Accepted Manuscript

Sanitation and hygiene practices among primary school learners in Ngamiland district,
Botswana

Olekae T. Thakadu, Barbara N. Ngwenya, Nthabiseng A. Phaladze, Benjamin

Bolaane

PII: S1474-7065(16)30057-2
DOI: 10.1016/j.pce.2018.02.006
Reference: JPCE 2652

To appear in: Physics and Chemistry of the Earth

Received Date: 19 May 2016

Revised Date: 16 May 2017
Accepted Date: 7 February 2018

Please cite this article as: Thakadu, O.T., Ngwenya, B.N., Phaladze, N.A., Bolaane, B., Sanitation
and hygiene practices among primary school learners in Ngamiland district, Botswana, Physics and
Chemistry of the Earth (2018), doi: 10.1016/j.pce.2018.02.006.

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 ACCEPTED MANUSCRIPT

Sanitation and hygiene practices among primary school learners in Ngamiland District, Botswana

Olekae T. Thakadu1, Barbara N. Ngwenya1, Nthabiseng A Phaladze2, Benjamin Bolaane3

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Okavango Research Institute, University of Botswana, Maun; 2School of Nursing, University of

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Botswana, Gaborone; 3Department of Planning and Architecture, University of Botswana,

Gaborone.

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Correspondence: Olekae. T. Thakadu, Okavango Research Institute, Private Bag 285. Maun,
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Botswana.
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Tel. +267 681 7230 – Fax: +267 686 1835

E-mail: othakadu@ori.ub.bw
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Contributions: the authors contributed equally.

Acknowledgements

Funding for this study was provided through the GEF Small Grants Grant funding.

Co funding by the Office of Research and Development, University of Botswana and Southern

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African Regional Environmental Program (SAREP) Contract 674-C-00-10-00030-00

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Conflict of interests: the authors declare no potential conflict of interests.

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The study protocol was approved by the Institutional Review Board no. E1/20/2/X111/25

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Conference presentation: part of this paper was presented at the 16th
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WaterNet/WARFSA/GWP-SA Symposium on Integrated Water Resources Management and

Infrastructure Planning for Water Security in Southern Africa, 2015 October, Pointe Aux
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Piments, Mauritius.

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Abstract

Improved sanitation and personal hygienic practices are considered important towards reducing
the risks of spreading communicable diseases and improving public health. Diarrheal related
deaths amongst adolescents are reported to be amongst the top ten for the age groups 10-19 year
olds and second among the age group 10-14 year olds globally. Primary school learners in
developing countries are among the most vulnerable sub-population. These mortalities and

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illnesses can be reduced by addressing personal hygiene among school children and
simultaneously promoting better school attendance and improved learning. In order to facilitate
improved health and educational outcomes, it is necessary therefore to effectively address water,

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sanitation and hygiene matters within the school environment. This study explored hygiene
education, personal hygiene practices among learners, environmental sanitation and hygiene
within three primary schools in the Ngamiland district, Botswana. From the three schools, a total

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sample of 285 pupils was selected using proportionate stratified random sampling technique, and
15 teachers purposively selected as key informants. Data was collected using semi-structured
questionnaires with key informants and social survey instrument for learners. Results show that
very few learners linked poor hygiene to the following diseases; diarrhea/upset stomach (31.7%);

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malaria (23%); bilharzia (16.4%), and cholera (14.8%), demonstrating low hygiene knowledge.
Hygiene education in schools is infused in the curriculum, and teacher training on hygiene
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education is only through in-service training workshops. Regarding personal hygiene practices,
over 70% of the learners indicated that they ‘always’ wash their hands before and after eating,
with slightly over one-fifth indicating ‘sometimes’. Overwhelming majority of learners dispose
solid waste in dustbins (99.3%, n = 284), use refuse bags (80.8%, n = 231), open skips (64%, n =
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183) and very few throw trash anywhere either on the school compound or classroom (9.1%, n =
26 and 8.7%, n = 25 respectively). The current low levels of hygiene knowledge among learners
in the study area has potential to affect learners’ performance at school as risky hygiene practices
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make them vulnerable to contracting infectious diseases and missing school. This prompts the
need to think beyond the infusion approach used in schools. Extra-curricular clubs in schools
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should be established to promote pro-hygiene behaviors and to facilitate adolescence meaningful

and sustained participation.
Key words: Hygiene behaviors, sanitation, primary school, learners, public health, Okavango
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delta, Ngamiland
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Introduction

Better sanitation and personal hygienic practices are considered important towards

reducing the risks of spreading communicable diseases and improving public health. Water,

sanitation and hygiene (WASH) attributable diseases are a cause of concern globally (Anthonj,

