Factors influencing access to basic water, sanitation, and hygiene (WASH) services in schools of Bishoftu Town, Ethiopia: a cross-sectional study

Access to basic water, sanitation and hygiene services is the most effective mechanism to reduce many infectious diseases. WASH in schools related to better educational outcomes although adequate water, sanitation, and hygiene services were unavailable to millions of school-age children in Ethiopia. Therefore, it is crucial to assess the level of WASH coverage and identify factors affecting access to basic water, sanitation, and hygiene services. A cross-sectional study was carried out among 82 school facilities. A structured questionnaire and an observational checklist were used to gather the data. Water samples were taken from the schools' water storage. Descriptive and multivariable logistic regression analyses were used to analyze the data. In this study, 74.7%, 61. 3% and 37.3% of the schools had access to basic drinking water, sanitation, and hygiene services, respectively. Additionally, 21.3%, 29.4%, and 30.7% of the schools had access to limited drinking water, sanitation, and hygiene services, respectively. However, 4%, 9.3%, and 32% of the schools lacked water, sanitation, and hygiene services, respectively. We discovered that schools with male heads were 7% less likely to have access to basic hygiene services (AOR = 0.07 with 95% CI 0.01–0.5) than those with female directors. In addition, schools with hygiene and environmental health clubs had an 11.8-fold higher access rate to basic hygiene services (AOR = 11.8 with 95% CI 1.35–104) than schools without such clubs. Besides, schools that conduct WASH lessons at least once a week were 8.63 times more likely to use basic hygiene services (AOR = 8.63; 95% CI 1.18–63.22) than schools that did not. This study offers scientific evidence that could be used for sound decisions to fill the school WASH gaps. This is a unique study in determining the level of WASH coverage and identifying factors affecting access to basic hygiene services. The investigation provides some insights into how access to WASH services can be improved at the grassroots level. Federal and regional governments should implement effective interventions that assist schools to attain Sustainable Development Goal 6 by 2030. School administrators and other partner organizations should take proactive measures to enhance and maintain the WASH services.


Study area
The study was carried out in the Town of Bishoftu in the Oromia National Regional State. It is located 44 km away from Addis Abeba, the country's capital. It covered an estimated 18,278 hectares of land [23]. It also has five rural and nine urban Kebeles. Additionally, it has an estimated population of 171 227 people [24]. According to information from the Town's education office, 164 schools provide education from Kindergarten (KG) to the eighth grade. Additionally, there are 61,268 students and 1941 teachers. In the Town, a large project titled "Hygiene and Environmental Health Services" is currently underway. The project's goal is to design a model learning city concerning urban water, sanitation, and hygiene services. The study area was selected by the Ministry of Health Ethiopia using different criteria. The major criteria for choosing the learning model city were having a significant tourist flow, proximity to Addis Ababa, and suitability for higher government and expert supervision. Similarly, having a landfill, substantial investments and good experience with WASH were among the requirements.

Study design
Between January and February 2022, a cross-sectional study was conducted among the educational facilities in Bishftu Town.

Study population
The study population was made up of all the chosen schools in the Bishoftu Town administration.

Sample size determination
With a 95% confidence interval (CI), a 5% margin of error (m), and a 12% assumption for the percentage of schools with a limited drinking water service, a single population proportion formula was used to calculate the study's sample size (P) [18]. Then, However, the authors used the population correction formula because the sample was drawn from a small sample of 164 (N < 10,000) schools in Bishoftu Town.
where n is the final calculated sample size, n 0 is the calculated sample size, and N is the total number of schools in the Town. Then, Therefore, the sample size (n) for this study was = 82 schools.

Sampling procedures
A method of systematic random sampling was used to choose the educational facilities. The Bishoftu Town education office provided a sampling frame consisting of a list of the 164 schools. The number of school facilities was divided by the study's sample size (82) to determine the sampling interval. After that, a two-sampling interval was decided. Following that, one school facility was chosen by a lottery process, and the sampling interval was added to get the necessary 82 schools. Water samples from the schools' water storage were taken to test the bacteriological and chemical water quality. The water samples were collected in 1000 ml plastic bottles for chemical measurements and 250 ml heat-sterilized vials for bacteriological values. Within six hours, the bottles were sent to the lab, where they were kept chilled at four degrees Celsius until it was time for the examination. The WHO recommendations for drinking water quality served as a model for the sampling techniques [25].

