tanker truck/cart with drum (0.1%), surface water (0.3%)
and other sources (0.7%). Furthermore, around 92.6% of the people drink this water
13
without proper treatment (National Institute of Population Studies, Islamabad,
Pakistan and Measure DHS, ICF International, Calverton, Maryland, USA 2013). Since
the overall study relates to the district/city of Lahore, Punjab approximately 74% of the
households utilizes tap water as the main source of drinking with a proportion of 85%
(22% boiling and 8% filtration) being in urban areas - though there is a problem being
addressed by the author which shows that even though different survey had been
conducted for using improved source of water yet the water quality hasn’t been tested
which is another critical issue to be addressed (Planning and Development Department,
Punjab 2014; Bureau of Statistics, Government of the Punjab 2011).
The second most important aspect of WASH is the availability of latrine or toilet
facilities which in total 58.8% of population in Punjab is using improved, not shared
facility with a breakdown of flush/pour flush to piped sewer system (23.4%),
flush/pour flush to septic tank (22.8%), flush/pour flush to pit latrine (12.4%),
ventilated improved pit (VIP) latrine (0.1%) and pit latrine with slab (0.2%), 13.6% of
the household population is still using shared facility and 27.5% are still having non
improved facility with flush/pour flush not to sewer/septic tank/pit latrine (8.1%), pit
latrine without slab/open pit (0.3%), bucket (0.0%), hanging latrine (0.0%), no
facility/bush/field/OD (18.7%), other (0.2%) and missing (0.2%) (National Institute of
Population Studies, Islamabad, Pakistan and Measure DHS, ICF International, Calverton,
Maryland, USA 2013). According to the multiple cluster indicator survey (MICS) report
of 2011, Punjab a survey was conducted about hand washing practices where
observational data was collected regarding the location of hand washing, availability of
soaps and water in households which later showed a result of 94% of households in
Lahore having proper hand washing locations as well as soap and water whereas
overall 97% - 77% had availability of water and soap- households in Punjab having a
nominated location for hand washing, 1.1% did not have any specific place for hand
washing and the rest did not gave the permission to enter their premises however, it
is also mentioned that presence of soap and water is correlated positively with the
wealth quintiles (Bureau of Statistics, Government of the Punjab 2011).
14
Though sanitation has been institutionalized at a policy level in Pakistan yet so far the
implementation and monitoring has not been much effective. The institutional
structure defines the roles and responsibilities of concerned department which
includes the Housing, Urban Development and Public Health Engineering Department
(HUD&PHED) and Local Government and Community Development Department
(LG&CDD) at Provincial Level whereas at Local level, Water and Sanitation Agency
(WASA) is responsible for larger cities along with this Town/Tehsil Municipal
Administrators (TMAs) are responsible for urban and rural water sanitation in their
districts (Planning and Development Department, Punjab 2014). Unfortunately there
isn’t any budget allocation or a national action plan for WASH in schools, though in 2009
an MoE was signed in collaboration with different governmental agencies (PHED, LG
and DoE) introducing standards for WASH in schools but in 2011 the Federal Education
Ministry was dissolved and all the programmes and activities related to education was
reassigned to the provinces (UNICEF 2012). No. of policies addressing environment has
been published such as National Sanitation Policy 2006, which provides a structure and
guidance at government level in order to improve and sustain proper sanitation
throughout the country by developing strategies and sustainable plans for bringing an
improvement in public’s quality of life and work environment (Ministry of
Environment, Government of Pakistan 2006) along with National Drinking Water
Policy with no. of programmes following such as CLTS, SLTS etc. but unfortunately most
of them lack in timely monitoring & evaluation and also suffer political interferences
during the implementation phase which results in difficulty in achieving the main goals
(Ministry of Planning, Development and Reform 2013). In 2009 a study was conducted
in Pakistan through which a no. of observations were undertaken by some authors
concluding that most of the time the needs, expectation along with desires of people are
quite different from the institutional policies and understanding of the issues by
government and NGOs which leads to the sanitation system that are not applicable with
the community therefore a need of common interests and understanding is required
amongst the local people, government and NGOs (Umbach and Bergstrøm 2009). It is
further researched that most of the time in Sanitation led activities people do not
understand the governmental policy but rather consider it a written piece which is
15
never implemented as a result this shows that there is lack of awareness among the
local citizens in accordance to the sanitation policies for which advocacy strategies
should be introduced in schools and community so that people can understand and
apply them in practice (Shayamal et al. 2008). Due to change in the constitution (18th
amendment) now governance of water and sanitation is being taken up as a provincial
subject in order to have a better understanding of the gaps in policies related to
sanitation and for an effective execution a “draft Punjab Sanitation Policy” has been
under construction by June 2013 which is aligned by National Sanitation Policy 2006
following up with the approach of SLTS as of WASH in schools (Government of Punjab,
Pakistan 2014; Planning and Development Department, Punjab 2014).
Apart from having this responsibility of providing the structure and facilities inside
schools, Government sector needs to work out on the outreach and awareness for
WASH in schools and considering other divisions private and NGO sector companies
can play a vital role in this area. In 2009, a private sector company along with an NGO
launched a programme of building 100 schools all over Pakistan which targeted
approximately 40,000 children along with raising awareness about their health and
hygiene which also sheds light on the fact that Public-private partnership needs to be
strengthened for development of children (Afzal and Yusuf 2013). Awareness for how
to utilize the already available facilities is yet another very important as well as a cost
effective aspect in middle/secondary government level schools. Since building more
school latrines and providing WASH facilities would not help, if first, the quality of
existing school latrines and WASH facilities are not maintained according to the
standards as per different studies shows that the quality of school latrine can be a factor
associated with the low level of attendance amongst students (Dreibelbis et al. 2013)
and second, quality nor quantity of sanitation facilities has been properly and in depth
addressed in the National Sanitation Policy of 2006 which results in having less or no
awareness at provincial level during sanitation related activities in schools (Ministry of
Environment, Government of Pakistan 2006). A society where choice of sanitation
model depends on the status, privacy and ease rather than health and environment, and
where the consequence of death caused by poor sanitation is accredited to the will of
God, this kind of society can be changed by proper hygiene education and awareness
16
for behavior change (Nawab et al. 2006). Creating an ownership among the community
and giving them the responsibility of monitoring can be result in sustainable sanitation.
The present study was undertaken to assess prevailing WASH conditions along with
practices adopted by children and teachers for utilizing toilets and hand washing
facilities inside secondary/middle government schools of Lahore and Islamabad. Field
visits were done in order to collect the data by filling in the survey forms. The study
also deals with understanding the level of awareness children and teachers have
towards the sanitation standards and policy. Furthermore, the study will see how the
poor sanitation conditions can impact children’s health by testing the drinking water.
Analyzing the level of E. coli in water will help to develop a better understanding of the
sanitation conditions occurring inside the schools and later suggesting/recommending
how the overall system can be improved.
Following are the main objectives of the study conducted:
c) Research Objectives
1. To understand and explore through literature review the available data /
information regarding sanitation, sanitation conditions in educational institutes, and
impact of bad sanitation and environment on overall educational performance and
health of students
2. To identify the gaps in the existing sanitations system in Government secondary
schools and WASH schools
3. To compare and highlight the impact of provided sanitation facilities on student’s
performance, their condition and whether they are sufficient to meet the requirement
of students
4. To assess the level of awareness of teachers and students regarding the dangers and
effects they face due to poor Water and Sanitation Hygiene (WASH) conditions
d) Area of Study:
Governmental secondary schools in Lahore vs. WASH nominated Government
Secondary Schools in Islamabad, Pakistan.
17
e) Research Questions
1. How Water and Sanitation Hygiene (WASH) schools are better in sanitation system
than the governmental secondary schools?
a. Whether there are improved toilet facilities in schools or not?
b. Whether the children use toilet facilities properly or not?
2. How poor sanitation conditions affect student performance in schools?
3. Are teachers and students aware of the effects caused by poor sanitation?
Chapter 2: Conceptual Framework
Sanitation has been associated with a lot of theoretical and conceptual frameworks. The
present study will deal with a conceptual framework of several theories defined by
different authors. Interaction of different derivatives would be seen under the
overarching topic and determine how to further operationalize the applied scientific
research in a comprehensive yet methodical framework. The main purpose of using
such structure for the current empirical study is to clarify the basic concepts which will
further explore the Meta dimensions related to health of children and how it is affected
18
with vulnerable conditions of sanitation inside the government secondary schools of
Lahore and Islamabad, Pakistan.
a) WHELL (Water, Health and Livelihood) Framework:
Amongst many studies a conceptual framework of WHELL (Water, Health and
Livelihood) focuses primarily on
strengthening access to sanitation
facilities leading to an improvement
in HIV/Aids and gender as shown in
figure no. 22, it further describes in a
case study from Africa showing that
WHELL framework also embeds
capacity building among the local
government and civil society along
with accomplishing high level of
awareness, policy interventions and
sustainable practices towards water
and sanitation in three districts
(CARE 2009). WHELL highlights challenges in Sanitation in Africa similar to those of in
Pakistan which directly affects health and livelihood of families consisting of
predominantly children. Since it has already been discussed above that due to poor and
inadequate sanitation or WASH facilities, approximately 670,000 children miss their
schools every day (UNICEF 2012). Although the main objective of the framework is to
mainstream AIDS/HIV and gender by improving sanitation however, the subprograms
are also involved in creating awareness and policy development therefore it can be
inferred while considering the health status that the framework can be utilized in
improving the livelihood of children by providing awareness and putting forward
policies at institutional level.