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Rechenburg, & Kistemann, 2016). For example, diarrhea is among top ten (10) causes of death

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among the 10-19 year olds (WHO, 2017a; 2017c), and the second among 10-14 year olds

(Taghizadeh Moghaddam, Bahreini, Ajilian Abbasi, Fazli, & Saeidi, 2016). Primary school

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learners in developing countries are among the most vulnerable sub-population (Dube and

January, 2012). This is due to inadequate facilities for domestic water supply, as well as poor

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sanitation and hygienic conditions and services (Ansari and Warbhe, 2014; Greene et al., 2012;
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Shrestha and Angolkar, 2014). In Botswana, like elsewhere in developing countries, there is less

overt public demand to provide waste disposal and personal hygiene facilities in public schools.
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Promoting better personal hygiene behaviors such as hand-washing, domestic hygiene and
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sanitary disposal of human waste are pinnacles to improving public health (Ansari and Warbhe,
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2014; Wijk and Murre, 1995). The behaviors may be promoted through hygiene education

interventions, which form a critical component in public health. Improving personal hygiene
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among school children is important as it can promote better school attendance and improved

learning (Caruso et al., 2014; Shrestha and Angolkar, 2014). Mostly, children miss school when
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they contact hygiene related diseases, consequently affecting their learning (Dube and January,
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2012; Freeman et al., 2012; Adams, Simms, Chartier, & Bartram, 2009).

Many communicable diseases are likely to be transmitted by hand contact (Comer,

Ibrahim, McMillan, Baker, and Patterson, 2009; Stedman-Smith et al., 2015), making school

children most vulnerable. In a school environment, children learn and play together thereby

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making it easy to pass pathogens along. Transmission of pathogens can be controlled and

prevented through safe disposal of stool and waste, adequate hand washing and provision of

sustained clean and safe drinking water (World Bank, 2005). Globally, water, sanitation, and

hygiene (WASH) intervention programs were promoted and implemented, primarily targeted to

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prevent and control the spread of communicable diseases at household level (Ramesh, Blanchet,

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Ensink, & Roberts, 2015). In schools, the WASH programs were targetted to the provision of

WASH facilities and services, inculcating life skills and undertaking communty outreach

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(Adams et. al., 2009; UNICEF, 2012).

The sanitation sector is seldom given priority and/or integrated into national development

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planning worldwide (Rosemarin et al., 2008). Despite the global MDG target for water being
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met, the MDG review revealed that sanitation coverage targets were not met, mostly from the

least developed countries (UNICEF/WHO, 2015). Notwithstanding missing the global target, an
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increase from 54% to 68% globally during the MDG period was recorded (UNICEF/WHO,
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2015). According to the review assessment, ninety-five (95) countries did not meet the MDG
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targets. Building on the gains of the MDGs, 17 SDGs were adopted by the UN General

Assembly, with the Sustainable Development Goal 6 (SDG 6 – the water SGD), to focus on
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drinking water, sanitation and hygiene as part of the overall SDGs framework for 2015-2030

(UN, 2015). SDG 6 is overarching because water, sanitation and hygiene development are
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instruments of sustained development, economic growth, and poverty reduction. This makes
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SDG 6 the most critical SDG for the achievement of other SDGs. It relates to others dealing with

health, cities, consumption-production, marine resources and terrestrial ecosystems (World Bank

Group and UNICEF, 2017). At least 40% of the world population is affected by water scarcity

and 2.4 billion lack access to basic sanitation (UN, 2017), with only one person in three in sub-

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Saharan Africa having access to improved sanitation (WHO, 2017b). According to the

WHO/UNICEF Joint Monitoring Programme, by 2015, 946 million people defecated in the open

worldwide, with one third (33%) of people in sub Saharan Africa still practicing open defecation,

signifying an increase from the 1990 statistics (WHO, 2015). Water and sanitation are intricately

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linked to hygiene, so much that when either one is compromised, hygiene becomes a concern.

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The post 2015 WASH targets review underscored the need to promote hygiene in all settings

(WHO & UNICEF, 2015). Realizing that the pre 2015 WASH programs primarily targeted

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households, the post 2015 targets identified health care facilities and schools as priority settings.

Studies have underscored the need to target pro-hygiene behavioral interventions in

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school children as their age is conducive for learning life-long positive health habits (Ansari and
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Warbhe, 2014; Shrestha and Angolkar, 2015; Taghizadeh Moghaddam, Bahreini, Ajilian Abbasi,

Fazli, & Saeidi, 2016). Others have indicated paucity of research and the consequent need for
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dedicated studies on hygienic practices and habits among school going children or adolescents in
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developing countries (Adams, Simms, Chartier, & Bartram, 2009; Caruso et al., 2014; Dube and
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January, 2012; Patton et al., 2016; Sarkar, 2013; Shrestha and Angolkar, 2014; Watson et al.,

2017). This exploratory study assessed hygiene education, personal hygiene practices among
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learners, and environmental sanitation and hygiene within three primary schools in the

Ngamiland district, Botswana.

