Abstract
This study aims to determine the extent to which water, sanitation and hygiene (WASH) coverage is established in rural schools, and the barriers to accessing WASH services in the Dehiovita educational zone of the Kegalle District in Sri Lanka. Random sampling was used to collect data from 500 students in grades 7–13 from 15 schools using a semi-structured questionnaire. The analysis shows that 43% of children use unsafe plastic bottles, 62% reported broken taps as a major barrier to safe access to water, and 54% reported receiving inadequately treated water. The majority of respondents (88%) mentioned that they do not use soap after using the toilet. In terms of menstrual hygiene management, 26% of female students do not use the sanitation facilities due to issues such as poor quality or safety concerns in the sanitary services provided, and this may prevent the achievement of gender justice in WASH coverage. These findings highlight the urgent need to raise awareness in schools about safe water consumption, sanitation, hygiene practices and spread of water-borne diseases.
Keywords
Introduction
The present study aims to investigate how schoolchildren in mostly disadvantaged communities in Sri Lanka perceive their access to safe drinking water, sanitation and hygiene (WASH) services. In terms of sustainable community development, access to clean water and sanitation is at the heart of overall health outcomes that pave the way for their capacity development. However, many developing countries face challenges in ensuring access to clean water and sanitation. Women and children bear the greatest burden of these challenges. Therefore, we strive to understand the extent to which schoolchildren in underprivileged rural communities in Sri Lanka have access to WASH services and appropriate menstrual hygiene management (MHM) at the community level. Even though there are several largely marginalised and disadvantaged communities, such as the plantation sector, indigenous communities and war-affected areas, the focus of the present study is on rural communities. Despite receiving little attention, these communities accommodate over 80% of the country’s schoolchildren (Little et al., 2011). The public education system in the country is strong and based on welfare principles, so that all children in the country receive free education, yet there are severe disparities between rural and urban communities. Little et al. (2011) show that rural schoolchildren are often underprivileged and less resourced. As a result, despite the capacity of schools to promote child health and effective development, barriers can exist that hinder the promotion of WASH coverage and menstrual hygiene, particularly among girls. This, in turn, can prevent them from accessing proper healthcare and achieving effective age-relevant development (Udayanga, 2023; Udayanga et al., 2024). In order to inform policies for the implementation of WASH and proper MHM, we provide support by indicating the extent to which WASH and MHM have been implemented, how effectively they benefit rural schoolchildren and challenges associated at the community level, with a particular focus on girls.
Goal 6 of the 2030 Agenda for Sustainable Development aims to ensure that WASH coverage is available and managed sustainably. It also targets universal access to safe drinking water, sanitation and hygiene (Deacon, 2016; United Nations [UN], 2015). Improving access to safe drinking water has significant health benefits, particularly for children and women. Research indicates that women and children in developing countries lag behind their peers in affluent countries in terms of access to safe drinking water (Tomberge et al., 2021; Udayanga, 2023). Moreover, women and girls in disadvantaged communities are more likely to be vulnerable to severe health hazards compared to those in more affluent or resourced communities, such as urban areas, as often evidenced in Sri Lanka (Lakshman, 2023; Udayanga et al., 2024). The disparities in resource distribution and the lack of readiness for healthy practices at the rural level can hinder children’s effective development and jeopardise other positive outcomes, such as readiness to study (Herath, 2022).
Furthermore, some studies show that the growth and development of children, especially girls, can be more effectively fostered in school environments in developing countries rather than their homes, owing to resource limitations and harmful traditional practices in houses (Perera et al., 2018; Reynolds, 2022). Globally, studies show that schools in the most vulnerable regions continue to face challenges related to insufficient WASH facilities (WHO, 2023), and that leads to a set of health and sociocultural problems (Tesha et al., 2023). Nonetheless, UNICEF has identified that ensuring WASH coverage in rural schools can be instrumental in ensuring the optimum development of children and ultimately the gender justice (UNICEF, 2020; UNICEF/WHO, 2019). While there is no universal consensus on how to ensure safe drinking water, each country has established specific guidelines to address its unique requirements, and it is agreed that safe water standards should be aligned with country-specific standards for chemical, biological/microbial and physical quality (including radiological and acceptability aspects) (Reddy et al., 2017).
Different countries have established specific guidelines to ensure safe drinking water based on their unique needs. For example, Sri Lanka has undertaken initiatives to improve water quality through community-based water supply projects, particularly in rural areas, to ensure safe drinking water for its population (Balasooriya et al., 2022). On the other hand, a study proposed a system that uses machine learning (ML) to provide clean drinking water for schoolchildren, demonstrating how technology can address water quality challenges in specific settings like schools (Feng et al., 2024). Additionally, reviews on the use of ML in assessing and ensuring water quality in engineered water systems highlight the potential of ML to monitor, simulate, predict and control drinking water quality, showcasing a modern approach to water quality management (Feng et al., 2024).