2 (CARE 2009)
Figure 2: Whell framework
19
b) Proceed Precede theoretical framework
Education plays an important role in sanitation which is further influenced by
behaviors in the overall process (Vivas et al. 2010) similarly Proceed Precede
theoretical framework takes into account the hygiene behavior and education
describing that behavior related to health is influenced by multilayered factors which
can be divided into three main categories namely, predisposing, enabling and
reinforcing (Glanz, Rimer, and Viswanath 2008).
In a research by (Dube and January 2012) hygiene behavior is observed amongst
school children studying in a small town of Chitungwiza, Zimbabwe by using Proceed
Precede Model where as a result of poor sanitation facilities children were getting
affected and it was determined that through reinforcing factors such as family, friend,
social networks., Enabling factors, such as teaching skills, service provision, facilitation
and Predisposing factors, such as knowledge, beliefs, attitudes, values or confidence can
arose a specific behavior amongst the children leading them to healthy quality of life
Figure 3: Proceed Precede theoretical
Framework
20
(figure no. 3)3. It can be assumed that the hygiene behavior and education amongst the
students in the current research is also influenced by the reinforcing factors causing a
major impact on the level of awareness about sanitation practices they need to adopt
in their daily lives. The theoretical framework can also be related to concept of School
Sanitation and Hygiene education (SSHE) as it takes into account enhancing children’s
behavior and improve it through educational tools (Adhikari and Shrestha 2008;
UNICEF et al. 2013). Some authors also suggests that this framework apart from taking
into account behaviors considers the social cultural situations which can be associated
with the behavior as well further referring it to the sanitation condition in Pakistan
where the social and cultural norms are highly embedded with this topic amongst the
community members (Ashwell and Barclay 2009; Nawab et al. 2006).
c) Improving Environmental Sanitation, Health, and Well-Being
This conceptual
framework entitles three
main spheres which
includes health status,
physical environment &
social, cultural and
economic environment.
The sphere comprising
of health status can be
assessed by health
related behavior and
pathogens affecting the
human body while the
sphere encompassing physical
environment deals with the
excreta, wastewater, solid
waste management, water supply, drainage system and services related to it. The last
3 (Dube and January 2012)
Figure 4: Framework for Improving Environmental Sanitation, Health & Well-Being
21
sphere is the social, culture and economic environment which identifies equity patters
along with economic statuses. All merged, these spheres can be related to the current
topic of sanitation since the author with the help of the conceptual framework identifies
the relationship between environmental sanitation, health and wellbeing of the
community of local members of the population (Nguyen-Viet et al. 2009).
Based on the literature review we can see that some of the others authors also
mentioned a presence of direct relationship of sanitation with health, physical and socio
cultural environment (Dreibelbis et al. 2013; Bureau of Statistics, Government of the
Punjab 2011; Nawab et al. 2006) which will be further utilized in the current study. The
tools used in this framework are questionnaires, surveys, testing of waste water and
drinking water samples, solid waste management while also taking into account the
institutional, methodical and administrative aspects.
Figure 44 shows an overview of the framework describing the spheres as well the
methodology adopted in blue abbreviations. In regards to the current study conducted
the purpose of utilization of the Improving Environmental Sanitation, Health, and Well-
Being framework for this study is to understand the vital issues of a certain area
regarding sanitation and proceed further with improvement in sanitation planning.
As discussed above conceptual framework can be related with several other theories
by further designing one’s own inputs, activities, outcomes and the impacts of the study
(Gelting, Delea, and Medlin 2012). Based on the above theories and literature a
conceptual framework (Figure 5) is designed by taking into consideration three
different theories associated with sanitation and further using the derived concepts
from those theories relating them within the overall process. The first level in the given
framework is input matrix which depicts the three theoretical framework and their
derivative concepts which further helps us in understanding the dimensions of
sanitation and how it is related with aspects of health, wellbeing, education, behavior
and socio cultural as well as economic environment (CARE 2009; Dube and January
2012; Nguyen-Viet et al. 2009). An essential part of the designed conceptual framework
4 (Nguyen-Viet et al. 2009)
22
will allow us to generate variables which will be easy to measure later providing an
opportunity of performing an assessment of the relationship between children and
impact of the sanitation problems in school which may for example include their
absenteeism along with assessing difference of sanitation facilities in both kinds of
schools i.e. Government secondary schools, Lahore and Government WASH Secondary
School, Islamabad.
The second part of the framework involves the proposed activities of the whole process
which can also be considered as tools for measuring those variables derived from the
theories and researched data & questions. The proposed activities for our framework
would involve statistical analysis for developing correlation between two variables and
assessing the significance level. The correlation would be developed by using
questionnaires, field surveys, observations etc. Apart from the statistical analysis
differentiation would be performed which will based on the testing of water samples
collected from both schools as well as the measuring the compliance sanitation
standards and accessibility to the sanitation facilities. The above mentioned theories
which helped in developing the conceptual framework for the current study also
applied the same kind of tools for further exploring different dimensions of sanitation
and development (Dube and January 2012; Ashwell and Barclay 2009; Nguyen-Viet et
al. 2009; CARE 2009). These activities would allow us to reach certain outcomes by also
identifying the independent or dependent relationships of variables on each other
hence progressing towards favorable impacts.
In the third matrix of the framework, research questions were used to form as expected
outcomes which will lead us to reach our nominated goals or objectives. The research
questions structured for the study will proceed in evaluating the final impacts of
sanitation on children studying in governmental schools. Apart from the conditions and
standards there is a focus on the policy level as well bearing in mind the involvement
of teachers and municipal administration regarding monitoring and its application on
ground. The fourth and the final matrix of the conceptual framework are the impacts of
which are assumed to be of the overall process or study. These can also be seen as
expectations from the overall course of research or study.
23
Reinforcing Factors
(parents, friends etc.)
Physical Environment
WHELL framework
Figure 5: Conceptual Framework
Proceed Precede
theoretical
framework
Improving
Environmental
Sanitation, Health,
and Well-Being
framework
Hygiene Behavior &
Education
Health & Livelihood
Frameworks Derivation of
research concepts
2) Proposed Activities
Socio-cultural and
Economic Environment
3) Expected
Outcomes
4) Assumed
Impacts
Questionnaires
Water sampling and
testing
1) Inputs
Interviews
Observations &
photographs
Changes in WASH
Practices
Maintenance of
existing facilities
Access to better drinking
water quality
Improved Attendances
(better health)
Improved monitoring
mechanisms
Improved latrine/
toilet facilities
Well aware teachers
and students
Building up a
Conceptual
Framework
Statistical Analysis
for correlation
Assessment of water
quality in schools
Comparative analysis
of sanitation facilities
between Gov. Sec
WASH schools,
Islamabad and Gov. Sec
School, Lahore
Evaluation of possible
correlation between
absenteeism and
school sanitation
Assessment of
sanitation education
and level of awareness
24
Chapter 3: Methodology
a) Plan of work (research design)
The present study conducted deals with the current sanitation condition of 21
government middle/secondary schools of Lahore and 05 government
middle/secondary schools which are registered under WASH (Water and Sanitation
Hygiene ) programme in Islamabad. The study was carried out to observe, examine, and
evaluate the current situation of sanitation inside the schools. Primary and Secondary
data was collected to analyze the school conditions. For primary data collection a
combination of quantitative and qualitative questionnaires were prepared for children
and teachers of school. Along with this water sampling was done for 22 schools to
evaluate the E. coli count in 100 ml water. The whole process of primary data collection
was done in the month of April, May and June 2014. The following table shows the name
of the schools surveyed and their respective Union Councils/Sectors.
Sr No. Name of School Union
Council/Sector City
1 Wapda Girls middle school - Shalimar town 36
Lahore
2 City district Government girls middle school - sadan kalan 85
3 City district Government boys middle school - sadan kalan 85
4 Government middle school - awan town 110
5 CDG Junior model middle school Chohan road 83
6 CDG Junior model middle school Chohan road 83
7 Government Islamia middle school mohni road 71
8 Government Wazir Model middle school sanda 83
9 Government Middle school Dev samaj road 80
10 Government Girls Middle saadi park Mazang Lahore 79
11 CDGL JM Dhobi Mandi (Old Anarkali) 72
12 Gov. middle school English medium - lahkodair wagha town 49
13 Moqdooma Junior School, CDGL 83
14 Asif Suleman Government middle school 150
15 Government Middle school - Badoki 150
16 Government elementary school - Dav Kalan 63
25
17 Government elementary school - Harpalky 63
18 Govt Saleem Model School Urdu Bazar 29
19 Govt. Middle School Gulberg 97
20 CDGL girls middle school, Sant Nagar 80
21 Gov Islamia Middle school, Gawalmandi 73
22 Islamabad Model school F-6/1
Islamabad
23 Islamabad model school G-8/2
24 Islamabad model schools street no.58 G-11/2
25 Islamabad model schools - noor pur shahan F-7/2
26 Islamabad model school street 70 G-11/2
b) Sampling Site
The sampling was done from two cities of Pakistan i.e. Lahore and Islamabad. Lahore is
a city of approximately 8 million and is divided into two main zones which further
categorize them into union councils (UCs) as show in the Figure No. 7. The school sites
were selected by taking into account the geographical area as well as the union councils
or sectors of the two cities by covering maximum area in order to reflect diversity.