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Methodology
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Study area

The study was conducted in three villages; Shorobe, Matlapana and Tubu, all situated in the

Ngamiland district, north-western Botswana (Figure 1). Shorobe has a population of about 1 039,

Matlapana 1 449 and Tubu 483 (CSO, 2012). The three study villages have primary schools

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providing instructions from Grade 1-7, with a total enrolment level of 650, 350 and 135 learners

from Matlapana, Shorobe and Tubu respectively. Other facilities found in the villages include a

clinic at Shorobe and health posts at Matlapana and Tubu.

Insert Figure 1 about here

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The choices of the study sites, together with their respective schools, were based on

residential proximity to the peri-urban center of Maun and the Okavango delta. Matlapana is

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located in close proximity to Maun, the district capital, and on the tail end of the Okavango delta.

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Shorobe village, though also on the terminal end of the Okavango delta, is about 40 km from the

peri-urban center of Maun. Tubu, representing the smallest settlement among the three, is

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situated in the middle of the Delta and furthest from the peri-urban center. The three villages are
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all next to major tributaries from the Okavango delta, which are surface sources of water for

livestock and domestic needs. The study sites location to the peri-urban center of Maun and the
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Okavango delta represents different socio-economic developments, hydro-geological and

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ecological environments and processes that have a bearing on access to water and sanitation
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generally in primary schools.

Sampling
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Sampling followed a two-staged process. First, three schools from three villages were

purposively selected based on location with respect to the Okavango Delta and residential
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proximity to Maun, the district capital and commercial hub. From each school, a proportionate
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stratified random sampling procedure was employed to select the study participants. Enrolment

registration lists of pupils from Grade 3 – 7 were sourced from the school administration and

class lists from each educational level or standard. In cases where there was more than one class

at each level, they were combined into one, thereby representing stratum for each school. Pupils

from the same stratum from each school were sequentially numbered to facilitate sampling. Each

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stratum contained fairly equal numbers of boys and girls. From each stratum (standard level),

40% of pupils were randomly sampled using computer random number generator.

Data collection and analysis

Data on physical sanitation and hygiene infrastructure in the three primary schools was

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collected through non-obtrusive structured-observation tool. Primary data was collected from

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respective schools through a social survey administered face-to-face to sampled learners in

Grades 3-7. One-to-one semi-structured interviews were conducted with teachers, mainly those

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responsible for school health and environmental clubs. Data collected included learners’

knowledge, hygiene education and practices with regard to access to water, hygiene, sanitation

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infrastructure, water availability, hand-washing, knowledge and waste disposal in three selected
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schools.

Quantitative data was analysed using descriptive statistics and qualitative data using
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content and thematic analysis. The study protocol was approved by the Institutional Review
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Board no. E1/20/2/X111/25.

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Results

Socio-Demographic Profile
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A total of 286 learners were sampled and interviewed from the three schools, with female

learners slightly above 50% (51.9%, n = 149) [Table 1]. The mean age of the learners was 11.24
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(SD = 1.82) years and an age range of 8 – 16 years.

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Insert Table 1 about here

Hygiene education

Interviews with teachers suggest that they have had some training in hygiene education

through in-service training workshops. They also stressed that hand hygiene has long been part

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of the formal curriculum in Botswana primary schools. They reported to teach hand washing

techniques to pupils and were quick to point out that these were not regularly observed by

learners. Hygiene education is infused in the curriculum and it is anticipated that pupils will use

acquired techniques even at home. However, interviews with other teachers revealed that

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infusion was not without its own challenges. Teachers said they have to contend with time

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constraints to adequately address examinable subject content matter, inadequate background

knowledge on health education and lack of health material to guide and inform instruction.

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Based on what teachers said, learners were asked whether they were taught water

conservation, good hygiene practices and sanitation. In overall, over 70% of the learners (Table

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2) indicated that they were taught on three thematic areas: water conservation, hygienic practices
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and sanitation, thereby affirming the teachers’ responses.

Insert Table 2 about here

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The results were further analyzed based on gender of learners, and the cross tabulations
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revealed that in all three subject themes, boys claimed not to have been taught something
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compared to the girls. For instance, 55.4% (n = 46) claimed they were never taught water

conservation, 57.9% (n = 22) claimed no knowledge on good hygiene practices and 62.1% (n =
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36) on sanitation.