All things considered, in order to ensure the overall health of people, sanitation and hygiene are considered essential requirements, especially for vulnerable communities that often lack access to WASH coverage (Drechsel et al., 2022). It is estimated that approximately 32% of the world’s population (2.4 billion people) is at risk due to unsafe water and inadequate sanitation and hygiene facilities, leading to the spread of various diseases (Pawar, 2013; WHO, 2023). Recognising this global significance of WASH, numerous international policy forums have taken action and implemented various programmes (UNICEF/WHO, 2019). Moreover, in 2010, the UN declared (Resolution A/RES/64/292) sanitation and access to safe drinking water as fundamental human rights crucial for both health and overall quality of life (Water Supply and Sanitation Collaborative Council, 2010). Furthermore, UNICEF has enacted strategies to ensure safe and equitable access to WASH facilities for children in schools, early childhood development centres and health centres from 2016 to 2030 (UNICEF, 2020; WHO/UNICEF, 2015). All these global interventions highlight the need for appropriate efforts to improve WASH coverage and MHM, specifically targeting the most marginalised communities, such as rural areas in Sri Lanka. They propose schools as central locations for promoting WASH and MHM, as children often spend extended periods in these systematically organised environments where they can be effectively monitored (Davis et al., 2024).
The basic requirements of sanitation involve access to safe methods of human waste disposal and the ability to maintain hygienic conditions through services such as wastewater treatment, garbage collection and overall waste management practices (UNICEF/WHO, 2019; World Health Organization [WHO], 2014). Limited access to safe water, inadequate sanitation facilities and poor hygiene practices are among the primary causes of illness in many developing countries (Montgomery & Elimelech, 2007). This primarily creates an unfavourable environment, especially for women and girls in disadvantaged communities. Rural areas of Sri Lanka also suffer from inadequate access to WASH coverage and, as a result, encounter several health hazards (Perera et al., 2018). This can be seen even in the estate sector, where many plantation labourers inhabit (Udayanga, 2024).
Continuous provision of and access to safe drinking water, the promotion of latrine-use ethics among staff and students, and regular handwashing are identified as effective approaches for improving hygiene and sanitation in schools. In terms of child rights, every child worldwide should have the opportunity to learn in a safe and healthy environment (Water Supply and Sanitation Collaborative Council, 2010). Since children represent the future of a nation, a healthier child population can significantly contribute to a country’s development. This shows the importance of individual responsibility, from the national level down to the school level, to ensure the availability of safe drinking water and sanitation facilities (Girmay et al., 2023). However, the lack of access to safe water and sanitation in schools can lead to the spread of water- and sanitation-related diseases among students (Bishoge et al., 2023). This situation results in poor student health, reduced school attendance, lower learning outcomes, compromised privacy and dignity, challenges in achieving gender equity and increased poverty (Reddy et al., 2017). All these findings also highlight the importance of a bottom-up approach to implementing WASH facilities and effective MHM. This is where community-based approaches emerge as a viable strategy for school-centred WASH and MHM implementation (Davis et al., 2024; Pawar et al., 2023).
Girls and female school staff bear the greatest burden of inadequate and poor-quality WASH coverage in the Global South (Malik et al., 2023; Tesha et al., 2023). Females constitute the majority of users of WASH services and often serve as the primary water and sanitation workers on the ground worldwide (WHO, 2023). However, there is typically low participation at the decision-making level (Shalabi-Abbas et al., 2018). Concerning female students, the absence of adequate facilities for menstrual hygiene can result in these students missing school days and, in some cases, dropping out of education (Pawar et al., 2023; Shumie & Mengie, 2022; Sommer et al., 2016). For example, adolescent female students and teachers attending school during menstruation require appropriate toilets and water supplies for changing and disposing of sanitary pads and washing in private (Sivakami et al., 2019). A global trend in rural areas highlights that the lack of proper MHM negatively impacts female students’ school participation (Sivakami et al., 2019; Van Eijk et al., 2016). Therefore, the management of menstrual hygiene facilities and utilities is a critical factor for the well-being of female students and staff at the school level.
In Sri Lanka, nearly one million people do not have access to safe sanitation facilities, even though the island has general sanitation coverage that reaches almost 92% of the population (Asian Development Bank, 2015). Additionally, almost one million schoolchildren, or nearly 1,300 out of 9,500 primary and secondary schools, lack access to a sanitary method for waste disposal (Bandara, 2003; Ferronato & Torretta, 2019; Hettiarachchi & Kshourad, 2019). Sri Lanka is a lower- to middle-income country with a gross domestic product (GDP) of approximately $80 billion at current market prices. In terms of education, the Government of Sri Lanka (GoSL) allocated approximately 1.9% of the budget, while healthcare received around 3.76% of the budget in 2022 (World Bank, 2023). Due to the economic crisis in the country, these allocations were further reduced in 2023. However, Sri Lanka experiences a drinking water coverage of about 94% and a sanitation coverage of 92%, which is the highest in South Asia (WaterAid, 2019). However, there are still areas in need of improvement, including sanitation in rural schools, facilities for differently abled individuals and challenges related to groundwater contamination (Ahuma-smith & Bavuno, 2020; WHO, 2014). Despite significant progress in WASH and MHM coverage in Sri Lanka, the concurrent economic challenges have caused acute shortages of water-treatment and testing chemicals. This shortage has negatively impacted WASH coverage, particularly in schools (UN, 2023).