Whereas the schools registered under WASH programme in Islamabad were randomly
selected by list of Secondary government schools provided by UN Habitat officials in
Islamabad, Pakistan.
Table 1: Name of schools visited and their UC/Sectors
26
Figure 6: A map of City District Lahore and Islamabad
27
Figure 7: CDGL showing the UC’s & Locations from where the samples were obtained
c) Sampling Procedure
The schools were selected by dividing the city into two nominated zones as shown in
the above Figure no. 7 and further chosen from different Union Councils and Sectors
(figure 6) in order to reflect the diversity existing in the entire city. The sampling
procedure had been conducted in two main steps:
Step 1: 10 students (5 male and 5 female), aged 10 to 14 years and 2 teachers (1 male
and 1 female) were selected from each school to fill the questionnaires for the proposed
study. This in total accounts for 26 schools i.e. 260 children and 52 school teachers.
28
Step 2: In order to perform water sampling to detect E. coli count, 100 ml drinking
water was collected from 22 schools (17 government middle school, Lahore and 5
WASH schools, Islamabad). The water sample was collected in 500 ml of autoclaved
centrifuge tubes and delivered to the lab for testing within 24 hours of collection. For
ethical considerations samples were coded so that not to disclose the school name.
Every water sample collected was taken from two different locations inside the school
as the water sources within the school sometimes used to vary such as hand pumps,
filtration plants, private tube wells and direct pipelines from WASA (Water and
Sanitation Authority).
Figure 8: An overview of Sampling Procedure
d) Data collection methods and tools
There were various methods and tools utilize for primary and secondary data
collection.
Field analysis: The data was collected manually by going into schools and asking
children/students and teachers questions by filling in the standard questionnaires.
Apart from the questionnaires, water samples were collected as well and were
separated into the polythene bags later transferred to Pakistan Council of Scientific and
Industrial Research (PCSIR) present at canal road, Lahore for further analysis.
Questionnaires: The data was collected in three phases via questionnaires.
Sampling Procedure
Questionnaires
Own Observations
2 Teachers/ school
10 Students/ school
Water Sampling
22 Schools
29
The first questionnaire was designed for own observations and general data
collection of the schools visited such as total no. of toilets and wash basins, drinking
water sources, cleanliness conditions of toilets etc.
The second questionnaire was addressed to students asking questions about basic
sanitation facilities, absenteeism, sanitation education and general knowledge.
whereas;
The third questionnaire was addressed to teachers assessing if they know about
sanitation standards and policies.
The main reason of having different questionnaires was to assess the level of awareness
and education regarding sanitation amongst teachers and students, to assess if there is
evidence of relationship between children’s performance and poor sanitation and to
identify the contradictions made by students and teachers as compared to the personal
observations done during the field survey. Sample questionnaires for Personal
observation, students and teachers are attached as Annexure 1.
Attendances/ Absenteeism: The attendance registers were monitored for three
months i.e. January, February and March 2014 specifically for those 10 students (5 male
and 5 female) who were interviewed in each school.
Diarrheal incidences: With the help of examining the attendance of interviewed
students it was also noted that how much absenteeism or sick leaves have been
registered under the cause of diarrheal incidences such as stomach upset, vomiting,
fever, abdominal pain, nausea, cramping, malnutrition etc.
Water Samples: During the field survey of schools water samples were collected in
order to detect Escherichia coli also known as E. coli in 100 ml water. Presence of E. coli
in drinking water can cause severe diarrheal problems specifically among children
(Ashbolt 2004). 22 samples of drinking water were collected from 17 government
middle secondary schools of Lahore and 05 water samples were collected from WASH
schools in Islamabad. The sampling procedure conducted was followed in accordance
to American Public Health Association (APHA). Centrifuge bottles were used to collect
the 500 ml of water samples and they were autoclaved for 2 h in order to decontaminate
30
them (Collins and Collins 2004). Before
taking the samples it was made sure
that the tap is properly cleaned with
alcohol dipped cotton and flame so that
it is sterilized. After cleaning the tap the
water was kept running for 1 min and
then the 500 ml of water sample was
taken while making sure that there is no
air left in the tube. The samples were
collected in polythene bags and
transferred to lab within 6 hours whereas the samples collected from Islamabad were
stored in ice box in order to limit the multiplication of the bacterial activity and
transferred to lab within 24 hours.
Figure 9 : Centrifuge tubes containing water
31
Research Methodology
Secondary Data
Acquiring sanitaton standards from NEQS Pakistan and WHO
Scientific journals and Publications
Assessment of Prevailing Sanitation System
Literature review of:
o Sanitary system in schools
o Relationship of sanitation & MDGs
o Level of education in Pakistan
o Sanitation conditions affecting
children health
Secondary Data
Scientific journals
Publications
Case studies from Pakistan
Sanitation policies
WASH and BCC strategies adopted
in Pakistan
Review of Existing situation
Quantitative Analysis
Primary Data
1. Field visits in schools
2. Acquiring Data of WASH schools from UN HABITAT in Islamabad
3. Questionnaire with own Observations
Assessing the existing sanitation system in school: o No. of toilets and wash basins o Water access and availability o Attendance registers: No. of sick
leaves/ month o No. of diarrhea incidence o General cleanliness conditions
inside the toilets
4. Focus group
Questionnaires To assess the awareness level of
sanitation from: o Students o Teachers
5. Collection of Water
samples to detect E. coli
Software and experimentation
SPSS to assess the significance amongst variables
Microsoft excel to develop comparison of sanitation standards and current practices among Gov school in lahore and WASH schools
Membrane filter method for detecting of E. coli
Data Processing & Outcomes
Data Collection Methods, Analysis and Tools
Analysis
Chi square test to assess significance
among variables
Develop comparison among own
observation and answers from teachers
and students
Comparison of schools sanitation
systems and the E. coli level found in
drinking water
Table 2: An overview of the Research Methodology
32
e) Parameters Measured
Presence and total count of E. coli in water
Water samples were taken to determine the E. coli count in 100 ml water by using
Membrane Filter Method (MFM). For every sample 100 ml of water was passed through
47 mm diameter (0.45 μm pore size) of sterile membrane filter. After this sterile
absorbent pads were placed in petri dishes and 2.5 to 3ml membrane lauryl sulphate
broth (MLSB) was poured on the surface. The membrane filter was then placed face up
on the pad and incubate at 30°C for 4 hours and later transferred to 44°C for 14 hours.
MFM was conducted in two stages i.e. the presumptive test and confirmatory test. After
the incubation all the yellow colonies were counted within few minutes and were
reported as presumptive E. coli count in 100ml water. For confirmatory tests for E. coli
the yellow colonies membranes were further incubated at 44°C for 24 to 48 hours by
using MacConkey and Nutrient Agar. Samples which had red ring formation were
considered as positive for E. coli. The method was conducted by the lab technicians of
PCSIR.
Figure 10: Incubator for media growth and Autoclave for decontaminating
tubes
33
Assessment of school sanitation, hygiene education (SSHE) and awareness
An assessment of SSHE and awareness level was conducted with the help of two
Questionnaires designed for teachers and students. Awareness index was created for
students and teachers with different questions relating to Information, education and
communication (IEC) and basic knowledge of poor Water and Sanitation Hygiene
(WASH) practices and how they can lead to diseases. Based on the criteria by asking
children to answer any two diseases caused by poor WASH practices knowledge level
was assessed whereas teachers were asked the same question as well as about
sanitation as a subject in school curriculum along with sanitation related workshops.
Questions related to the sanitation standards such as availability and no. of latrines per
person/student, no. of wash basins and level of ecoli were also asked from teachers and
students of both the schools. A differentiation of school sanitation and hygiene
education (SSHE) was assessed among the students and teachers belonging from
Governmental WASH schools in
Islamabad and the students who
were studying in Governmental
schools in Lahore.
Apart from the practices related
to sanitation there were some
policy oriented questions for
teachers as well where they were
requested to answer about the
sanitation policy of Pakistan and
how the monitoring practices are being adopted by the governmental institutions.
Additionally, own observation
questionnaire helped in assessing
the cleanliness condition of sanitation inside both types of schools which included
presence of hand wash/soap, availability of water basin and water, functionality of the
existing latrines, presence of janitor in the toilets, disposal facilities etc. Identification
Figure 11: Classroom in Gov. Middle School, Lahore
34
of contradictions was also made based on teachers and students answers as compared
to observations noted.
Assessment of Performance level of students
In order to assess the performance level of students in school a statistical analysis was
developed by using Statistical
Programme for Social Sciences
(SPSS) and testing with Chi
Squared Test. Figure no. 125 is
representation of the formula
used in analysis which is also
knows as Pearson's chi-
squared test. Attendance registers
and questionnaires were used as tools to develop a relationship and see if there is
significance between different variables. Several studies depicts that the Chi Squared
test has been utilized by several other authors in sanitation (Jenkins and Scott 2007;
Minamoto et al. 2012; Lee, Rosenzweig, and Pitt 1997) for assessing the significance
between education and sanitation or motivations, constraints or satisfaction levels etc.
Before performing the test and analyzing the relationship between variables an
assumption was made to assess the student performance which is
Total no. of school days to be attended: 26 days/month (30 days/ month & excluding
4 Sundays)
If a child takes 3 days/month sick leaves the attendance will be: 23 days/month
(88%)
Assumption 1: If a student is absent less than 87% (3 days/month or more) in the class
his or her performance will be decreased (Oster and Thornton 2010).
