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A Survey of Water, Sanitation and Hygiene in Schools in the Caribbean Coast of Nicaragua: Findings, Lessons Learned, and Recommendations for Future Studies

Tania Jordanova1, Ryan Cronk1, Octavio Zeledon Medina2, Rinko Kinoshita2

1University of North Carolina-Chapel Hill, 2UNICEF Nicaragua

Background

Schools in rural areas of developing countries lack the resources to build, operate, and

maintain water, sanitation and hygiene (WaSH) infrastructure.

Lack of adequate WaSH facilities in schools can:

Increase health risks and spread of disease

Decrease a child’s ability to learn due to increased absence from class

Contribute to inequality in education of girls and boys

Nicaragua lacks basic, disaggregated data at the local level on WaSH in schools

To understand where investment is most needed to support WaSH in Schools, UNICEF

Nicaragua worked with government agencies to conduct a survey (Nov-Dec 2012)

Acknowledgments We would like to thank: Jessica Rocha and Connie Bushey (GRAAN), Nubia Ordóñez and Inés Hernádez (GRAAS), Oscar Aburto (Min.Education); Wanda Obando, Philippe Barragne-Bigot, Walter Gomez, and Jose Ramon Espinoza (UNICEF Nicaragua) ; Emma Chávez and Luciano Lucchesi (Consultants for UNICEF Nicaragua)

Methods and Data

Urban and Rural Discrepancies

Prioritize assistance to help schools meet the minimum national WaSH standards.

Address urban vs. rural inequalities in WaSH, through concentrated focus on aid and projects for rural areas.

Increase financial investment in maintenance and cleanliness of existing facilities. (gov. budget or school-level fundraising)

Require environmental health training for teachers and mobilize teachers with training to lead WaSH improvement projects.

Organize parents in areas which lack water infrastructure to fundraise, advocate for and participate in building a water system.

LOCATION: Northern and Southern Atlantic Autonomous Regions (RAAN and RAAS), Nicaragua

TOOL: A semi-structured survey with 102 questions was pretested and administered to the

directors of primary/secondary schools.

OBJECTIVE: (1) assess WaSH conditions in schools to identify areas of greatest need and (2)

analyze associations between variables to determine possible interventions and future studies.

RESPONSE RATE: 524 of 1,229 targeted schools (42.6%) responded to the questionnaire.

Individual questions had lower response rates.

SCHOOL CONTEXT AND TYPE: dispersed rural (53.4%), concentrated rural (29.2%), urban

(17.4% ). Primary and/or preschool (84.6%), secondary only (7.1%), all school levels (8.3%).

ANALYSIS: The majority of variables were categorical. Differences in proportions were analyzed

with Chi-sq. tests, using R Version 2.15.2.

Statistical Analysis Results

Water Sanitation

Hygiene

Sanitation Infrastructure at School

Student Per Toilet Ratio

Toilets Separated by Gender

Water Infrastructure at School

Water Transport Method to School

Water Treatment

Personal Hygiene Training

In Past 3 Years Frequency of Bathroom Cleaning

Drinking from a Shared Cup

Absence

No Absence Total

Proportion Absence*

No Water Infrastructure

74 26 100 74.0%

Water Infra. 95 64 159 59.7%

*Proportions significantly different at the p<0.01 level.

Teachers Involved

Not Involved Total

Proportion Involved*

Hygiene Training 67 67 134 50.0%

No Training 29 65 94 30.9%


Parents Involved

Not Involved Total


None 16 7 23 69.5%

Carry 70 14 84 83.3%

Piped or Well

34 54 88 38.6%


Association Between: Parent Council Involvement in Water System Planning

and Maintenance and Type of Water Transport to

School [In Non-Urban Areas]

Association Between: Prolonged Student Absence from School Due to Sickness

(as estimated by directors) and Water Infrastructure at

School

Percentage of Children in Extreme Poverty

in Study Area Image of Latrines at a Nicaraguan School

Source: INIDE and UNICEF Nicaragua 2013 (measured by multi-dimentional

poverty indices)

Implement Personal Hygiene Program 57% of schools don’t have water infrastructure (n= 455)