Theoretical Consideration
The Sustainable Development Agenda calls for global partnerships for clean water and sanitation, considering them essential human rights that can promote people’s optimal development (UN, 2017). WASH coverage and proper MHM are at the centre of this process, with children considered crucial for providing such services. Because children often stay in schools for considerable periods, schools are seen as centres for promoting healthy practices (World Bank, 2014). We employed this initial lens and strove to understand how schoolchildren perceive water consumption, sanitation and hygiene.
We used the WHO framework for WASH-related SDG monitoring to conceptualise WASH coverage in rural school environments (WHO, 2018). SDG 6 outlines several targets, including universal access to drinking water, sanitation and hygiene for all, improved water quality and efficient water use. These are the four targets we focused on. In line with WHO guidelines (2018), we also emphasised the participation of school communities in ensuring WASH and MHM facilities.
Focusing on these essential targets observed within schools, we incorporated a social sustainability framework embedded in the theory of change to accelerate sustainable WASH services (WASH Alliance, 2016). This approach highlighted the importance of awareness of hygiene behaviour, demand creation for WASH, and organising local people for WASH and MHM. Our study was limited to these areas and did not delve into the functioning of WASH markets and the public sector.
Objectives
Our intention is to deeply investigate the integration of WASH and MHM facilities into rural school systems in Sri Lanka, with a focus on understanding bottom-up approaches to ensuring sanitation and hygiene. However, we will demonstrate in the discussion that the situation is quite similar in other rural schools in Sri Lanka.
In light of the present situation, the current research was conducted with two main objectives:
To understand the issues with available WASH and MHM facilities in rural schools, and To explore perceptions regarding the improvement and promotion of attitudes and practices related to WASH and MHM facilities.
Research Method
The present study employed an embedded, multiple-unit case study design (Yin, 2003). From 15 schools, 500 children were selected within the selected rural context. An interviewer-guided, semi-structured questionnaire survey was conducted to collect data. Further details of the research method are as follows.
Study Area
The rural population in Sri Lanka comprises approximately 17.9 million people, accounting for over 80% of the total population in the country (Central Bank of Sri Lanka, 2023). Among this population, there are about 4.06 million schoolchildren (2.02 million males and 2.04 million females), residing in more than 25,000 rural households. Although there are several rural areas in the country, we selected Kegalle district as the study area for the research, as it is urbanised but still contains a large number of under-resourced rural schools (World Bank, 2014). Within the district, the Yatiyantota division was selected because a community-based WASH and MHM project needed to understand the existing situation in the area, and we were to provide them with insights. The land area of the Yatiyantota DSD covers 187 square kilometres, making it the fourth-largest in the Kegalle district, as depicted in Figure 1. In total, there are 531 schools in Kegalle, with the Dehiovita Zonal Education Area in the Yatiyantota DSD containing a total of 50 schools. For the present study, 15 schools were selected, all of which are situated in remote rural areas. Dehiovita area is one of the most economically challenging areas in the Kegalle district, and according to the key informant interviews (five interviews), there are many schools lacking infrastructure and human resources for proper maintenance of these rural schools.
The Location of the Study Area in Kegalle District.
Sampling and Population
Kegalle district recorded a total population of 163,686 schoolchildren and 11,729 teachers in 2022. This population of schoolchildren in the Kegalle District represents 23.5% of the total number of schoolchildren in Sri Lanka. Moreover, there was a 0.3% representation in the DSD study area compared to the total population of Sri Lankan schoolchildren (Department of Census and Statistics, 2017; Sabaragamuwa Provincial Council, 2018). In the DSD, there were 53,083 students, of whom 14,068 were in the Yatiyantota division, which included 40 schools and 952 teachers. Out of the total students, 7,076 were male and 6,992 were female (Ministry of Education, 2021). To accurately represent the student population of 14,068 in Yatiyantota, we decided to recruit a sample of 455 students with a 97% confidence level and a 5% margin of error. We decided to recruit 500 students, rounding this number to the nearest integer. We used a simple random sampling technique to select 500 male and female students in grades 7–13. This sample size ensured representation of at least 30% from one school (all data from the Annual School Census of Sri Lanka, 2021).