5 Source: Wikipedia (http://en.wikipedia.org/wiki/Pearson's_chi-squared_test)
Figure 12: Pearson's chi-squared test
35
Assumption 2: If there is no soap in the toilet there is a probability that a student can
get sick because of not washing their hands leading to absenteeism causing decrease in
performance
Based on the assumptions mentioned above the data was extracted from the student
questionnaire by developing a correlation among two questions regarding holidays i.e.
No. of holidays I (student) do in a month? And is their soap available in the toilet?
The word “holiday” is considered as sick day or sick leave taken by a student from the
school. The calculation was done by developing a relationship between variables as
shown in the table below:
Table 3: An overview of Questions and variables used for applying Chi-Squared Test
Questions addressed to students Variable Answering Options
Is their soap available in the school
toilet? Soap
Always
Sometimes
Never
I don’t know
Correlation Question
No. of holidays I do in a month? Sick leave
None
More than 2
More than 4
36
Assumption: If a student is absent less than 87% (3 days/month or more) in the class his or her
performance will be decreased.
Better performance
I don’t know Never Always Sometimes
Acquiring Sick leaves Two possibilities No sick leaves
More than 4 More than 2
Decreased performance
Assumption 2: If there is no soap there is a probability of getting sick leading to
sick leaves causing decrease in performance
Assessing if there is any relationship between absence of soap and student sick leaves?
Applying Chi-Squared test
How many holidays/sick
leaves I do in a month? None
Is their soap available in school toilet?
Variables: a) Soap b) Sick Leaves
Two possibilities No Relationship Presence of Relationship
Children getting sick leave can have other
reasons of sickness and not related to poor
sanitation conditions in school
Children having attendance less than 87% might be getting
sick cause of diarrheal infection caused by not washing
hands with soap after toilet
Figure 13: Overview of the Assessment of student performance
37
The null hypothesis is:
“There is no relationship between absence of soap and student sick leaves.”
The answers were considered for only those 10 students from 26 schools who were
interviewed. The test will be conducted to evaluate if there is significant relationship
between two variables or whether the two variables are dependent on each other or
not.
Following table shows the coding which was done for all the answers in SPSS before
running the test.
Question addressed to
students Variable Coding for SPSS
Is their soap available in the
school toilet? Soap
Always 1
Sometimes 2
Never 3
I don’t know 4
Correlation Question Coding for SPSS
No. of holidays I do in a month? Sick leave
None 1
More than 2 2
More than 4 3
f) Result Interpretation
The data was presented in the form of graph and tables while average was calculated
to create a differentiation between school and sanitation standards. Means of various
parameters were compared using standard errors which showed variation in data. The
results were also statistically analyzed and chi squared test was applied using software
such as SPSS.
Table 4: An overview of coding done for Chi-Squared Analysis
38
g) Ethical Considerations
Ethical considerations were taken at four different stages.
First, during the field analysis and data collection participation was made
voluntary. None of the students and teachers was forced to be filling out the
questionnaire if any uncomfortable behavior was noticed;
Second, the respondents especially children were allowed to ask questions at
point of confusion and were given ample opportunity to completely understand
the question before answering or filling out the survey form;
Third, teachers and school principals were assured that none of the results
deducted from school analysis would be published or handed over to any
governmental agency and;
Fourth, all the names of the schools were submitted as codes in laboratory for
water testing.
39
Chapter 4: Results
The study was conducted on the Water and Sanitation Hygiene (WASH) system placed
in 21 middle/ secondary schools of Lahore and 05 middle/ secondary WASH schools in
Islamabad. The data was collected through field surveys and school inspections were
done throughout three months i.e. April, May and June 2014. The main purpose of going
to Islamabad was because WASH Schools in Lahore didn’t exist or the concerning
authorities didn’t allow to be visited. The data related to student attendance was
collected for the month of January, February and March 2014. Analysis was done by
using questionnaires as well as measuring different parameters such as E. coli
detection, comparison between sanitation facilities and evaluation of significance in
different variables by applying Chi-squared test. The results were consolidated and
analyzed by referring to the intended research questions by summarizing the key
findings as follows.
1. How Government middle/elementary/secondary Water and Sanitation
Hygiene (WASH) schools, Islamabad are better in sanitation system than
the governmental elementary /secondary schools in Lahore?
In order to gather the data to create a comparative analysis between two schools
parameters were set for the comparison. First, sanitation standards for the toilets
would be used to see the difference between two schools; second, general cleanliness
conditions such as if the toilets were smelly, stained, feces inside/outside the pan or
choked? will be monitored and third requirement would be assessed if the toilet were
enough as compared to the no. of students.
The data collected in this part will be deducted from the information given by teachers,
students and the questionnaire which was utilized for own observations while doing
field surveys. A point to be taken into consideration is that due to time constraints and
emergency situation in the city not many schools were able to be covered which means
that the current study is conducted between 5 Gov. WASH schools in Islamabad
whereas the comparison is done with 21 Gov. Schools of Lahore. We can also say that
since the WASH schools are lesser than Gov. School in Lahore, so rather than a strict
40
comparison only 05 WASH schools were assessed as a practical example to be taken for
the Gov. Secondary schools in Lahore.
According to WHO sanitation standards there are improved and not improved version
of sanitation facilities which in other words mean if the excreta is not disposed off safely
and is left open then it’s not safe (World Health Organization and WHO/UNICEF Joint
Monitoring Programme for Water Supply and Sanitation 2006). The following is a list
of toilets based on their safety:
Toilet system Improved/ Not improved Sanitation
Facilities
Flush or pour piped sewer system/septic
tank/pit larine Improved
ventilated pit latrine Improved
pit latrine with a slab Improved
composting toilet Improved
Flush or pour flush to elsewhere (street, yard,
open plot, open drainage, open sewer) Not improved
Pit latrine without slab or open pit Not improved
Bucket Not improved
Hanging toilet or hanging latrine Not improved
No Facility/Bush or field Not improved
Table 5: Differentiation of Improved and Not Improved Sanitation facilities
a. Whether there are improved toilet facilities in schools or not?
Considering the standards mentioned above in the table no. 5, sanitation facilities were
monitored in the schools visited. Following is the graph (fig 14) depicting the situation
in the government schools in Lahore. Out of 21 schools visited there were 6 schools
equipped with Flush or pour piped sewer system in other words which were improved
sanitation facility, there were 14 schools which didn’t have proper facility and were
flush or pour flush to elsewhere (street, yard, open plot, open drainage, open sewer)
whereas one school didn’t have any facility at all.
41
In comparison to the 21 Gov. Schools in Lahore, all 5 WASH schools in Islamabad were
equipped with improved sanitation facility of Flush pour latrine to piped sewer system
(FPLPSS) as shown in the Figure no. 15 below. Although we can see that the WASH
schools are less in no. but we can still assume that they are in better condition because
UN Habitat gave the authorization to visit any 05 schools amongst 36 WASH schools in
Islamabad.
6
14
1
0
2
4
6
8
10
12
14
16
Schools with FPL Schools with FPLPSS School with Nofacility
Types of toilet in Gov. schools, Lahore
types of toilet
Figure 14: Types of Toilet in Government Secondary Schools, Lahore
42
Figure 15: Comparison between Toilet in Gov. and WASH Secondary Schools, Lahore
FPL: flush pour latrine to somewhere else (street, yard, open drainage, plot)
FPLPSS: flush pour latrine to piped sewer system
After the comparison being made on personal observation questionnaire about the
types of sanitation facility the schools were equipped with, children were also asked
some questions related to the facilities. Considering that there are schools with
unimproved sanitation facilities where the excreta might not be disposed-off properly
when 210 students (10 children/ school) from Gov. School in Lahore were asked about
if they feel easy to use the existing latrines in school? 10% students answered
“always” whereas 39% said “never” and 35% stated “I don’t know”. We can analyze that
the percentage of children answering never and I don’t know is quiet close which can
also be assumed that they are not aware about the fact that what safe or improved
latrines are. Moreover, 5% children didn’t answer (NA) anything because of having no
facility in the school. In WASH School, Islamabad 50 children (10 children/ school)
were interviewed in total out of which 58% children said that toilets are always easy to
use where as 16% said that they don’t know. A graphical representation of both schools
is shown below in Figure no. 16 and 17.
6
14
10
5
00
2
4
6
8
10
12
14
16
Schools with FPL Schools withFPLPSS
School with Nofacility
Type of toilet in Gov. and Gov. WASH Sec Schools
Gov. sec schools, Lahore
Gov. WASH school, Islamabad
43
Figure 16: Usage of Latrines in Gov. Secondary Schools, Lahore
Figure 17: Usage of Latrines in WASH Secondary Schools, Islamabad
Moreover, when children from Gov. Schools in Lahore were asked that why they don’t
feel easy to use the existing sanitation facilities the answers were mostly related to the
conditions inside the toilet such as most of the times the toilets are choked (72% yes)
and non-operational whereas when they were asked if the toilets have stains 53% said
0
5
10
15
20
25
30
35
40
45
Always Sometimes Never I Dont know NA
Usage of Latrines in Gov. Schools, Lahore
The latrines are easy to use
0
10
20
30
40
50
60
70
Always Sometimes Never I Dont know NA
Usage of Latrines in WASH schools, Islamabad
The latrines are easy to use
44
yes and 42% said no. The students didn’t have any idea about sanitation facility of being
improved or not which can be assumed of not being aware. Regarding feaces
inside/outside the pan they answered with 14% yes and 81% no. The graphical
representation (fig no. 18) below shows a comparison of conditions in Gov. and WASH
schools where 86% student in Gov. school in Lahore said that they have no soap in toilet
while 82% students in WASH school said yes they have access to soap for washing
hands. However, the answers students gave regarding feaces and stains were
contradictory to the personal observations done during the visit and proven by the
Figure no. 19 and 20.