26% of water infrastructure is broken (n= 196)

30% of schools require water to be carried from a distance (n= 455)

63% of school directors know the school water is treated (n= 202)

37% of schools don’t have sanitation infrastructure (n= 411)

28% of toilets are not used due to poor conditions or habits (n=261)

35% of schools had separate bathrooms for boys and girls (n= 368)

81% of schools don’t have sinks for hand washing (n= 463)

74% of schools don’t have soap for hand washing (n= 362)

41% of schools do not implement any type hygiene program (n= 413)

Percent of Schools with a Dedicated Budget

for Supplies, Maintenance

and Operations:

Water (n= 142): 6%

Sanitation (n= 270): 8%

Hygiene (n= 362): 1%

Association Between: Teacher Involvement in Water System Planning and

Maintenance and At Least One Type of Hygiene

Program at School

© UNICEF / NICARAGUA – 2012 / W. Obando

Cost and logistical constraints in remote rural areas.

Based on convenience sample (not random).

Missing values can mislead interpretation of proportions.

Lack of buy-in from some communities.

Use of self-reporting instead of trained interviewers.

Potential bias from school principals due to:

lack of knowledge and forgetfulness

misunderstanding of the question

desire to give a good impression

other unconscious personal biases

Recommendations for Interventions

Recommendations for Future Studies

To avoid response or reporting bias, future studies can take the following approaches:

Carefully define the questions and responses to eliminate as much subjectivity as possible

Verify responses through third-party observation (such as observation of hand washing practices)

Have trained and objective employees or volunteers collect data based on specific guidelines

Collect quantitative data (such as water quality samples)

Standardize Data Reporting: Require schools to track and regularly report standardized data. E.g.: each school should keep

accurate records of student absences and report numbers to the ministry of education monthly.

Deploy Rapid Surveys: Surveys with fewer questions and a smaller sample size are an alternative to long-format surveys and

can be used to study a specific research question in a smaller geographic area. Use innovative data collection techniques for geographically remote areas such as SMS/text messaging.

Recommendations

The percentage of schools with water infrastructure increases from 28%

to 68% when moving from dispersed rural to urban areas. This difference

is statistically significant (p-value: <0.001).

Association Between: Existence of Teachers’ Association and Teacher

Involvement in Water System Planning and

Maintenance [In Non-Urban Areas]

Teachers Involved

Not Involved Total


Teacher Assoc.

39 23 62 62.9%

No Assoc. 36 84 120 30.0%


Association Between: Frequency of Latrine Cleaning and Personal Hygiene

Training at School in Past 3 Years

Hygiene Training No Training Total

Proportion w/ Training*

Daily 36 42 78 46.2%

Weekly 28 91 119 23.5%

Over a Week

10 36 46 21.7%


Limitations

Urban schools have a higher proportion of functioning water systems,

while rural schools have a higher proportion of carrying water from

outside of school. The differences are statistically significant (p-value:

<0.001).

The percentage of schools with water treatment increases from 50% to

83% when moving from dispersed rural to urban areas. This difference is

statistically significant (p-value: <0.001).

The percentage of schools with sanitation infrastructure increases from

56% to 79% when moving from dispersed rural to urban areas. This

difference is statistically significant (p-value: <0.001).

The percentage of schools with toilets separated by gender increases

from 24% to 49% when moving from dispersed rural to urban areas. This


While not statistically significant, there is a strong pattern of higher

student per toilet ratios in more urbanized areas. [Median ratio is 55, 33,

and 24 for urban, concentrated, and dispersed rural respectively].

The percentage of schools with personal hygiene training increases from

22% to 54% when moving from dispersed rural to urban areas. This


The percentage of schools with a personal hygiene program increases

from 35% to 65% when moving from dispersed rural to urban areas. This


The percentage of schools where students drink from a shared cup

decreases from 48% to 34% when moving from dispersed rural to urban

areas. This difference is not statistically significant (p-value: 0.1648).

Urban schools have a higher proportion of daily latrine cleaning, while

rural schools have a higher proportion of weekly or less frequent cleaning.

The differences are statistically significant (p-value: <0.001).

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