Data Collection
A brief information session was conducted before the study, and consent was obtained from the students and their parents to participate before providing them with the study questionnaire. The interviews with the students took place after their regular school hours in a convenient and safe place so that their privacy was ensured, ensuring that they did not disrupt their academic classes. Questionnaires were filled in the presence of their parents. This approach facilitated a smooth transition from classes to the survey study, enabling participants to respond freely to the questionnaire content within a short period of time. Each participant provided written responses to the survey questionnaire. All students who consented to participate were included in the study, with no exclusions. The survey focused on criteria such as accessibility and availability of WASH practices, MHM practices, and perceived suggestions for promoting and developing standard sanitation and hygiene practices among students in rural schools. When developing the questionnaire, some of the previous studies were considered. The patterns of water consumption practices were comprehended by considering factors such as the volume and material of the water bottles, the frequency of water consumption and the method of purification. The questions used to assess water consumption were based on previous research (Senterre et al., 2014). The determination of safe and unsafe plastic materials for water bottles was made using recycling codes (Song et al., 2021), while the selection of filtration methods was based on empirical evidence and existing literature on water purification (Popescu et al., 2017). The assessment of sanitation behaviour, MHM and awareness was conducted by examining the regular practices and behaviours of schoolchildren.
Analytical Strategy
The collected data were transferred into the IBM SPSS software package while quality control measures were being implemented. The tabulated data were re-checked with the original data to avoid discrepancies and errors, and they were corrected accordingly. The percentages of the respondents were illustrated graphically.
Ethical Considerations
The study subjects voluntarily participated in the study, and they were given a free chance to withdraw at any time. The confidentiality of the participants was ensured by the research team. We appropriated the Helsinki guidelines in ensuring the privacy of participants, and the initial proposal indicating ethical concerns was approved by the Research Ethics Committee at the Faculty of Humanities and Social Sciences, University of Ruhuna, Sri Lanka (REC/FHSS-R/2023/06).
Results
Demographic Information
The demographic observations, which include gender, grade and medium of study, are presented in Table 1. Of the 500 selected students, 53.6% were male and 46.4% were female.
Demographic Information of the Sampled Schoolchildren.
Patterns of Water Consumption in Rural Schools
The volume of the water bottle used serves as a standard indicator reflecting the water consumption habits of school students and their readiness to stay hydrated. The highest number of respondents, 47%, fell into the 500–700 mL group, while the lowest percentage was observed in the above-700 mL group. Notably, 27% of the children reported not using a water bottle at school. This means that nearly one-third of rural students do not use water bottles during school hours, which can hinder their access to adequate water and may lead them to rely on unsafe water sources. Moreover, the results indicate that a significant number of students prefer using water bottles brought from home, often filled with boiled and cooled water (Figure 2a). Even though this cannot be generalised to the whole country, oftentimes the studied population tend to show such patterns of water consumption.
We used four categories of materials (aluminium, unsafe plastics, glass and reusable plastics) to gather responses regarding the type of water bottles (Figure 2b). A significant percentage (43%) reported using unsafe plastics, while only 5% mentioned using glass water bottles. In total, 67% of the respondents use plastic containers. Consuming water from unsafe plastic bottles over time can lead to the accumulation of harmful substances in the body. This can potentially cause long-term health effects, particularly in children, whose bodies are still developing and are more vulnerable to toxins. This indicates a lack of awareness among children, their parents and teachers about the proper use of everyday water containers. It is essential to educate them on safe practices for using water bottles. We assessed the frequency of water bottle usage across four groups, ranging from once to more than three times per day (Figure 2c). Half of the students (50%) reported using water bottles twice a day, while 10% stated that they used them more than three times a day. A quarter of the students stated that they only used their water bottles once during the school day. Although schoolchildren generally believe they should drink enough water, our results show that they inadvertently fall short in their water consumption.
Among the four purification methods examined, chlorination was the most common, accounting for 45%, while 36% of the respondents reported not using any purification method. Boiling was mentioned by only 1%, traditional methods by 8% and filtering by 2% (Figure 2d). Overall, the results suggest that rural areas now have access to chlorinated tap water, and the use of boiled water as a purification method is declining. Even though the majority of families tend to use chlorinated water, a substantial number of families still tend to use water without purification, as indicated above, and this may lead to chronic health problems in children. This is another area where community-based approaches to safe drinking water can be promoted.
Water Consumption Among Students. (a) Volume of Water Bottles Used, (b) Type of Water Bottles Used, (c) Frequency of Using Water, and (d) Purification Method Used for Water Purification.
Issues Associated with Water Consumption
Even though there are several issues with WASH facilities on school premises (World Bank, 2021), our focus was primarily on facilitation of drinking water for schoolchildren and the methods of purification. Approximately 36% of the respondents reported not having guaranteed access to safe drinking water, while 64% indicated having access to an available water supply. Additionally, a significant number of respondents (62%) faced issues with broken taps, and 54% of children encountered problems related to inadequate water treatment. Furthermore, 10% of the children experienced problems with smelly water, and 36% of respondents reported insufficient tap availability for water consumption in schools (Figure 3). Among the respondents, only 22% expressed satisfaction with the water supply at their schools, indicating that a substantial proportion was dissatisfied with the provision of safe water in schools.