Figure 18: Comparison of toilet conditions inside Gov. Lahore & WASH Schools
During the field survey it was also noted that the apart from schools not having proper
sanitation facilities there were major problems of maintenance since the latrines or the
drinking facilities already available were not taken care of properly as shown in Figure
32 and 37 whereas in Gov. WASH schools the administration was maintaining the
toilets and sanitation facilities far more better.
0
20
40
60
80
100
120
Gov.Sec
WASHschool
Gov.Sec
WASHschool
Gov.Sec
WASHschool
Gov.Sec
WASHschool
Gov.Sec
WASHschool
Gov.Sec
WASHschool
Smelly Stains Feacesinside/outside
the pan
Choked Soap Wash basin
Comparison of toilet conditions inside Gov. Lahore & WASH Schools
Yes
No
NA
45
Figure 19: Non-operational latrine & Open drainage present in Gov. Sec Schools, Lahore
Figure 20: Conditions inside Gov. Sec Schools, Lahore
The second part of the comparison is based on the exiting sanitation facilities for
students in both schools and assessment of the actual requirement in accordance to the
guidelines as per the total no. of students studying. The information was taken from the
school principal or the teachers who were interviewed. WHO guidelines are used for
setting the standard for sanitation facilities as per the total no. of students (1 toilet/25
girls and 1 toilet/50 boys) (UNICEF 2012).
46
b. Whether the children use toilet facilities properly or not?
The usage of the toilet or latrine facilities is associated with the assumption that
students use the toilet facility properly when the toilets are enough to fulfill their
requirement. Keeping in mind this assumption a comparison is made between the two
schools. Total no. of schools visited in Lahore were 21 which had approximately 11000
students including both male and female whereas 05 schools in Islamabad had about
1600 students. The requirements of sanitation facilities or toilets were calculated by
following the above mentioned WHO guidelines. The following Figure shows that how
many toilets were present for all the girls and boys and how many are required.
Figure 21: Toilets present and required for students in Gov. Sec School, Lahore
50
239
50
120
0
50
100
150
200
250
300
Toilets present forgirls
Toilet Required forgirls
Toilets present forboys
Toilet Required forboys
Toilets present and required for students in Gov. Sec School, Lahore
Series1
47
Figure 22: Toilets present and required for students in WASH school, Islamabad
Figure 23: Comparison of Sanitation Facilities present and required in Schools
The above Figure shows a comparison of the toilets/latrines present in the schools
where Government Secondary/Middle School in Lahore had approximately 50 separate
toilets for girls and boys whereas 239 toilets were required (1 toilet/25 girl) for girls
and 120 for boys (1 toilet/50 boys) whereas in Islamabad WASH schools 24 separate
24
32
24
16
0
5
10
15
20
25
30
35
Toilets present forgirls
Toilet Required forgirls
Toilets present forboys
Toilet Required forboys
Toilets present and required for students in WASH school, Islamabad
Series1
50
239
50
120
2432
24 16
0
50
100
150
200
250
300
Toilets present forgirls
Toilet Requiredfor girls
Toilets present forboys
Toilet Requiredfor boys
Comparison of Toilets present and required for Schools
Gov school
WASH school
48
toilets were present for boys and girls whereas girls (1 toilet/25 girl) require 32 toilets
and boys (1 toilet/50 boys) require 16. In WASH Schools the no. of toilet for boys were
exceeding the required amount whereas girls were having a bit less. However, in
Lahore the situation was worse in schools regarding the toilet requirements as the
present situation doesn’t even cover half of the required amount of sanitation facilities
as compared to the no. of students enrolled in the schools.
In order to examine if the students also feel the necessity of having more toilets they
were addressed with a question “Do I have to wait for the toilet to be free? “ 60% of
the students from Government School, Lahore said always, 24% said sometimes, 12%
said never and 5% of them didn’t answer anything because of having no facility in the
school whereas while addressing the same question to the WASH School students 62%
said they never have to wait for the toilet to be free while 38% said sometimes.
Figure 24: Overview of students waiting for the toilet facilities
Furthermore, since the no. of toilets were far less as compared to the guidelines it can
be assumed that the toilets currently present will be over-utilized which may lead to
dirty conditions further causing an impact on the students. In order to assess if this has
an impact on the student they were addressed with the question if they avoid going to
the toilet? The following Figure shows the results with an answer of 17% stating
always, 48% said sometimes, 31% said never whereas 5% were Not Applicable (NA)
0
10
20
30
40
50
60
70
Always Sometimes Never I Dont know NA
Do you have to wait for toilet to be free?
Government Sec school
WASH school
49
cause of no facility. On the other hand in WASH schools 34% said sometimes whereas
66% said never.
Figure 25: Overview of students avoiding the usage of Toilet Facilities
The relationship of the requirement leading it to avoidance from the toilets/ latrines
can be seen in the Figure no. 27 given below:
Figure 26: Students toilets inside Gov. Secondary School, Lahore
0
10
20
30
40
50
60
70
Always Sometimes Never I Dont know NA
Do you avoid going to toilet?
Government Sec. Schools
WASH Schools
50
Figure 27: An overview of relationship b/w requirement & avoidance from toilets
Since the assessment regarding requirement was made on personal observation and it
was deduced that the no. of toilet or sanitation facilities do not fulfill the requirement
of students enrolled in the school but as we move further with the questions of waiting
for their turn and avoidance it can be seen that the student answers contradict their
statements as 60% of the students interviewed said that they “always” have to wait for
their turn but while asking them about avoidance only 17% said “always” while 48%
said “sometimes” and 31% said “never” which means even if they have to wait for their
turn and the toilets are dirty inside they still “sometimes” use it. Having dirty conditions
and still sometimes using the toilet can also be related to their behavior or socio
economic backgrounds when asked from students most of them belong from lower
middle class families having shared toilet facilities at home and the earning hand is only
eldest male member of the family having a job of rickshaw driver, farmer or a security
guard. In contrast to this 62% of the students from WASH school said that they “never”
Do children have to wait
for the toilet to be free?
Since the toilets are not enough Yes
Fewer toilets used by more
people
Over usage of the facility by
large no. of students
Dirty conditions
inside
Avoidance to use
it
51
to wait for their turn to use the toilet consequently leading to a similar answer of
“never” avoiding the toilet as well from 66% of the students.
Figure 28: Toilet conditions inside WASH Sec Schools, Islamabad
2. How poor sanitation conditions affect student performance in Gov. School,
Lahore?
As mentioned in the methodology SPSS was used to see if there is any evidence of
relationship between two variables. All the answers given by the students for the two
questions correlated were coded and can be seen in table no. 4. The second assumption
made was if there is no soap in the toilet there is a probability that after using the toilet
students which do not wash their hands can get sick which will cause absenteeism
decreasing their school performance.
Chi-squared test was applied on two variables as described in Figure 13. After the test
was conducted a value of .000 came which shows that there is significant relationship
between soap and sick leaves or in other words these two variables are dependent on
each other. The null hypothesis stating that there is no relationship between soap and
sick leaves is hence rejected in favor of the alternative hypothesis. Following table
shows the cross tabulation between two variables and the Pearson’s chi-squared test
results.
52
How many sick leaves a student do in a month? * Is
their soap present in toilet? Cross tabulation
Is their soap present in toilet?
Always sometimes Never
How many sick leaves
a student do in a
month?
More than 2 days
Count 2 6 45
Expected Count 5.8 14.1 26.0
More than 4 days
Count 19 45 49
Expected Count 15.2 36.9 68.0
Total
Count 21 51 94
Expected Count 21.0 51.0 94.0
How many sick leaves a student do in a month? * Is their soap present in toilet?
Cross tabulation
Is their soap present
in toilet?
Total
I don’t know
How many sick leaves a
student do in a month?
More than 2 days
Count 5 58
Expected Count 12.2 58.0
More than 4 days
Count 39 152
Expected Count 31.8 152.0
Total
Count 44 210
Expected Count 44.0 210.0
53
Chi-Square Tests
Value df Asymp. Sig. (2-sided)
Pearson Chi-Square 34.956a 3 .000
Likelihood Ratio 36.062 3 .000
Linear-by-Linear
Association 2.163 1 .141
N of Valid Cases 210
Attendance registers were utilized to see how many sick leaves those 10 students/26
schools do in a month. The schools were yet again divided among Gov. School, Lahore
and WASH schools in Islamabad to evaluate the percentage of presence in school. An
average of 82.1% came out for girls having approximately 4.6 days sick leave from
school every month whereas 85% attendance was noted for boys every month with 3.7
days average of sick leave in Gov. Secondary schools in Lahore. In WASH schools,
Islamabad 1.5 days sick leaves/month was noted for boys with 94.3% of attendance
while 92.8% attendance of girls by having 1.9 sick leaves/month. Taking into
consideration the first assumption we can evaluate that the children studying in the
WASH schools have better sanitation facilities which makes them take less sick leaves
or in other words their absenteeism from school is less than the students who are
studying in Gov. Secondary Schools in Lahore. Moreover, as mentioned earlier 86%
students said that they have no soap in the school toilets which can be related with the
second assumption of children getting sick and taking more sick leaves in Lahore
schools than the students in WASH schools though it is true that children might be
getting sick because of other reasons which can be further related to their household
sanitation and socio economic statuses but observing the school toilet conditions there
is a probability of students getting sick due to the poor sanitation conditions prevailing
inside the schools in Lahore. This argument can also be supported by a study done by
54
another author who reports that 40% of children getting diarrhea is caused by school
transmission rather than home transmission (Snel, Shordt, and Mooijman 2007).