Data collection procedure
A structured questionnaire and observational checklist were used to assess the level of WASH coverage and evaluate the factors affecting basic hygiene services. Most of the questions were adopted from the JMP core questions and indicators for monitoring WASH in schools [26]. Additional questions and an observational checklist were used from https:// wash. unhcr. org/ downl oad/ wash-in-schoo ls-check list/. Demographic and main indicators of WASH variables were collected using a questionnaire and an observational checklist. The Open Data Kit (ODK) was used to integrate the questionnaire and collect the data. Data were gathered by six health experts with a Bachelor of Science. The data collectors received five days of training. School directors were interviewed to assess water, sanitation, and hygiene services. Additionally, an observational checklist was completed. A pre-test was done on 5% of the overall sample size, and the questionnaires were squared to ensure homogeneity and fullness. Clarity-demanding queries underwent reshaping and modification.

Response variables
The outcome variables of this study were basic water, sanitation and hygiene services, and drinking water quality. To measure the coverage of school WASH services, the JMP core questions and indicators were asked to school directors and assessed observationally. Additionally, to measure water quality, water samples were taken from the schools' drinking water storage.

Explanatory variables
The predictor variables of this study were the sex of the school directors, ownership of the schools, hygiene and environmental health clubs or WASH clubs, a budget line designated for WASH, schools' practice of community involvement, type of school, human resources, and at least one weekly lesson on WASH services. Some explanatory variables of this study were chosen based on earlier research [27].

Data analysis
Data were transferred from Open Data Kit (ODK) into Stata version 16 for analysis after being squared for accuracy. Binary and multivariable logistic regression analyses were used in addition to descriptive statistics. Variables were created in accordance with the JMP ladders for WASH definitions. A P-value of 0.05 or lower was regarded as statistically significant in each analysis. According to the United States Food and Drug Administration, the membrane filtering method was used to count the microorganisms Escherichia coli, Total Coliform, and Fecal Coliform [28]. Additionally, Ion-Selective Electrode (ISE) testing was performed in accordance with USEPA guidelines to measure the amount of fluoride in the water [29]. Further, the American Public Health Association/American Water Works Association/Water Environment Federation (1998) Standard techniques for evaluating water and wastewater were followed to evaluate the nitrate concentration using an ultraviolet spectrophotometer [30].

Ethical approval
The scientific and ethical review board of the Ethiopian Public Health Institute gave its approval to the investigation's protocol, which was given the reference number EPHI-IRB-358-2021. The study was carried out in conformity with the ethical guidelines outlined in the 1964 Declaration of Helsinki and its later revisions or with ethical guidelines of a similar nature. The goal of this study was clearly stated to the directors or heads of schools to secure their agreement. The directors provided their written, fully informed consent, and no one was required to engage in the investigation if they did not want to. Participants' anonymity and privacy were upheld throughout the inquiry.

Water quality
The schools' water quality was determined according to the World Health Organization drinking water guideline [31]. Water samples with < 1 Colony Forming Unit (CFU)/100 ml for indicator bacteria were assumed as potable, and samples with ≥ 1 Colony Forming Unit (CFU)/100 ml were unclean. Also, water samples with ≤ 1.5 mg/liter and ≤ 50 mg/liter of fluoride and nitrate values were assumed to be free from chemical contamination, respectively. However, water samples with > 1.5 mg/liter and > 50 mg/liter concentration values of fluoride and nitrate were supposed to be chemicalcontaminated, respectively.

Service level Definition
Drinking-water service ladders Basic service The proportion of schools (including pre-primary, primary, and secondary) with drinking water from an improved water source available at the school Limited service Drinking water from an improved source, but water is unavailable at the school at the survey time No service Drinking water from an unimproved source or no water source at the school Sanitation service ladders Basic service Having improved sanitation facilities at the school that was single-sex and usable (available, functional, and private) at the survey Limited service Improved sanitation facilities at the school that are either not single-sex or not usable at the survey time No service Unimproved sanitation facilities or no sanitation facilities at the school Hygiene service ladders Basic service During the survey, handwashing facilities with water and soap were available at the school Limited service Handwashing facilities with water but no soap available at the school at the time of the survey No service No handwashing facilities available or no water available at the school

Sociodemographic characteristics of the schools
In total, 82 heads of schools participated in the study, with a 91.5% response rate. The bulk (64%) of the school administrators were men. In addition, private ownership comprised 76% of the schools. In addition, 64%, 76%, and 56% of the schools, respectively, lacked hygiene and environmental health clubs, a separate budget line for WASH-related initiatives, and community participation in the development and upkeep of WASH services. Nearly half (46.7%) of the schools lacked at least one weekly lesson on the benefits of WASH services. The average number of boys and girls in the schools was 146 and 165, respectively. Similarly, the average teacher was 8 for women and 5 for men (Table 1).