These results demonstrate that, despite several interventions aimed at ensuring access to safe drinking water in rural schools, students still believe that the provision of drinking water is unsatisfactory due to various issues they encounter, such as problems with broken taps and not having proper ways for water purification. Even when tap water is provided, it often remains unusable due to poor management, preventing easy and safe access to drinking water, particularly for those who did not bring a water bottle from home. This issue has become a serious concern in rural schools, even in other parts of Sri Lanka (Lakshman, 2023). Our findings indicate that inadequate management of WASH services in schools is the primary barrier to ensuring WASH coverage.
Issues Associated with Water Consumption Among Students.
Sanitation Practices
Proper sanitation practices are essential for children’s optimal health, along with water consumption. Since children spend a considerable amount of time in schools, facilities that ensure their sanitation and hygiene are paramount for their active participation in education (World Bank, 2014). We examined how schoolchildren perceived the provision of such sanitation facilities in rural schools. The use of latrines and the practice of using soap are closely linked, reflecting an inclination towards primary healthcare habits.
Students in the studied schools indicated that at least 32% use latrines once a day, while 48% of students use latrines more than twice daily. Generally, each student uses latrines at school at least once per day. However, only 12% of the children reported using soap after using the toilet, while the majority (88%) did not adopt the practice of using soap after toilet use (Figure 4). Washing hands with soap has not been a common practice in schools, primarily due to the unavailability of soap. Consequently, 88% of students do not demonstrate a preference for handwashing with soap.
Use of Soap After Latrine Use.
These findings mainly indicate that rural schools often fail to provide sanitary facilities adequately. A significant percentage of students (78%) expressed dissatisfaction with the sanitary facilities at their schools, while only 22% reported being satisfied with the overall sanitary conditions. Among the various problems related to sanitation, the unavailability of soap was the most prominent issue, affecting 92% of respondents. Poor quality of latrines was a concern for 73% of students, and 67% mentioned a lack of cleaning equipment. Insufficient water supply and other minor issues were the least commonly reported problems in schools. Figure 5 illustrates the frequencies of problems encountered with regard to sanitary facilities. In addition, respondents claimed that factors such as insecurity in using public latrines is a main other concern faced, especially by female users.
The poor quality of latrines can sometimes discourage students from using them when needed. Despite the lack of quality in latrines, a significant number of students continue to use them, as indicated earlier, which could potentially pose health risks.
Issues Associated with Sanitation Facilities.
Management of Menstrual Hygiene
MHM is particularly important for female students. Some studies suggest that in several developing countries, proper MHM facilities can promote girls’ education and improve both their educational outcomes and health (Khan, 2022; Pawar et al., 2023; Sommer et al., 2021). In promoting girls’ education and preventing early marriage and pregnancy, the role of proper MHM has been greatly appreciated (Khan, 2022). Therefore, we investigated the extent to which MHM facilities are provided for students in the schools included in this study. When considering the daily frequency of female students using latrines, it was found that 28% of students used them at least once, while 26% opted to avoid visiting the sanitation facilities (Figure 6a). Despite the necessity, some girls refuse to use latrines due to their poor quality. Figure 6(b) illustrates the major issues reported by female students when using the sanitation facilities. Among these issues, 91% of students reported a lack of napkin disposal facilities, while 84% mentioned the absence of a place to wash. Furthermore, female students also reported issues such as a lack of safe latrines (58%) and water problems (72%). Compared to male students, female students face several challenges related to sanitation facilities in schools. Having safe latrines is crucial, yet more than half of the female students feel that the latrines are unsafe.
Management of Menstrual Hygiene (MHM) Among Female Students. (a) Frequency of Female Students Using the Sanitation Facility at School and (b) Issues Associated with Menstrual Hygiene Management.
The gender gap in schooling has been well studied, particularly in developing countries where girls are disproportionately disadvantaged in terms of access to education (Jing et al., 2023; Perera & Edirisinghe, 2022). Our results show that access to education also depends on non-education-related facilities, such as WASH coverage, where girls can face discrimination. The results indicate that female students often use toilets only once per day or not at all. Several obstacles prevent female students from using latrines as needed. More than 50% of students report a lack of safety in latrines, insufficient washing facilities, inadequate waste disposal mechanisms and a shortage of water. Consistent with our findings, other studies also indicate that women are disproportionately disadvantaged in accessing such services, even in public places (Bellanthudawa et al., 2023). This calls for community-based approaches that can be established at the school level for ensuring proper MHM, in addition to the facilities provided by external organisations.
Awareness on Hygiene Practices and Suggestions
In the previous section, we examined the extent to which schoolchildren are exposed to the required levels of WASH coverage and MHM. In this section, we assess how aware these students are of hygiene practices, their suggestions for improving facilities and their concerns regarding establishing a conducive environment for sanitation and hygiene in schools. The percentages reflecting the frequency of selected hygiene practices and awareness (Figure 7a), as well as suggestions to improve water consumption, sanitation and hygiene practices (Figure 7b), are presented below. Commonly reported areas of ignorance concerning personal hygiene included daily bathing (48%), the risk of diseases due to unhygienic practices (46%), nail clipping (40%) and consuming a balanced diet (40%). Overall, children demonstrated awareness of the importance of washing their hands before meals (85%) and after using latrines (70%). As shown in Figure 7, most primary health and sanitation practices have garnered attention from students. However, some students lack awareness of certain critical sanitary practices. For instance, over 40% of students do not regularly clip their fingernails.