Gov. Sec School, Lahore
Boys Girls
3.7 4.6 Average sick leaves/month
22.3 21.4 No. of days present in a month
85.7 82.1 Percentage/month
Acquiring Sick leaves
More than 4 or 2
Decreased performance (Less than 87%/month)
Applying Chi-Squared
test Presence of Relationship
Dirty hands causing
sickness
No Soap in toilet Assumption 2
Assumption 1
Null Hypothesis: There is no relationship between absence of soap and sick leaves
Figure 29: Overview of assessment of decreased student performance based on assumptions
55
Figure 30: Detection of E. coli in drinking water of Schools
E. coli detection was done with the help of membrane filter method and the results
came out can be seen in the above Figure. Since payment was required for testing the
water samples from a certified lab 22 schools were selected randomly out of 26. Water
samples were taken from 17 Gov. secondary schools of Lahore and 05 WASH schools,
Islamabad and the results came out were compared with the WHO guidelines as well as
Pakistan’s National Environmental Quality Standards (NEQS) which states that there
should be none or zero (0) E. coli in 100 ml water (Ministry of Environment,
Government of Pakistan 2010). As shown in the Figure above 12 Gov. Secondary School
from Lahore had E. coli in their drinking water whereas only 5 had none while in WASH
school, Islamabad out of 5 schools 1 was detected with E. coli in drinking water.
Water was collected from 04 different water sources present in schools. Following
diagram depicts the schools visited in total accounts for 46% of school having Gov.
Water and Sanitation Agency (WASA) pipelines whereas 27% schools having their own
private filtration plants. 05 WASH schools in Islamabad had their own filtration plants
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0
9.5
7.8
1010.3
9.49.7
10
0
7.8
0
1110.6
11
4.5
0 0
11
0 0 0
0
2
4
6
8
10
12
0 5 10 15 20 25
Presence of E. coli in water available in schools
Standard
E.coli
56
whereas some of the schools in Lahore were seen using hand pumps and drinking
ground water. As discussed earlier diarrhea is one of the main disease caused by E. coli
in water which can lead to absenteeism among children from schools (Ashbolt 2004;
Halcrow et al. 2010). As a result of this we can conclude that the presence of E. coli in
water can be seen as yet another cause of absenteeism from school especially for
students belonging from Secondary Schools in Lahore.
Figure 31: Drinking Water sources present in Schools
27
12
46
15
Water sources from Gov. Sec School, Lahore and WASH schools, Islamabad
Filtration Plant
Tube well
WASA pipeline
Hand pump
57
Figure 32: Drinking water places situated inside schools
3. Are teachers and students aware of the effects caused by poor sanitation?
The last part of the current study was to assess the level of awareness not only of
students who were interviewed but the teachers since education plays an important
role in the sanitation and building up hygiene behavior amongst students. The
awareness was assessed by the questionnaires developed for student and teachers of
both the schools. The scale of analysis or the index formed was based on three options
i.e. yes, no and I don’t know. The Figure below shows a comparison amongst
58
Government secondary schools of Lahore and WASH Secondary schools in Islamabad
of awareness questions regarding sanitation. The set of questions were divided into
two parts where the first part was related to only school sanitation facilities whereas
the second part of the questions was about sanitation education.
Figure 33: Comparison of awareness regarding school sanitation in Schools
When students were addressed with the question regarding sickness to assess if they
know that they can get sick because of dirty toilet? 70% of the students said yes
whereas 20% stated that they don’t know in Lahore schools. Among 50 Students
belonging from WASH schools 66% yes whereas 34% said I don’t know. Further when
students were asked if they can name the disease which one can get because of dirty
toilet or water? The answers were contradictory to the previous question as 69% of the
student from Gov. Secondary schools in Lahore said that they don’t know whereas 82%
of students from WASH schools answered appropriate diseases.
0
20
40
60
80
100
120
Gov. Sec WASHschool
Gov. Sec WASHschool
Gov. Sec WASHschool
Gov. Sec WASHschool
Gov. Sec WASHschool
Do you think thereshould be a toiletin your school?
Do u think that thetoilets in school
are enough?
Do you think thatthe conditions
inside toilet areclean?
Do you know thatyou can get sickbecause of dirty
toilet?
Can you name thedisease you canget because ofdirty toilet or
water?
School Sanitation Awareness among Gov & WASH Schools
yes
no
I don’t know
59
Figure 34: Comparison of awareness regarding sanitation education in Schools
In second part of the questionnaire students were asked about sanitation education to
see if they ever had this subject studied in school and if they have any know-how on
WASH (Water and sanitation hygiene). 75% of the students from schools in Lahore said
that they never studied sanitation as a subject in school where as approximately 76%
students from Islamabad agreed that they study about WASH in their schools. None of
the students at Gov. Secondary School, Lahore knew about WASH schools and 65% said
that they never had workshops regarding sanitation in school. 35% students agree that
private companies like “safeguard” arranged some workshops/events regarding
sanitation whereas above 95% students at WASH school agree that there are
workshops as well as events held for sanitation awareness and education such as World
Toilet Day, World Water Day etc. Apart from this WASH schools had environmental
clubs for sanitation inside their schools where children or students were awarded
when they keep their classes clean and monitor other students who doesn’t wash their
hands after using toilets.
0
20
40
60
80
100
120
Gov. Sec WASHschool
Gov. Sec WASHschool
Gov. Sec WASHschool
Gov. Sec WASHschool
Gov. Sec WASHschool
Did your teacherever told you
aboutcleanliness?
Does you schoolcurriculum haveenvironmentalsanitation as a
subject?
Did your schoolever had anyworkshops
regarding cleansanitation?
IEC Material?
Do you knowabout WASH
schools?
Do you want yourschool toilets to
be clean andhealthy for use?
Awareness about Sanitation Education among Gov. and WASH Schools
Yes
No
I don’t know
60
Figure 35: Comparison of awareness regarding sanitation policy among School Teachers
Similar questions as students were also addressed to teachers apart from one section
where teachers were asked about the sanitation policy of Pakistan. The purpose of the
questions was to assess if they know their rights towards sustainable sanitation system
inside the schools or not. As per the sanitation policy of Pakistan 2006 the ulemas
(religious scholars) will be involved in advocacy for raising the awareness regarding
sanitation along with an initiation of programme where training regarding sanitation
will be a part of the school curriculum as for the capacity building of students and
teachers while regular monitoring and implementation would be done by the staff of
Tehsil Municipal Administration (TMA) at Union Council (UC) level in schools to see if
the sanitation system is in place (Ministry of Environment, Government of Pakistan
2006). When teachers from both the schools (42 teachers from Gov. School, Lahore and
10 teachers from WASH School, Islamabad) were asked if they know about the
0
20
40
60
80
100
120
Gov.Sec
WASHschool
Gov.Sec
WASHschool
Gov.Sec
WASHschool
Gov.Sec
WASHschool
Gov.Sec
WASHschool
Gov.Sec
WASHschool
Do you knowabout
sanitationpolicy of
pakistan?
Do you knowwho is
responsible forsanitation in
schools at locallevel?
Is there anymonitoring
mechanism forsanitation inyour school?
Does the localTMAs monitor
the school?
Does youschool
curriculumhave
environmentalsanitation as a
subject?
Did yourschool ever
had anyworkshopsregarding
cleansanitation?
IEC Material?
Awareness about Sanitation Policy among Teachers
Yes
No
I don’t know
61
sanitation policy of Pakistan 95% teachers from Lahore Schools and 60% from WASH
schools said they don’t know.
Furthermore, when they were asked if someone came from TMA staff to monitor the
school sanitation system 98% teachers from Gov. School Lahore and 100% teachers
from WASH school said that no one ever came to the school however 90% teachers in
WASH school said that they have their own monitoring system in place with
organization such as UN Habitat, UNICEF or local NGOs who comes in for monitoring
purposes while only 26% teachers in Lahore school agreed that they have their own
monitoring mechanism for school sanitation. All the teachers apart from one school
said that they never had workshop regarding sanitation in their school while WASH
school teachers showed pictures of events and workshops held at their school
regarding sanitation.
Hence with the awareness situation evaluated it can be comprehended that even if the
school teachers knew that who is in-charge of monitoring and implementation the
system is weak at institutional or governmental level. The implementation of sanitation
policy is not being practiced and those schools that have monitoring mechanism in
place or have proper facilities are mostly those who have an agreement with
international or local organizations (NGOs such as PIEDAR) that comes in and give
some funds to the school administration so that they can cover the sanitation
expenditure. Although taking into consideration the point mention above regarding
maintenance of already existing sanitation facilities we can say that the situation can
be a bit better if the Government schools at least try to facilitate the students by
improving the current WASH structure inside schools. The current sanitation policy is
addressed at national level which makes the scope much broader and can be considered
as one of the reasons for not being implemented properly at provincial level.
