Environmental sanitation and health facilities in schools of an urban city of south India

Background : Environmental sanitation and health facilities in schools are an important public health issue. Aims : To assess the school environment, sanitation and health related facilities and to compare the availability of these facilities between government, aided and private schools. Materials and Methods : This cross sectional study was done in 30 schools in Mangalore city of south India in February 2010. Results : Out of the 30 schools surveyed, four were government, 12 were aided and 14 were private schools. Overcrowding was seen in one third of schools. The recommended minus desks was lacking in 23(76.7%) and chairs with back rest was lacking in 11(36.7%) schools. More than a quarter of schools had no drinking water purification facility. Water storage units were not cleaned periodically in 6(20%) schools. Quarter of all government schools and half of all aided schools had no dining hall for serving mid-day meals. Toilets were not adequate in 10(33.3%) and it was not separated for boys and girls in 8(26.7%) schools. Four of the surveyed schools had no medical examination of students and in 13(43.3%) schools daily morning inspection by teachers was not done. Hardly few schools had staff trained to deal with medical emergencies and in counselling activities. None of the schools had an immunization register. Although the performance scores between the types of schools did not differ significantly, the combined performance of only private schools were found to be satisfactory. Conclusion : A good number of schools in this urban area were found to be falling short of several essential requirements regarding sanitation and health facilities which needs to be rectified.

Keywords: Environmental sanitation, health facility, urban schools

School environment sanitation and health facilities are an important public health issue. A survey among school children in various parts of India revealed that about half of the ailments found are related to insanitary conditions and lack of personal hygiene. ^[1] To rectify these problems, essential facilities and regular health examination activities are required at schools. To fulfil these requirements in 1960, the Government of India set up a committee on school health (Renuka Ray Committee). The report of the Renuka Ray committee provided guidelines and recommendations for both the content and the appropriate transaction of health education at various stages of schooling. ^[2] Unfortunately the implementation of these along with the promises of school health and hygiene education programs has not always been fulfilled. ^[3] With this background, this study was done to know the ground realities as far as school environment, school structure, nutrition, sanitation and health related facilities at schools and to compare the performance in these aspects between government, aided and private schools in an urban area.

This cross sectional study was done in Mangalore, a coastal city situated in south India during February 2010. List of all co-education schools having both primary and high school facility was obtained from Department of Public Instruction, Government of Karnataka. ^[4] Principals of these schools were contacted and were informed about the purpose of the study. They were ensured that a total confidentiality of school identity shall be maintained. After obtaining their informed consent, the investigators examined the school and its premises and recorded the required information in a pre-tested questionnaire. Information with respect to periodicity of medical examination, daily morning inspection by class teachers, and presence of health educational materials was enquired. Maintenance of various registers like medical examination register, anthropometry register, immunization register in schools were also examined. The dimensions of floor, window and door were recorded using measuring tapes to calculate the area. The recorded information was compared against the standard requirements of school and its environment in India mentioned under the School Health Committee report. ^[2] Each criterion was given weighted scores and this formed the basis of comparison of performances between government, aided and private schools. More weightage was given to most essential requirements in schools like adequate ventilation and space in classrooms, safe drinking water, sanitation facilities and periodic medical examination by doctor. The scores allotted to the most essential requirements formed the basis for determining the minimum scores for satisfactory performance of schools which totalled to 52 points out of a possible 69 points. All the data collected was compiled and analysed using SPSS Version 11.5 into categories and percentages. Statistical tests like Chi-square and Kruskal – Wallis test were used for testing statistical significance and P value <0.05 was taken as the level of significance.