Learners were asked to list three most important things they remember about hand
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washing from previous taught lessons. Responses were thematically coded and analyzed using
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content analysis. Most learners (34.6%), though in the minority, remembered being taught the

importance of hand-washing before eating and after using the toilet, with about 10% recalling

being taught to use soap to wash hands after toilet usage (Table 3). The low frequencies of recall

reflect potential disregard for hygiene education messages on personal hygiene, specifically

hand-washing.

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Insert Table 3 about here

Learners were further asked to list three most important health problems associated with

poor hygiene and sanitation. An overwhelming majority of learners (85.5%) reported diseases as

a health problem associated with poor hygiene. Pollution and health risks were noted by 6.7%

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and 8.7% of the learners respectively.

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When asked which diseases they think are caused by poor hygiene practices, 31.7%

mentioned diarrhea/upset stomach; 23% malaria; 16.4% bilharzia, and 14.8% cholera.

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Personal hygiene practices

Learners were asked how often they washed their hands at home before and after eating.

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For both hand washing before and after eating, over 70% of learners indicated they ‘always’
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wash their hands, with slightly over one-fifth indicating ‘sometimes’ (Table 4).

Insert Table 4 about here

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Learners were also asked to indicate what they use when water is not available within the
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school to wash their hands. About two-thirds (66.4%, n = 190) of the learners indicated that they
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do not wash hands at all, 13% (n = 38) use bowsed water, while 11% (n = 33) use water brought

from home. Others use water provided by the school in buckets (3.5%, n = 10) with remaining
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learners using other means – such as using papers or school uniform to wipe-clean their hands

after eating. Learners indicated that water stored in buckets was reserved for drinking purposes
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only when there was no water in school from the main supply, hence not allowed to use it
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anyhow.

Learners were asked to indicate advantages of hand washing after using the toilet. Two

thirds of learners (66.3%, n = 187) stated it prevents disease transmission, 10.3% (n = 11) food

contamination while 18.4% (n = 52) indicated both. Interviews with teachers indicated that

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inadequate and unreliable water supply was a major barrier to personal hygiene within the school

environment.

Environmental sanitation and hygiene

Learners were asked to indicate the frequency of cleanliness of their classrooms and the

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school environment. Generally, learners individually and collectively perceived their classrooms

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and school compound to be clean ‘sometimes’ (Table 5). Overwhelming majority of learners

indicated that they dispose solid waste in dustbins (99.3%, n = 284), use refuse bags (80.8%, n =

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231), open skips (64%, n = 183) and very few throw trash anywhere, either on the school

compound or classroom (9.1%, n = 26 and 8.7%, n = 25 respectively).

Insert Table 5 about here

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Field observations indicated availability of solid waste receptacles resources in all

primary schools. The expectation is that learners use these waste disposal facilities to help
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manage waste and maintain cleanliness within the school’s physical and learning environments.
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Learners frequently used them and kept their school compounds relatively clean. The main
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problem was uncollected garbage in waste skip receptacles.

Discussions
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The study explored hygiene education, knowledge and personal hygiene practices among

learners in three primary schools in Ngamiland district, Botswana. Specifically, the study
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assessed hygiene education, personal hygiene practices among the learners as well as
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environmental sanitation and hygiene within the schools.

Hygiene education

The findings indicate that hygiene education is infused into school curricula, and it is

notable that Botswana curricula have included hygiene education at primary level. Teachers are

also trained in hygiene, through in-service trainings. Infusion of hygiene education in the

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curricula is a good approach as it allows coverage of hygiene matters within all subjects.

Proponents of infusion approach have advanced that infusion provides opportunities for teaching

and giving life-skills even when there are no dedicated time slots within timetables. It is further

argued that hygiene and sanitation education is a natural fit into most of the core curricula

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subjects in school (Bwayo, 2014; Hahn, FitzGerald, KeeMarkham, Glassman, & Guenther,

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2012).

Notwithstanding this, infusing additional subject content into a core curricula subject

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does not come without its own challenges. As teachers have noted, the tendency to prioritize and

emphasize core and examinable subject content material within limited time at the expense of

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hygiene education is defeating. However, studies from elsewhere have identified similar
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challenges with infused subjects such as: i) congested syllabus - leaving no room for additional

new material, ii) limited background knowledge and skills to teach the infused subject content,
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iii) unavailability of teaching materials and resources to facilitate teaching, iv) teachers’ attitudes
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and tendencies to devote most time on examinable material, and v) learners’ tendency to digress
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into infused materials that are not examinable (Hewitt, Candek, and Engel, 2006; Risiro, 2014;

Wilkinson, Rounds, and Copeland, 2002). To address limited WASH knowledge and skills,
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Teacher Training Colleges should include public health education as mandatory for all teachers.