62
4. Study limitations and Observations
Following are some of the limitations and observations confronted during the whole
study process and which if overcome could have contributed to make the study more
precise.
i. The study sample for Gov. Secondary WASH schools was less due to time constraint
but for future study more WASH schools can be used for analyzing in depth
comparison of sanitation facilities.
ii. Attendance registers were examined for three months which demonstrates that the
results gained from the study are more hypotheses generated rather than
confirmatory.
iii. Participation of teachers and school administration was sometimes a little
problematic since the teachers were hesitant in answering some questions, taking
pictures of school toilet facilities or allowing taking water sample for testing as they
were doubtful that the data might be used for other purposes than research.
iv. While filling in the questionnaires it was observed that some students were
influenced by each other’s answers which might have made the data a bit more
biased in terms of not answering what they felt but rather what was being answered
more often by their fellow class mates.
v. Apart from deriving variables and developing quantitative research a future study
can be established by doing qualitative analysis and studying how student’s
behavior influence WASH activities in Gov. Schools Lahore.
vi. Interview with teachers and international organizations such a UN habitat and
UNICEF officials were helpful in providing data and discussing the motivations and
views about WASH schools however none of the Governmental official agreed on
having dialogue regarding sanitation system in school which could have made it
easier to identify the loopholes.
vii. Although no. of organizations seems to be involved in Sanitation less efforts have
been done in regards to school sanitation. It also relates to the data where some
organizations have mentioned WASH systems being applied in Lahore schools but
none of the school was found with any such evidence.
63
Chapter 5: Discussion, Conclusion & Recommendations
Poor Water and Sanitation Hygiene (WASH) conditions not only have harmful effects
on the infants but also have a major impact on the health, overall attendance and
knowledge gaining capacities of school going children (UNICEF 2006). Similar is the
case in Pakistan where although the country is on track of achieving the MDG of
ensuring safe water quality and better sanitation facilities it still needs to ensure proper
monitoring mechanisms for systems already in place (UNICEF 2006; Ministry of
Planning, Development and Reform 2013). The current study aimed to understand the
impact of poor WASH facilities on children studying in government middle schools
along with an over view of the existing sanitation structure already in place. Based on
the literature review and results of the current study it can be comprehended that
existing Water and Sanitation Hygiene conditions studied and later compared in two
types of secondary/middle government schools in Lahore and Islamabad, Pakistan had
a difference in terms of sanitation facilities and infrastructure as well as students with
their hygienic conditions and level of sanitation education.
a) Water and Sanitation Hygiene (WASH) conditions inside Schools
The first objective was to assess the gaps in existing sanitation systems in the schools
studied and to compare and highlight the impact of those sanitation conditions on
children. Comparisons were developed to see if the no. of facilities were in accordance
to the WHO guidelines along with the required fulfillment of the students. As per the
results the conditions seen inside the Government secondary school in Lahore were
worse as compared to the WASH schools in Islamabad. Apart from the cleanliness and
standard requirement conditions it was also observed that the facilities already in place
such as latrines and places for drinking water were not maintained in Lahore Schools.
In most of the WASH schools janitors were present outside the latrines/toilets whereas,
most of the schools in Lahore, the janitors were either performing other duties or were
not available especially after the recess hour.
Though most of the schools had wash basins facility inside the toilet for washing hands
but none of the schools in Lahore had soap which can been assumed as the inadequacy
64
of practice of hand washing after using toilet amongst students. Apart from the absence
of soap water availability was another problem faced by students where the students
avoided using the facilities because first, less no. of toilets caused more usage of the
facility resulting in dirty conditions and second absence of water in the water tanker or
no water coming in directly from the WASA (Governmental Water and Sanitation
Agency) pipe lines. The findings mentioned above regarding the cleanliness conditions
inside the school toilets in Lahore can therefore suggest that students might be at a high
exposure to contamination as mentioned by some other authors as well that physical
environment can effect children’s health if conditions inside the toilets/ latrines are not
properly maintained (Annemarieke Mooijman. 2009).
In comparison to the toilet systems installed the results depict that the out of 21
Governmental secondary schools in Lahore 14 didn’t have improved facilities while 01
schools didn’t have facility at all whereas, all 05 WASH schools, Islamabad had
improved facility for students. This can also lead up to the conclusion that having an
improved toilet or latrine facility can cause less fecal contamination than those which
are not improved (World Health Organization and WHO/UNICEF Joint Monitoring
Programme for Water Supply and Sanitation 2006). However, we can also say that it is
a matter of financial and institutional backups as well since Gov. nominated WASH
Schools visited in Islamabad had international organizations such as UNICEF, UN
Habitat or several NGOs associated with them which also keeps a check on the facilities
along with providing funds to the school whereas in contrast to Gov. Lahore schools
didn’t have any such organizations associated with them resulting in no monitoring, no
funds and maintenance. Specific reasons given by some of the administrative personnel
of not having soap in toilets were that most of the time children steal it and take it home
or they throw the soap inside the toilets.
Furthermore, students didn’t have much opinion about the toilet facilities whether they
are improved or not which can be related to their socio economic lower class
background. Their socio economic background status can also relate to other points in
which their answers contradict to the personal observations such as when they were
65
asked about feaces and if the facilities are smelly or not since some of the students
belong from community where there was shared facilities between neighbors.
The schools in Lahore were way below the standards of required toilet (UNICEF 2012)
especially for girls as compared to the WASH schools in Islamabad. Yet again the point
of argumentation can be developed by mentioning that even though the requirement of
sanitation facilities in WASH Governmental School was also not sufficient for girls but
the overall hygienic conditions inside the school toilets were well maintained i.e., toilets
had soaps for washing hands, the floor was clean and the installed latrine facilities were
functional as shown in the Figure 36 below which can further validate the point of
students having an access to proper facilities even though they are less in no. as per the
standards.
Figure 36: Gov. WASH School having soap for washing hands
b) Occurrence of Absenteeism and Diarrhea
The study conducted evaluates a relationship between sanitation and student
absenteeism which was implied with the perception of performance. It is an obvious
fact that when a student happens to be absent from the school the performance in terms
of education decreases. The focus of the study was based on the fact of absenteeism
done due to incidence reported as sick leaves taken by the reason of diarrhea for the
66
month of January, February and March 2014. Taking the presence or absence of soap
in toilet as one variable and sick leaves as the other statistical analysis was done and
the results found were having a significant relationship (.000) between the variables
which meant that the absence of soap does have an impact on the students being absent
from the school. As a result of the significance it can be demonstrated that the hand
washing after using toilet facilities can prevent from diarrhea as stated by some other
studies as well reporting that 40% of children getting diarrhea is caused by school
transmission rather than home transmission (Snel, Shordt, and Mooijman 2007).
Although the fact that diarrhea could have been caused by home sanitation conditions
cannot be ignored but in order to support this fact that the sanitation conditions inside
the schools were also not up to the mark, water testing was also done in which E. coli
was detected and the results came out positive for 12 Gov. school of Lahore from 17 in
total whereas 01 WASH school also had E. coli out of 05 schools tested. The findings
based on absence of soap and E. coli detection in drinking water supports the
assumptions of students being at a high risk of diarrheal contamination and the leakage
of fecal matter in pipes supplying drinking water.
As mentioned above there were several drinking sources for water such as hand pumps,
filtration plant, tube well and WASA pipelines witnessed during the field survey. When
asked from the school administration about cleanliness or how often they change the
filters attached with water coolers the answers were mostly vague and were related to
not having many funds to change the filters or clean the water tanks present inside the
school whereas the WASH schools reported that filters are changed after every 4
months provided by UN Habitat and are checked on monthly basis. The conditions of
the filters attach with the water coolers can be seen in the Figure below as well. Analysis
of the absenteeism rate in relation to the detection of E. coli also provides a possible
elucidation of a student performance being better in WASH schools than the Gov.
Secondary Schools in Lahore. A possible explanation can be deduced that better water
quality in Gov. Secondary WASH schools and presence of Soap makes the absenteeism
rate much less than in the Gov. Secondary Schools in Lahore.
67
Figure 37: Filters attach with drinking water coolers
c) Sanitation Education and Awareness
One of the aims of the study was to assess that how much teachers and students are
aware of the harmful effects of the Poor Water and Sanitation Hygiene (WASH)
practices in school. The following objective was carried out with the help of
questionnaire by evaluating the level of awareness amongst not only students but the
teachers as well. Figure 33 and 34 shows the answers given by students about
Sanitation facilities present in school and about sanitation related education. Those
participants who said that they knew about getting sick because of poor sanitation
conditions were asked if they could name any diseases caused by poor WASH practices.
As a result not many students were assessed to know about sanitation related diseases
in Gov. School in Lahore as compared to Gov. WASH schools in Islamabad. The results
can also be examined qualitatively by comparing the after usage of toilets by students
in both types of schools i.e. flushing the facility after use or not, closing the water taps
after utilizing water, washing hands after using the toilet etc.