Out of the 30 schools surveyed, 4 (13.3%) were government, 12 (40%) were aided and 14 (46.7%) were private schools. It was observed that 25 (83.3%) schools were well placed with approachable roads and at a fair distance from busy places like markets and away from polluting atmosphere such as factories. All the schools surveyed in this study had fencing around school campus. All schools had a playground which is important for healthful school environment. Only 14(46.7%) schools (3 Government, 3 Aided and 8 Private) were single storied which is an essential requirement under the recommendations of school health committee report. Almost all schools, 29 (96.7%) had verandhas attached to class rooms. 10(33.3%) schools had less than 10 square feet per capita space in the classrooms and hence were overcrowded. Day light and ventilation in terms of floor, door/window area and cross ventilation was observed to be adequate in 29(96.7%) schools. 22(73.3%) schools had windows place at a right height (two or more feet) above the floor but walls were not whitewashed in 2(6.7%) schools Although all schools had a separate desk and chair, the recommended minus desk was present only in 7(23.3%) schools and chairs with back rest was present in 19(63.3%) schools. [Table 1]. The cumulative scores with respect to school structure and environment standards was 15.25 in government schools, 18.08 in aided schools and 17.86 in private schools. [Kruskal-Wallis test, P=0.958] With respect to midday meal scheme (which is implemented only in government and aided schools) it was observed that meals were prepared only in 3(18.7%) schools which were all aided. Among the other schools (4 government and 9 aided) food was prepared by outside caterers. One (25%) government and 6 (50%) aided schools had no dining hall for serving mid-day meals (MDM). None of the schools implemented Applied Nutrition Programme (development of a school garden by utilizing the facilities provided by UNICEF in the form of implements, seeds and manure). Source of water in all the surveyed schools was tap water provided by the city corporation. Hardly 3(10%) schools had press taps which are very beneficial in minimizing the water loss after usage. 8(26.6%) schools had no water purification facility and 6(20%) schools were not periodically cleaning their drinking water storage units. [Table 2]. The cumulative scores with respect to school drinking water and sanitation facilities was 21 in government schools, 17.17 in aided schools and 20.71 in private schools. [Kruskal-Wallis test, P=0.769] Health related posters were present in 29(96.7%) schools and health related assignments like health project works were given in 9(30%) schools. 26(86.7%) schools had medical examination of students by a doctor and that too done at least once every year. Eye examination and dental examination were not a part of medical examination in 12(40%) and 7(23.3%) schools respectively. Although 29(96.7%) schools had a first aid kit, only in 2(6.7%) schools both of them private it was well-equipped. Only 4(13.3%) schools (all private) had teachers trained in rendering emergency care to students. Only 3(10%) schools (all private) had counsellors who were trained to help children with maladjustments and in career guidance [Table 3]. The cumulative scores with respect to health related activities at schools was 12.25 in government schools, 11.42 in aided schools and 12.79 in private schools. [Kruskal-Wallis test, P=0.916] Few schools 3(10%) were not maintaining health records or anthropometry registers (3 monthly record of height and weight of students by teachers). None of the schools had an immunization register [Table 4]. The cumulative scores with respect to maintenance of health records was 2.75 in government schools, 2.58 in aided schools and 2.43 in private schools. [Kruskal-Wallis test, P=0.733] The overall performance score considering all aspects were best among private schools followed by government and aided schools. [Kruskal-Wallis test, P=0.86] Also the cumulative scores of only private schools were above the minimum requirement (52 points) of satisfactory performance.