Among the suggestions offered to improve WASH practices, students express interest in gaining more knowledge about diseases associated with poor hygiene and acquiring additional information about hygiene, sanitation and water consumption patterns. Furthermore, 70% of the students are keen on strengthening the WASH clubs in their schools. Additionally, 57% have requested activities to promote attitude and behavioural change, while 65% have called for increased government funding to enhance the existing utilities and infrastructure. The overall data indicate that students in rural schools are eager to become more aware and learn standard sanitation and health practices that are essential for enhancing their well-being.
In terms of suggestions provided by students, the highest priority, indicated by over 70% of respondents, is awareness of diseases spreading due to unhygienic practices. The need for heightened awareness on hygiene, sanitation and water consumption patterns follows closely behind. Strengthening WASH clubs at the school level is also a significant concern, with around 60% of students emphasising its importance. Students also highlight, albeit to a lesser extent, the importance of protecting existing utilities and allocating more government funds for their development. These insights suggest that while there is a foundational understanding of hygiene, there are critical areas requiring further attention and resource allocation to create a more conducive environment for sanitation and hygiene in schools. School-based projects also have the potential to promote effective WASH coverage, as our findings indicate.
(a) Awareness of Healthy Habits, Personal Hygiene, and (b) Suggestions Chosen by Students to Improve Water Consumption, Sanitation and Hygiene Practices Among Students at the School Level.
Discussion
The implementation of measures to guarantee access to safe drinking water, quality sanitation and hygiene practices among students in educational institutions contributes to the improvement of their overall quality of life (Yusufu et al., 2023). Despite the implementation of national and international interventions aimed at enhancing WASH coverage in schools across developing countries like Sri Lanka, challenges in accessing safe drinking water and maintaining adequate sanitation and hygiene practices among students from low-income or underprivileged communities remain unaddressed. Therefore, we add to the body of knowledge by showing that, even though rural schools in Sri Lanka have some WASH coverage, under-management, a lack of readiness for healthy practices and a disregard for appropriate WASH methods may jeopardise the implementation of these facilities.
The study findings showed that the majority of students are accustomed to using small to average-sized water bottles with a low volume. It is thus evident that most students are not consuming an adequate amount of water, which will lead to negative health outcomes. Despite the low drinking water intake, some students have not developed the practice of using water bottles. The results of the present study correspond with Kenney et al. (2020) and Bethurem et al. (2021), and some literature has reported that inadequate consumption of drinking water links with poor health indicators, including arising headache conditions among students at schools, primarily affecting both health and education of students (Maresh et al., 2004; Shirreffs et al., 2004). Furthermore, ensuring an adequate amount of water during the school period is crucial for cognitive functions, including visual attention (Bar-David et al., 2005). However, our findings imply that, at least for the participants in the present study, neglect of appropriate use of water bottles and taking an adequate amount of water might lead to severe educational and negative health outcomes.
According to the European Food Safety Authority (EFSA), teenagers require 1.5 L of water per day for girls and 1.7 L per day for boys (EFSA Panel on Dietetic Products, Nutrition, and Allergies, 2013). Many studies reported that school students are reluctant to consume the required amount of drinking water at schools due to odour, poor taste and unreliability of existing tap water (Graydon et al., 2019). The present study also discovered that water consumption is relatively low among rural schools due to issues related to odour and unreliability. Furthermore, barriers to accessing water, stemming from the mismanagement of water systems, have been identified as a significant concern in the present study. This warns of the future potential risk that can be posed to student populations in developing countries due to the inadequacy of hydration during school time. As solutions, efforts have been taken by the administrations in different countries to overcome some of these concerns in academic settings, such as schools and universities. For example, many studies asserted that the installation of water refilling stations at convenient points in schools and universities has increased the level of hydration among students (Brady et al., 2017; Richard & Boyer, 2021; Uehara & Ynacay-Nye, 2018). However, we revealed that the studied schools have not implemented adequate solutions. Despite broken water taps, no administrative or local-level initiatives have been taken to repair them. Additionally, the analysis indicated that the use of safe water bottles has not received considerable attention, and children tend to use unsafe plastic bottles. This highlights the need for awareness campaigns regarding the use of safe water bottles. To make this effective, the installation and monitoring of refilling stations in the proximity and reliability of these stations should be ensured so that students can easily access these utilities to fulfil their drinking water requirements.