68
Similarly regarding sanitation education and knowledge not many students were able
to answer appropriately than the children from WASH schools. The students studying
in WASH schools had documentary and visual evidence as pictures of sanitation clubs
and workshops organized in their school on world toilet day or global hand washing
day etc. whereas out of 21 schools only one or two schools agreed that private
organizations such as “safeguard” came to do some workshop once, other than this
none of the schools had conducted any sanitation workshops or teach sanitation as a
part of their school curriculum. Hence based on the above assessment it can be valued
that the children studying in WASH schools were more aware about environmental
sanitation rather than the students in Gov. School, Lahore. The assessment can be again
related with the overall institutional arrangement since WASH schools are in affiliation
with the international organization who conduct these activities and event for raising
awareness whereas at the governmental level none of the actors are involved or taking
any necessary course of action for participating or organizing such workshops. Another
observation concerning the fact that the children studying at WASH schools are more
acquainted with sanitation knowledge can also be related to the dissemination of
information amongst students with the help of leaflets, brochures, posters on the wall
emphasizing Water and Sanitation Hygiene at school whereas others schools were
lacking in IEC material for school children.
Policy makers, politicians and the local community plays an important role in
promoting the WASH related programmes in schools (A. Mooijman et al. 2010). A part
of the awareness section was also related to the policy oriented questions where
teachers were addressed with the questions of sanitation policy of Pakistan and the
results seems to show that the teachers at both schools didn’t know much about the
sanitation policy of Pakistan. When they were addressed with the question of
monitoring the teachers belonging from both school denied that no one ever came from
the governmental organization to check the sanitation system in school however the
teachers from WASH school mentioned that they have their own monitoring
mechanism established with the organizations which provides them funds. The
workshops and awareness events held at the WASH schools were mostly organized by
the organization as well and there was no role played by the government itself. During
69
the field survey some of the teachers also provided the information that there are some
governmental officials coming to perform monitoring checkups for dengue virus which
shows that there are teams established for monitoring purposes but none is
operationalize for sanitation. Though the national sanitation policy does address
monitoring and make officials at district level such as TMAs to be responsible for the
regular inspections (Ministry of Environment, Government of Pakistan 2006; Ministry
of Environment, Government of Pakistan 2010) .
Since the answers towards policy oriented questions showed that teachers didn’t have
much knowledge and on addressing them with these questions most of them were of
the view that the sanitation policy is considered a well written piece of paper which
doesn’t fulfill the requirement of the school or pupils hence a possible explanation can
be derived based on the overall study process that the current sanitation policy is
addressed at national level which is considered a problem as agreed by some other
authors that the policy doesn’t identify or discuss in depth the quantity or the quality
of the sanitation facilities resulting in no awareness amongst the citizens along with the
scope where it should have been addressed at provincial level so that the execution can
be carried out more effectively at community level (Umbach and Bergstrøm 2009;
Shayamal et al. 2008; Dreibelbis et al. 2013).
d) Conclusion
Human health specifically in developing countries are facing a key obstacle of which a
large factor is related to unsafe drinking water and unimproved sanitation structure
70
affecting the health (Ashbolt 2004). Apart from the study limitations discussed above
it is evident from the study conducted that schools play an important role towards
shaping a child’s knowledge in terms of Water and Sanitation Hygiene (WASH).
However, the results showed that the physical environment the children are studying
in also matters (Annemarieke Mooijman. 2009) for which the exiting situation needs
to be improved. The drinking water assessment revealed that most of the schools had
E. Coli in them which can be one of the main cause of diarrhea affecting students’
performance. Fecal contamination can be caused by the sanitation conditions inside the
Government Secondary Schools, Lahore where most the toilets were not equipped with
proper facilities such as wash basins or soap for hand washing.
The Government Secondary WASH Schools, Islamabad can be taken as a practical
example by the Schools in Lahore. It cannot be ignored that the Government schools in
Lahore has less budget than the private schools or schools having international
association and due to this fact the conditions in government schools in Pakistan is
mostly not very appreciable but collaboration efforts can be done with organizations
which can help the teachers and students to arrange funds and awareness events. Lack
of interest by the school administration or teachers is mainly because of the financial
barriers due to which the sanitation conditions inside the schools are not maintained
for which it is important to involve the local citizens or NGOs to help them recognize
issues and assist in solving them (Samwel and Gabizon 2009). Hence, Gov. Secondary
schools in Lahore instead of dedicating their efforts towards increasing the student
capacity in schools should also consider maintaining and improving the WASH
conditions by introducing School Sanitation and Hygiene Education (SSHE)
programmes or adopting School Led Total Sanitation (SLTS) approaches.
Government on the other hand is required to take urgent actions towards sanitation
inside school and ask the officials stated by the national policy to perform their
responsibilities. Till July, 2014 there isn’t any provincial sanitation policy and the
current national sanitation policy 2006 does not addresses school sanitation in depth.
Political will along with all the actors and stakeholders are required to participate
together to solve this problem.
71
As concluding remark based on the study conducted above water and sanitation
hygiene (WASH) cannot be considered as a general topic at the end of the day or it
should not be associated with water and health issues only, it is about living with
dignity and social equity for a better development for which more research is needed
to develop achievable targets and coherent policies so that facilitation can be provided
in Government Schools for children to have a better future.
e) Recommendations
i. There is an urgent need to strengthen educational institutions programme
related to health in accordance to water and sanitation hygiene.
ii. Before approving any upgrading of existing school infrastructure, Latrine/ toilet
facilities should be considered as the basic component along with ensuring that
there is a sufficient no. for students and teachers keeping in mind the privacy
needs for females.
iii. WASH should be included as one of compulsory subject in school curriculum
along with giving an experience of theory and practice for having a better
understanding.
iv. A strong monitoring mechanism should be developed to keep a check on the
sanitation conditions inside the school along with water quality assurance by
the school administration.
v. Government responsible authorities should provide necessary support, funds
and knowledge to sustain healthy WASH practices in schools along with helping
the school administration for overcoming obstacles.
vi. Advocacy towards enforcement of the current national sanitation policy along
with development of an effective provincial sanitation policy addressing in
depth school sanitation.
vii. A linkage between government schools and WASH promoting organizations
should be established resulting in capacity building and training camps for
teachers.
72
viii. Workshops and events should be organized in schools by involving not only
students but parents as well so that a message could be steered from children
all way downstream to the households/ community.
ix. Small incentive given by teachers to children in terms of providing them
opportunity for example, acting like a leader for one week would motivate them
to change their behavior and follow WASH practices.
x. The school authorities should in any case maintain the existing facilities such as
nonfunctional latrines and wash basins by ensuring cleanliness inside latrines
and access to safe drinking water.
73
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Annexures I
Scanned Images of Questionnaire for Children, Teachers and Own Observations
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Annexure II
Questionnaires translated into Urdu
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Annexure III
Pictures of Government Secondary WASH Schools, Islamabad
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Annexure IV
Pictures of Government Secondary Schools, Lahore
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Annexure V
Scanned Image of E. coli test in Drinking Water
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Annexure VI
Chi Squared Test Results
CROSSTABS
/TABLES=Absentism_students BY Soap
/FORMAT=AVALUE TABLES
/STATISTICS=CHISQ
/CELLS=COUNT EXPECTED
/COUNT ROUND CELL.
Crosstabs
Notes
Output Created
Comments
Input
Data C:\Users\Nisa\Dropbox\thesi
s\student performance.sav
Active Dataset DataSet1
Filter <none>
Weight <none>
Split File <none>
N of Rows in Working Data
File 220
Missing Value Handling
Definition of Missing User-defined missing values
are treated as missing.
Cases Used
Statistics for each table are
based on all the cases with
valid data in the specified
range(s) for all variables in
each table.
101
Syntax
CROSSTABS
/TABLES=Absentism_studen
ts BY Soap
/FORMAT=AVALUE
TABLES
/STATISTICS=CHISQ
/CELLS=COUNT
EXPECTED
/COUNT ROUND CELL.
Resources
Processor Time 00:00:00.02
Elapsed Time 00:00:00.03
Dimensions Requested 2
Cells Available 174762
Case Processing Summary
Cases
Valid Missing Total
N Percent N Percent N Percent
How many sick leaves a
student do in a month? * Is
their soap present in toilet?
220 100.0% 0 0.0% 220 100.0%
How many sick leaves a student do in a month? * Is their soap present in toilet? Crosstabulation
Is their soap present in toilet?
Always sometimes Never
How many sick leaves a
student do in a month? No holiday
Count 0 0 20
Expected Count 2.1 5.1 10.4
102
More than 2 days
Count 21 51 9
Expected Count 11.7 28.5 58.1
More than 4 days
Count 0 0 75
Expected Count 7.2 17.4 35.5
Total
Count 21 51 104
Expected Count 21.0 51.0 104.0
How many sick leaves a student do in a month? * Is their soap present in toilet? Crosstabulation
Is their soap
present in
toilet?
Total
I dont know
How many sick leaves a student
do in a month?
No holiday
Count 2 22
Expected Count 4.4 22.0
More than 2 days
Count 42 123
Expected Count 24.6 123.0
More than 4 days
Count 0 75
Expected Count 15.0 75.0
Total
Count 44 220
Expected Count 44.0 220.0
Chi-Square Tests
Value df Asymp. Sig. (2-
sided)
Pearson Chi-Square 179.905a 6 .000
103
Likelihood Ratio 230.467 6 .000
Linear-by-Linear Association 1.487 1 .223
N of Valid Cases 220
a. 2 cells (16.7%) have expected count less than 5. The minimum
expected count is 2.10.