Generally, male learners claimed or did not recall being taught hygiene issues more than
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female learners. This finding is not surprising as studies from elsewhere have shown that
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knowledge level of male learners is often lower than female learners (Sarkar, 2013). This may

further explain why other studies have found that males exhibited sub-optimal hygiene behaviors

than girls (Peltzer and Pengpid, 2014; Tran, Phongsavan, Bauman, Havea, and Galea, 2006).

There is need for hygiene behavior intervention to focus more on the boy-child to promote better

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hygiene behaviors. The sub-optimal hygiene behavior shown by boys is a matter of concern. A

study by Borchgrivink et al., (2013) conducted in a college town in the USA on hand washing

behavior in adults revealed that women washed hands more often than men after using public

toilets. These findings indicate that if boys at adolescence are left to display their sub-optimal

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hygiene behavior, they tend to grow with the behavior, as demonstrated by the study. Clough

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(2011) opined that this may be due to cultural roles and expectations put on boys and girls when

they grow. She blamed the gendered social expectations which emphasize cleanliness and

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neatness more on girls than boys. A concerted effort is therefore needed between parents and

teachers to ensure conceptual and cultural change towards the upbringing of boys and girls when

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it comes to hygiene behaviors. Prior to this, there is also a need to better understand the cultural
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and traditional belief systems towards hygiene behaviors (Kaltenthaler and Drašar, 1996) and the

role they play in gendered hygiene behaviors.

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Proportion of learners who recalled what they have been taught on hygiene at school is
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very low within the study area. Very few learners (34.6%) could recall what they were taught in
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school with respect to hand hygiene and could only recall ‘diseases’ as a problem associated with

poor sanitation and hygiene. This low level of knowledge of basic hygiene and sanitation is a
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cause of concern in the study area. Diarrhea, as one of the top three infectious diseases causing

children mortality globally (Liu et al., 2015), is caused by inadequate access to water, lack of
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hygiene and sanitation facilities. Role modeling, correct and consistent hand washing may also
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be useful for learners to ensure understanding, as this may be a newly enforced practice in

schools. An increase in posters in the classrooms and near toilets could continue to help educate

and remind learners how and when to wash hands before and after eating as well as before and

after using toilet. Frequent water shortage challenges may be addressed by using alcohol based

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sanitation methods, which have been proven more effective than hand washing with antiseptic

soap (Jumaa, 2005). Placing hand sanitizer dispensers in each classroom would help learners and

teachers in areas where water shortage is a problem.

Hygiene practices

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Personal hygiene practice of learners was assessed with respect to hand washing at home

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before and after eating. About 70% of learners in both instances indicated that they ‘always’

washed their hands, though only about two-thirds indicated that they ‘always’ do so before

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eating at school. This finding indicates that generally personal hygiene is not satisfactory among

learners. The low proportion of hand washing at school before eating may be explained by

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inadequate and unreliable water supply within the schools. Other similar studies have reported
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about 85% learners washing their hands before eating in India (Sarkar, 2013), an average of

about 97% reported washing hands before and after meals in Ethiopia (Vivas et al., 2010) and
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76.1% in Nigeria (Oyibo, 2012). However, these findings are better compared to the national
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average recorded for Botswana in 2005. A study conducted on hygiene behaviors in nine African
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countries reported an average of 61.4% for hand washing behaviors before eating among

adolescents in Botswana, with Senegal highest with 77.4% (Pengpid and Peltzer, 2011).
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Generally, the self-reported frequency of hand-washing prior to eating in the study area

and Botswana is lower when compared to those reported from studies of similar school
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populations from other countries. This calls for: 1) promotion of personal hygiene education
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(Freeman et al., 2014), 2) strengthening partnerships between parents and teachers on learners’

hygiene behaviors at home and school (Adams et. al., 2009). This could be through Parent

Teacher Associations, seminars and workshops on hygiene and sanitation; and collaboration with

the school health team, and 3) innovative strategies beyond infusion of hygiene and sanitation

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education in school curricula. In implementing WASH programs within schools, authorities

should consider the WASH standards for schools in low-cost settings guidelines (Adams et al.,

2009) and the WASH in schools manual (UNICEF, 2012). The former is more relevant to the

study sites setting as they were developed to fit similar environments.