The outcomes of the study present that school students show a preference for using either single-use plastic bottles or other plastic bottles over glass or aluminium bottles. Plastic bottles are usually lightweight, economical and easy to handle. Unlike glass bottles, plastic water bottles are preferred for hard use (Bethurem et al., 2021). These factors justify the observed results of the present study in terms of preference for plastic water bottles. However, the potential risks associated with plastic usage due to the harmful constituents of plastics are yet to be heavily explored. Water bottles are commonly made from materials such as single-use polyethylene terephthalate (PET)-based plastic, high-density polyethylene (HDPE), polypropylene (PP), glass and aluminium. PET bottles are recommended for single use due to the risk of chemical leaching and bacterial growth if reused. Chemical leaching occurs when macroplastic materials release microplastic particles into the water due to adsorption, degradation, fragmentation and migration between the container and the water. Potential contaminants like bisphenol A (BPA) and phthalates (PAEs), including benzyl butyl phthalate (BBP), di-n-butyl phthalate (DBP) and di(2-ethylhexyl) phthalate (DEHP), as well as brominated flame retardants, have been found to have adverse effects on human and animal health (de Silva Costa et al., 2021). Therefore, the consumption of single-use plastic bottles is raising significant health concerns.
Findings indicate that water purification is minimal in rural areas, even with tap water being treated with chlorination. Although students can be encouraged to drink the required amount of water, consumption without purification may result in diseases. Freeman and Clasen (2011) observed that rural communities can be encouraged to purify water using traditional methods, yet in the studied community, the utilisation of these traditional methods remains significantly low. Therefore, a strong intervention is required to promote the use of certain traditional methods, including boiling water before consumption.
According to the results obtained, 36% of students do not even use the traditional purification method (filtration with a piece of cotton cloth). In Sri Lanka, water quality issues related to hardness, fluoride, salinity, alkalinity and dissolved organic carbon are frequently reported in the dry zone (Cooray et al., 2019). Various technological interventions, such as reverse osmosis techniques and nanofiltration membranes, have been employed to purify drinking water. However, challenges like low recovery rates, high fluoride levels, a lack of expertise and membrane fouling need to be addressed by the national system (Cooray et al., 2019). Furthermore, compromised sanitary facilities, including the lack of latrines, soap and taps, have resulted in various water-borne, respiratory and other infectious diseases. This has led to absenteeism, poor academic performance and school dropout (Azupogo et al., 2019).
A significant number of students reported their dissatisfaction with the available sanitation facilities, with most of them citing poor-quality latrines and a lack of soap and female latrines. As UNICEF shows, this can lead to higher levels of school dropouts and early marriages in rural areas (UNICEF, 2020). This is closely associated with domestic violence and child abuse.
The national response system and policies have reached a consensus on the critical need for the development of proper water supply and sanitation infrastructure for the entire nation. The National Policy for the Rural Water Supply and Sanitation Sector has established and identified the fifth principle, emphasising that water supply, sanitation provision and hygiene education should be integral components of all sector projects and programmes, underscoring the importance of WASH facilities. However, in reality, the majority of densely populated cities enjoy the privilege of having adequate water supply and sanitation services, while people in rural areas suffer due to limited access to safe water and sanitation facilities in Sri Lanka. According to reports from the WHO (2023), 88% of diarrheal diseases are estimated to be attributed to inadequate water supply and sanitation. Many school absences are a result of illnesses related to poor hygiene and sanitation. Therefore, it is imperative to identify vulnerable groups that require focused attention to improve their livelihoods and ensure equity for everyone.
In rural areas, female students often have limited access to sanitary products, knowledge about MHM, and information about infectious diseases caused by poor hygiene. Additionally, socio-economic background has played a significant role in the purchase of sanitary products, with some students resorting to using reusable cloth pads (Kaur et al., 2018). The improper disposal of sanitary products in public toilets has led to choking problems due to a lack of awareness. Therefore, adequate sanitary facilities are considered crucial for proper MHM (Kaur et al., 2018). One of the promising goals of the 2030 Agenda for Sustainable Development is to ensure gender justice in promoting menstrual hygiene. However, this goal is at risk of being compromised due to the lack of facilities in rural schools in Sri Lanka, as indicated by research.
Awareness levels regarding certain sanitary practices, such as taking a daily bath, clipping nails and consuming a balanced diet, were found to be unsatisfactory, along with a lack of awareness on water-borne and food-borne diseases. In response, many students provided suggestions to improve their awareness of diseases related to poor hygiene and WASH concepts.
According to the findings, awareness of healthy habits and personal hygiene was at a satisfactory level. However, some topics, such as water-borne diseases, nutrition and healthy habits like taking regular baths and clipping nails, have only recently been understood by the students. Therefore, implementing awareness programmes, workshops and educational subjects on WASH that cater to the students’ needs could have significant health benefits. For instance, interventions focusing on knowledge, attitudes and practices (KAP) have been proven effective at the community level (Berhe et al., 2020). It is crucial to conduct comprehensive surveillance research with larger sample sizes across the country to gain insights into the quality and standard of WASH facilities in schools and rural households. Disease surveillance and screening are also essential for controlling and monitoring the spread of water-borne and infectious diseases. Additionally, the effectiveness of water purification methods, sanitation practices, facilities and hygienic practices should be re-evaluated through research and development at the national level.