Access to basic WASH services of the schools
In this survey, 74.7%, 61. 3% and 37.3% of the schools had access to basic drinking water, sanitation, and hygiene services, respectively. Additionally, 21.3%, 29.4%, and 30.7% of the schools had access to limited drinking water, sanitation, and hygiene services, respectively. However, 4%, 9.3%, and 32% of the schools lacked water, sanitation, and hygiene services, respectively (Fig. 1).

Drinking water quality and contamination risk levels
Most (96%) of the schools' primary water sources were improved. Besides, 66.7% of the schools had no access to a continuous water supply. Above half (55.6%) of the schools had no drinking water accessibility to the smallest children. Only 7% of the evaluated schools' total enrollment had water treatment procedures in place (Table 2).

Type of sanitation facilities and availability of menstrual hygiene services
In the survey, 90.7% of the schools used improved restrooms. However, 9.3% of the schools used unimproved restrooms. Additionally, 86.7% of the schools had sex-separated toilets for students. However, 90% of students' toilets' lighting was not functional, and 53.3% of the schools' restrooms' had no culturally appropriate anal cleansing materials. Further, 32% of the schools had no functional handwashing facilities. Besides, 78.6% of the schools had no handwashing facilities accessible to students with limited mobility or vision. In addition, 43% of the schools lacked handwashing facilities that were reachable by the smallest students (Table 3).

Factors associated with basic water, sanitation, and hygiene service
The binary logistic regression analysis was conducted to assess the association between dependent (basic hygiene service) and independent variables. Accordingly, a significant association between six explanatory factors (sex of school directors, having hygiene and environmental club, having a budget line specifically for WASH, community involvement in planning, monitoring, and maintaining WASH services, having at least one weekly lesson about WASH, and ownership of the schools) and the basic hygiene service was observed. However, in the condensed model, five predictor variables, including the sex of the head school directors, the existence of hygiene and environmental health clubs, having a budget line specifically for WASH services, community involvement in WASH-related activities, and the presence of at least one weekly lesson about WASH were significantly associated (P-value 0.05 at 95% CI) with basic hygiene service. Similarly, a binary logistic regression analysis was carried out to determine the association between the independent and the outcome (basic water and sanitation services) variables. However, none of these predictor variables showed a significant association with the provision of basic sanitation and water services (Table 4).