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To promote better hygiene behavior among learners, it is also necessary to establish and

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promote environmental health clubs in schools. The initiative is similar to environmental clubs

formed to promote environmental awareness among students. Environmental health clubs are

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being implemented in Uganda and are found worthwhile (Muzaku, 2011). The initiative is hailed

for playing community advocacy on hygiene and sanitation matters within and outside the

school.
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Environmental sanitation and hygiene

Waste disposal facilities like dustbins, drums and open skips are very important in a
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learning institute in order to handle the waste produced. The three schools have these sanitation
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facilities; hence they facilitated sanitation enabling behaviors among learners. A study by Silo
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(2013) found that teachers and learners’ main concern regarding environmental sanitation was in

relation to the unsanitary state of the toilets and litter picking activities without use of gloves.
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Similar findings were reported by Shaibu and Phaladze (2010) who further indicated that schools

still relied on students to clean classrooms and toilets. Environmental health assessment is the
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most neglected aspect of the Botswana School Health policy. While the study noted that
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classroom cleaning was done by learners as extra-curricular activity, the practice has since been

replaced by hiring school cleaners. The main concern is inadequate cleaning personnel and

resources, a situation which may explain why majority of students considered classrooms

cleaned ‘sometimes’. It is thereby necessary that adequate cleaning staff is provided to keep

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classrooms conducive for learning. Studies have advanced the importance of targeting learners

during adolescence to promote better hygiene behaviors (Assefa and Kumie, 2014; Sarkar,

2013). Young people are considered change agents and best placed to learn and influence

hygiene habits at school and home (Adams et. al., 2009). It is therefore imperative that resources

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are committed for WASH programs and services. Pragmatic measures also to be taken within the

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school environment to facilitate pro-hygiene behaviors.

While it is commendable that efforts are in place to provide the schools with sanitation

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enabling facilities for solid waste management as observed in the three schools, it is also

defeating that solid waste is not removed timely within school premises. The practice is not

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hygiene enabling as solid waste and litter run the risk of being blown by wind and/or scattered
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around the school environment by wild and domestic animals. This may de-motivate learners in

the long-run. Proper waste disposal is a key factor of sanitation, and is crucial to public health.
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Conclusions
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The study was conducted to assess hygiene education, knowledge and personal hygiene
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practices within three primary schools in Ngamiland district, Botswana. The study found out that

hygiene education is offered in the three schools, albeit through infusion approach. The infusion
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approach if found to have its own challenges. Teachers should be capacitated to effectively teach

hygiene and sanitation education through training. Teacher Training Colleges curriculum should
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also include a mandatory subject on public health for all prospective teachers. The study found
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that hygiene behaviors and knowledge in the study area are unsatisfactory, prompting the need to

think beyond the infusion approach and to establish health clubs in primary schools. While

hygiene enabling facilities were found in the study area, mainly for solid waste management, the

study found that garbage collection within the school environment is not done timely as it should

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be. It is necessary that garbage collection is closely monitored, as there is a potential for both

domestic and wild animals to undo the good hygienic efforts by the learners.

Hygiene education, improved water supply and sanitation are key to reducing the burden

of diarrheal diseases and other water related diseases. School authorities and stakeholders must

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collaborate to ensure a healthy school environment, conducive for teaching and learning through

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provision of appropriate, adequate and functioning WASH facilities. Instilling positive hygiene

practices among learners at home and school should be continued through hygiene education.

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Hygiene education at home and school should be emphasized during parents-teacher association

meetings to conscientise parents on the need to promote pro-personal hygiene behaviors at home,

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School authorities and stakeholders will benefit mostly by complying with the WASH and
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standards guidelines developed by WHO for schools in rural areas (Adams et. al., 2009).

Furthermore, there is need to review curriculum in teacher education institutions to

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include mandatory public health education. Implementing effective WASH programmes in

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schools need to be continuous. Adequate resources must be committed to WASH programmes in

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schools including capacitating teachers through in-service training. Timely removal of solid

waste from school premises is also crucial. Future studies focusing on examining determinants of
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pro-hygiene and sanitation behaviors are recommended across different regions in Botswana.

This is essential because factors such as socio-economics, culture, and ethnicity, interpersonal,
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urban or rural domicile have been found to influence adolescence health-related behaviors and
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practices (Mahalik et al., 2013; Patton et al., 2016; Taghizadeh et. al., 2016). Previous studies

have highlighted the need to understand cultural and traditional belief systems and the role they

play in gendered hygiene behaviors. These initiatives, together with empirically informed

interventions, will likely contribute towards reducing hygiene related diseases in the district and

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the country. It is necessary that interventions targeted to influencing adolescents’ health are

relevant to the socio-cultural settings and its realities for effectiveness. Most health promotion

interventions implemented are informed by evidence from high-income countries, with the

potential to affecting effectiveness (Patton et al., 2016). Active collaboration among all

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stakeholders coupled by requisite and adequate funding from governments and non-

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governmental actors will help ensuring that targets for the water SDG 6 are fully met by all

countries by 2030.

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Acknowledgements

Funding for this study was provided through the GEF Small Grants Grant funding.