As school children spend good number of hours at schools, the school health and environment constitutes a major influencing factor as far as their health is concerned. This study gives an insight into the situation analysis and priority issues of these factors in schools in an urban set up in India. In this study it was observed that ventilation, lighting and space for students were more adequate in schools than observed in another study done by Majra et al. ^[3] Lack of minus desks in more than 3/4 of schools and more than 1/3 of schools having chairs without back rest is a cause of concern. These need to be rectified else children will suffer from ailments related to faulty postures such as back ache in future. Half of aided schools and a quarter of government schools not having separate rooms to serve the MDM is another issue of concern. Usage of verandas or classrooms in these schools for serving MDM will make the classrooms and its surroundings unclean. Besides MDM was prepared in majority of schools by outside private caterers. This was due to lack of pucca kitchen sheds in these schools. But as per the recommendations of the school health committee, schools should have arrangements for providing MDM through their own cafeteria. Although water was available in all the surveyed schools in this study, more than a quarter of schools had no means for water purification and one fifth of the schools were not cleaning their water storage points periodically. Similar observations have been made in studies done elsewhere in India. For example, Ministry of Human Resource Development, Government of India reported that 17.3% schools in India are without water supply ^[5] A study done in Mysore district revealed that only 79% of schools had water supply facility, of which 91% were actually functioning. ^[6] This an important area where school authorities need to focus considering the fact that diarrhoeal diseases such as Typhoid and Hepatitis A take a heavy toll among school children in India. Almost three quarter of schools in this study had no water cooling facility which is very much required in Mangalore city having a hot and humid climate. Although toilets in all the surveyed schools in this study were functioning, it was found to be inadequate and not separated in few schools. In a study done by Majra et al, latrines were found inadequate in about 50% of schools for students. ^[3] In a sanitation survey done in Mysore district it was found that 15% schools do not have latrine. ^[6] In a study conducted by Ministry of Human Resource Development, Government of India, 45.9% schools in India are without toilets. ^[5] Provision of safe drinking water and sanitary latrines are among the most basic amenities to be made available at schools. Moreover provision of separate toilets for boys and girls is a sensitive issue as far as enrolment ratios of girls in schools are concerned. The toilets need to be not only provided adequately but at the same time has to be well maintained also. In this study, in 2(6.7%) schools toilets were not cleaned periodically. In a study done in schools in Mysore district it was found that in 30.5% schools latrines were not maintained in good condition. ^[6] Although health related posters were present in most schools, health related assignments were given only in few schools. In the study done at Mysore it was found that only in 38% of schools the Information Education and Communication materials were placed at appropriate location and hence were mostly not well utilized. ^[6] Although medical examination was done periodically in most schools, both eye examination and dental examination was lacking in good number of schools. Considering the gravity of dental caries, refractive errors and Vitamin A deficiency disorders as supported by the findings of several studies done among urban school children ^[7-9] the eye and dental examination forms an important constituent of school medical examination. Teachers in most schools in this study practiced daily morning inspection which helps in early detection of any ailments among children. Regarding dealing with any medical emergencies most schools were poorly prepared in terms of presence of trained personnel and fully equipped first aid kits. Also very few schools in this study had counsellors. Role of counsellors has become vital in urban schools nowadays considering the problems like juvenile delinquency, maladjustments, drug addictions, stress related to poor academic performance and choice of career among students. Although daily morning inspection was practiced only in 17 schools, 22 schools were maintaining the register. This meant that few schools were maintaining false registers when this activity was actually non-existent. However as a whole most schools had a sound accountability of heath activities by maintaining up to date health registers. The performance scores of only private schools in total were found to be satisfactory. The least performing were aided schools. If aided and government schools receive more funds and support from concerned authorities probably the situation in these schools will improve.

A good number of schools in this urban area were found to be falling short of several essential requirements regarding sanitation and health facilities. School administration and concerned authorities needs to introspect and rectify the various loop holes identified in this study for the betterment of environmental sanitation and health facilities in schools for the benefit of students.

The authors would like to thank Dr. Nagaraj K, Professor and HOD, Department of Community Medicine, Kamineni Institute of Medical Sciences, Narketpally for his continued support throughout the study. We thank M.B.B.S students, Ms. Juhi Dhanawat, Mr. Pratik Kumar, Ms. Ridhima Sakhuja, Ms. Richa Singh, Mr. Prashant Mishra and Ms. Aditi Singh for helping us in data collection. We also thank the Principals and teachers of the surveyed schools for their cooperation rendered to us during the period of data collection.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1755-6783.10512

[Table 1], [Table 2], [Table 3], [Table 4]