Policy Implications
The results of our study have significant implications for establishing policies at various stakeholder levels, and we strongly advocate for community-based approaches (Pawar, 2013) to improve WASH coverage and proper MHM. The results underscore the necessity of improving WASH facilities in rural schools to ensure a healthy learning environment. Schools must prioritise the maintenance and management of these facilities, making sure that water sources are safe and readily available. Given that nearly one-third of students do not use water bottles during school hours, schools should provide clean drinking water through easily accessible and well-maintained taps. Additionally, the prevalent use of unsafe plastic bottles necessitates educational programmes about the dangers of such materials and the promotion of safer alternatives like reusable plastic or glass bottles.
Sanitation facilities require urgent attention, as the majority of students are dissatisfied with the current conditions. Schools should ensure the availability of soap and regular cleaning of latrines to promote handwashing habits. Introducing and strengthening WASH clubs can further educate students on hygiene practices and encourage peer-led initiatives to maintain cleanliness. Furthermore, schools should implement regular monitoring and feedback mechanisms to promptly address issues such as broken taps and insufficient water treatment.
Educational programmes should focus on the importance of regular hydration, safe water consumption and the dangers of using unsafe plastic bottles. Health education curricula must emphasise critical aspects of daily hygiene, such as washing hands before meals and after using the latrine, bathing regularly and clipping nails. Schools should integrate comprehensive health education programmes covering the risks of water-borne diseases and the importance of using purified water. Encouraging active participation in WASH clubs can empower children to take ownership of their health practices and positively influence their peers.
The findings also highlight the need for community-based approaches to improve WASH facilities and practices. Communities must be involved in regular educational campaigns to raise awareness about the importance of safe water consumption and proper sanitation practices (Pawar, 2013). Parents should be educated about the dangers of unsafe plastic bottles and the benefits of using safer alternatives for their children. Community initiatives can include establishing safe water sources and promoting water purification methods, such as boiling and filtering, especially in areas where chlorinated tap water is not available. Collaborative efforts between schools and local health authorities can help monitor and improve the quality of water provided to children.
At the national level, policymakers must recognise the critical role of WASH facilities in promoting health and education. Policies should mandate regular inspections and maintenance of these facilities to prevent issues such as broken taps and inadequate water treatment. National health campaigns should focus on raising awareness about the dangers of unsafe plastic bottles and promoting the use of safer alternatives. The government can also incentivise the production and distribution of reusable plastic and glass bottles. Additionally, policies should support establishing and strengthening WASH clubs in schools, providing resources and training for students to lead hygiene and sanitation initiatives. Collaboration between educational institutions, health departments and community organisations is essential for creating a sustainable framework for improving WASH facilities and practices.
Finally, national strategies should include community engagement programmes to ensure that families understand the importance of safe water consumption and proper sanitation practices. This can be achieved through mass media campaigns, community workshops and school-based health education programmes. Overall, we emphasise the need for a multifaceted approach involving schools, children, communities and national policies to improve WASH facilities and practices.
Conclusion
Proper WASH and MHM practices are considered key components of the health of schoolchildren. Compromising any aspect related to WASH in practice can result in poor health. Therefore, continuous monitoring, surveillance and improvements in WASH and MHM are required to maintain health and well-being. The findings of this study have shown that there are issues related to water consumption practices, including the use of unsafe plastic water bottles and poor water filtration. The problems associated with water consumption are more related to the lack of water supply and poor water supply facilities. Hence, there is a lack of satisfaction with the water supply among the students. This dissatisfaction is also reflected in the area of sanitation, where there is a lack of sanitary facilities, leading to dissatisfaction among the students. This situation discouraged female students from using latrines in schools, especially during menstrual periods. In general, awareness about WASH concepts was at a moderate level, but further attention is required, particularly in educating students about diseases and promoting healthy habits such as bathing and proper sanitary practices.
Footnotes
Acknowledgement
The authors convey their sincere gratitude to Dehiovita Zonal Educational Zone in Kegalle for all their support.
Authors’ Contributions
The study was designed by D. M. L. J. Dassanayake. Data collection was done by D. M. J. L. Dassanayake, W. D. Darshana and M. M. T. D. Neththipola. Data analysis was done by B. K. A. Bellanthudawa, L. M. A. P. Lansakara and K. A. S. Udayanga. Preparation of the manuscript was done by K. A. S. Udayanga, B. I. L. M. Mendis, B. K. A. Bellanthudawa and N. M. S. K. Nawalage. Proofed by I. J. J. U. N. Perera.
Availability of Data and Material
Data collected for this research can be obtained from the first author upon reasonable request.
Consent to Participate
Consent to participate was obtained before the questionnaire survey.
Consent to Publish
Consent to publish was obtained before the questionnaire survey.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The corresponding author received funding for the publication (APC) of this article from the University of Bremen, Germany.
Research Ethics Statement
Research Ethics Committee at the Faculty of Humanities and Social Sciences, University of Ruhuna, Sri Lanka (REC/FHSS-R/2023/06).