Co-funding by the Office of Research and Development, University of Botswana and Southern

African Regional Environmental Program (SAREP) Contract 674-C-00-10-00030-00

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TABLES
Table 1. Respondents by school
Name of Sex of child

School Male Female Total %

Matlapana 86 81 167 58.4

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Shorobe 35 50 85 29.7

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Tubu 16 18 34 11.9

Total 137 149 286 100

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Table 2. Thematic areas recalled by learners
Response

Thematic area
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Yes No
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Water conservation 202 (70.9) 83 (29.1)
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Hygiene practices 247 (86.4) 38 (13.3)

Sanitation 226 (79.6) 58 (20.4)

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Parenthesis indicates percentage

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Table 3. Hand- washing lessons themes remembered by learners

Themes Number of learners %
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N = 245

Wash hands after toilet use 85 34.6

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Wash hand before eating 85 34.6

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Prevent disease/sickness transmission 31 12.6

Wash hand with soap after toilet use 26 10.6

Washing hands after handling dirty things, litter, and 18 7.3

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Table 4. Hands washing at home before and after eating

Hands washing at home
Response Before eating After eating
category N % N %

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Always 208 72.7 201 70.5

Sometimes 67 23.4 70 24.6

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Rarely 8 2.8 5 1.8

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Never 3 1 9 3.2

Total 286 100 286 100

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Table 5. Cleanliness of classroom/school compound
Premise Always Sometimes Rarely Never
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Classroom 120 (42%) 145 (50.7%) 18 (6.3%) 3 (1%)

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School compound 59 (20.6%) 190 (66.4%) 28 (9.8%) 9 (3.1%)

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FIGURES

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Figure 1. Map of study area

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References

Adams, J., Simms, J., Chartier, Y., & Bartram, J. (Eds.). (2009). Water, sanitation and hygiene
standards for schools in low-cost settings. Geneva: World Health Organization.
Ansari, S.Y., and Warbhe, P.A. 2014. Assesment of knowledge and practice regarding personal
hygiene among school children from an urban area. International Journal of Current
Medical and Applied Sciences, 4(1), 1-12.

PT
Anthonj, C., Rechenburg, A., & Kistemann, T. (2016). Water, sanitation and hygiene in
wetlands. A case study from the Ewaso Narok Swamp, Kenya. International Journal of
Hygiene and Environmental Health, 219(7, Part A), 606-616. doi:

RI
https://doi.org/10.1016/j.ijheh.2016.06.006
Assefa, M., and Kumie, A. 2014. Assessment of factors influencing hygiene behaviour among
school children in Mereb-Leke District, Northern Ethiopia: A cross-sectional study. BMC

SC
Public Health, 14, 1-11.
Borchgrevink, C.P., Cha, J., and Kim, S. 2013. Hand washing practices in a college town
environment. Journal of Environmental Health, 75(8), 18-24.
Bwayo, J. 2014. Primary school pupils’ life skills development the case for primary school

U
pupils development in Uganda. (PhD), University of Limerick Limerick.
Caruso, B.A., Freeman, M.C., Garn, J.V., Dreibelbis, R., Saboori, S., Muga, R., and Rheingans,
AN
R. 2014. Assessing the impact of a school-based latrine cleaning and handwashing
program on pupil absence in Nyanza Province, Kenya: a cluster-randomized trial.
Tropical Medicine & International Health, 19(10), 1185-1197. doi: 10.1111/tmi.12360
Clough, S. 2011. Gender and the hygiene hypothesis. Social Science & Medicine, 72(4), 486-
M

493. doi: http://dx.doi.org/10.1016/j.socscimed.2010.11.021

Comer, M.M., Ibrahim, M., McMillan, V.J., Baker, G.G., and Patterson, S.G. 2009. Reducing the
spread of infectious disease through hand washing. Journal of Extension, 47(1), 1-8.
D

CSO. 2012. 2011 Population and housing census. Population villages and associated localities.
In CSO (Ed.). Gaborone: Central Statistics Office, Government Printer.
TE

Dube, B., and January, J. 2012. Factors leading to poor water sanitation hygiene among primary
school going children in Chitungwiza. Journal of Public Health in Africa, 3(1), 25-28.
doi: http://dx.doi.org/10.4081/jphia.2012.e7
Freeman, M.C., Greene, L.E., Dreibelbis, R., Saboori, S., Muga, R., Brumback, B., and
EP

Rheingans, R. 2012. Assessing the impact of a school-based water treatment, hygiene and
sanitation programme on pupil absence in Nyanza Province, Kenya: a cluster-randomized
trial. Tropical Medicine & International Health, 17(3), 380-391. doi: 10.1111/j.1365-
C