Discussion
This study assessed the level of WASH coverage and identified factors affecting access to basic water, sanitation, and hygiene services. The best way to reduce many infectious diseases is to have access to basic water, sanitation, and hygiene services. To stop the spread of infectious diseases, the World Health Organization has acknowledged the need for water, sanitation, and hygiene practices in schools worldwide. The key tenets of the SDGs-access to clean water, adequate sanitation, and hygiene services-assist in improving children's health and academic performance in school. However, this investigation found that a significant percentage of schools lacked basic water, sanitation, and hygiene services. Besides, a substantial number of the schools used limited water, sanitation, and hygiene services. This could be a significant risk factor for the spread of several infectious diseases resulting from poor water, sanitation, and hygiene services. A lack of basic water, sanitation, and hygiene are far deadlier for children than war in more than a dozen conflict-affected countries [32]. Unsafe water and inadequate sanitation systems cause social, economic, and political instability. This also poses a threat to the survival, health, and development of children and communities. This is supported by https:// www. unicef. org/ stori es/ fast-facts-water-sanit ation-hygie ne-confl ict. The current survey revealed that only 37.3% and 30.7% of schools had access to basic and limited hygiene services. It means the schools had handwashing facilities with water and soap available, having handwashing facilities with water but no soap available at the school at the time of the survey. However, a basic hygiene service was available in 60% of schools worldwide in 2022 [10]. The recent findings revealed that a significant percentage of the schools are behind schedule in terms of achieving Sustainable Development Goal (SDG) six, which calls for universal access to basic hygiene services (> 99%) by 2030. This finding also highlights the need for a strong strategy to improve basic hygiene services and achieve the 2030 Sustainable Development Agenda. Poverty, a lack of political will, and a small budget for WASH services could be the leading causes. In this investigation, 32% of schools lacked hygienic facilities. It indicates that during the survey, there were no sinks or water available for hand washing at the school. This statistic was reasonable compared to the JMP 2020 school WASH progressive report, which found that 60% of schools in low-and middle-income countries lacked a hygiene service [17]. Although the present study's coverage of basic drinking water and sanitation services was in line with the worldwide report from 2022 [10], still many schools remained without these amenities. This might be a high-risk area for water-and sanitation-related illnesses, and it spreads various infections among the school communities.
According to the study's findings, 12%, 5.3%, and 1.3% of the drinking water samples collected from the schools tested positive for total coliforms, fecal coliforms, and E. coli. This revealed that a substantial number of water samples were microbiologically contaminated.
Contaminated water is linked to the transmission of diseases such as cholera, diarrhea, dysentery, hepatitis A, and typhoid fever. Absent, inadequate, or inappropriately managed drinking water service exposes individuals to preventable health risks [33][34][35]. This is particularly the case in school facilities where both students and staff are placed at additional risk of infection and disease when water is contaminated and sanitation and hygiene services are lacking [36].
Furthermore, 98.67% and 1.33%, respectively, of the water samples from the schools that were tested had low and high contamination risk levels. Poor water quality and poor hygiene practices are disastrous for young and school-aged children who spend a lot of time at school. Children frequently contract illnesses in school [37]. The inadequate water supply system and lack of water treatment technologies in schools may be the leading causes. All the water samples collected from the schools exhibited acceptable fluoride and nitrate concentration levels, in contrast to bacterial contamination. In this investigation, 61.3% and 6.7% of the schools used open burning and dumping to manage solid waste. This approach might pollute the environment and exacerbate global warming. Lack of adequate infrastructure and failure to enforce current environmental protection legislation may be the leading causes of incorrect solid waste disposal. The present study found that 88% of the schools had no plan for menstrual hygiene management, although it is an essential WASH component in schools [38].
Furthermore, just 16% of the schools provided dedicated spaces for managing menstrual hygiene. This showed that many schools lacked menstrual hygiene facilities. A 2017 study lends credence to this assertion [39]. However, menstrual hygiene management is necessary for good health, human dignity, and quality of life [40]. We discovered that schools with male heads were 7% less likely than schools with female heads to have access to basic hygiene services (AOR = 0.07 with 95% CI 0.01-0.5). This demonstrated that female directors had a greater impact on the availability of basic hygiene services. However, schools with hygiene and environmental health clubs were 11.8 times more likely than schools without such clubs to have access to basic hygiene services (AOR = 11.8 with 95% CI 1. . This result was in line with a 2020 study in which a strong association was observed between being a member of a school WASH club and the use of basic hygiene service (OR = 4.56, 95% CI 2.95-7.04), p = 0.001) [27].
In addition, access to basic hygiene service was 8.5 times more likely for schools having a budget line designated particularly for WASH services (AOR = 8.5, 95% CI 1.00-70) than for schools without it. These results confirmed that the significance of WASH clubs and the allocated financial resources for WASH services are key determinants of the accessibility of basic hygiene services in schools. Additionally, schools that had community involvement in the development, monitoring, and upkeep of WASH services were 12 times more likely to have access to basic hygiene services than schools that did not (AOR = 12 with 95% CI 1.88-78.48). This demonstrated that the 2030 SDGs agenda for school WASH services could not be achieved without community participation. In addition, schools that conduct WASH lessons at least once a week were 8.63 times more likely to have access to basic hygiene services (AOR = 8.63; 95% CI 1.18-63. 22) than schools that did not. This further demonstrated the significance of WASH lessons and how learning about WASH services affects the accessibility of basic hygiene services in educational settings.

Limitations of the study
Although microbiological and chemical contamination is the main and most important factor affecting health in developing nations, the physical characteristics of water have been used as an indicator of the quality of drinking water. However, due to their priority and budget constraints, this study measured the drinking water quality only for microbial and selected chemical contaminants. Therefore, not studying the physical properties of drinking water is the main limitation of this study.

Conclusion
This is a unique study in determining the level of WASH coverage and identifies factors affecting access to basic hygiene services in Bishoftu Town, Ethiopia. The investigation provides some insights into how access to WASH can be improved at the grassroots level. As the study followed standard sampling procedures and ensured representativeness, the study will represent the school WASH status of the country and will provide a clue to policymakers and programmers. Additionally, this study offers scientific evidence that could be used for the up-to-date decision to fill the school WASH gaps. The availability of basic hygienic services was low. A sizable number of schools were still without access to water and sanitation services. A significant proportion of the water samples had microbiologic contamination. Numerous elements that affect basic hygiene services have been identified. The findings of this investigation suggest that federal and regional governments should implement effective interventions that assist schools to attain Sustainable Development Goal 6 by 2030. Additionally, the administrators of the schools and other partner organizations should take proactive measures to enhance and maintain the WASH services. Furthermore, the schools should implement eco-friendly solid waste management practices like composting, recycling, reduction, and reuse methods.
Author contributions AMG contributed to the methodology and writing of the original draft. SDM and AMG contributed to the conceptualization and process. MGS and MGW contributed to Fluoride analysis. TAA, MAK, ZAA, and BW contribute to Nitrate analysis. WG and GF contributed to bacteriological examination. All the authors contributed to the investigation, coordination, and data collection. AMG, MGW, and EAA performed data analysis. All authors read and approved the final manuscript.
Funding None declare.
Data availability All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Competing interests
The authors declare no competing interests.
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