3156.2011.02927.x
Freeman, M.C., Stocks, M.E., Cumming, O., Jeandron, A., Higgins, J.P.T., Wolf, J., . . . Curtis,
AC

V. 2014. Systematic review: Hygiene and health: systematic review of handwashing

practices worldwide and update of health effects. Tropical Medicine & International
Health, 19(8), 906-916. doi: 10.1111/tmi.12339
Greene, L.E., Freeman, M.C., Akoko, D., Saboori, S., Moe, C., and Rheingans, R. 2012. Impact
of a school-based hygiene promotion and sanitation intervention on pupil hand
contamination in western Kenya: A cluster randomized trial. The American Journal Of
Tropical Medicine And Hygiene, 87(3), 385-393.
Greenland, K., Cairncross, S., Cumming, O., and Curtis, V. 2013. Editorial: Can we afford to
overlook hand hygiene again? Tropical Medicine & International Health, 18(3), 246-249.
doi: 10.1111/tmi.12055

21
 ACCEPTED MANUSCRIPT

Hahn, J.E., FitzGerald, L., KeeMarkham, Y., Glassman, P., and Guenther, N. 2012. Infusing oral
health care into nursing curricullum: Addressing preventive health in aging and disability.
Nursing Research and Practice, 2012, 1-10. doi: 10.1155/2012/157874
Hewitt, J.B., Candek, P.R., and Engel, J.M. (Writers). (2006). Challenges and successes of
infusing environmental health content in a nursing program: Blackwell Publishing Inc.
Jumaa, P.A. 2005. Hand hygiene: simple and complex. International Journal of Infectious
Diseases, 9(1), 3-14. doi: http://dx.doi.org/10.1016/j.ijid.2004.05.005

PT
Kaltenthaler, E.C., and Drašar, B.S. 1996. The study of hygiene behaviour in Botswana: a
combination of qualitative and quantitative methods. Tropical Medicine & International
Health, 1(5), 690-698. doi: 10.1111/j.1365-3156.1996.tb00097.x

RI
Liu, L., Oza, S., Hogan, D., Perin, J., Rudan, I., Lawn, J. E., . . . Black, R. E. (2015). Global,
regional, and national causes of child mortality in 2000-2013; with projections to inform
post-2015 priorities: an updated systematic analysis. The Lancet, 385(9966), 430-440.

SC
doi: 10.1016/S0140-6736(14)61698-6
Mahalik, J. R., Levine Coley, R., McPherran Lombardi, C., Doyle Lynch, A., Markowitz, A. J.,
& Jaffee, S. R. 2013. Changes in health risk behaviors for males and females from early
adolescence through early adulthood. Health Psychology, 32(6), 685-694. doi:

U
10.1037/a0031658
Moshabela, M., MacPherson, P., Ezard, N., Frean, E., Mashimbye, L., Elliott, J.H., and
AN
Oldenburg, B. 2012. Clinical and social determinants of diarrhoeal disease in a rural
HIV/AIDS clinic, South Africa: a case-control study. International journal of STD &
AIDS, 23(5), 346-350. doi: 10.1258/ijsa.2011.011285
Muzaku, S. (2011). Children as effective change agents: The case of school health clubs in the
M

promotion of urban sanitation and hygiene. Paper presented at the East Africa
practitioners workshop on pro poor urban sanitation and hygiene, Kigali, Rwanda.
Oyibo, P.G. 2012. Basic personal hygiene: Knowledge and practices among school children
D

agaed 6-14 years in Abraka, Delta State, Nigeria. Contineltal J. Tropical Medicine, 6(1),
5-11.
TE

Patton, G. C., Sawyer, S. M., Santelli, J. S., Ross, D. A., Afifi, R., Allen, N. B., . . . Viner, R. M.
2016. Our future: A Lancet commission on adolescent health and wellbeing. The Lancet,
387(10036), 2423-2478. doi: 10.1016/S0140-6736(16)00579-1
EP

Peltzer, K., and Pengpid, S. 2014. Oral and hand hygiene behavior and risk factors among in-
school adolescents in foru Southeast Asian countries. International Journal of
Environmental Research and Public Health, 11, 2780-2792.
Pengpid, S., and Peltzer, K. 2011. Hygiene Behaviour and Associated Factors among In-School
C

Adolescents in Nine African Countries. International Journal of Behavioral Medicine,

18(2), 150-159. doi: 10.1007/s12529-010-9109-6
AC

Ramesh, A., Blanchet, K., Ensink, J. H. J., & Roberts, B. (2015). Evidence on the effectiveness
of water, sanitation, and hygiene (WASH) Interventions on health outcomes in
humanitarian crises: A systematic review. PLoS ONE, 10(9), e0124688. doi:
10.1371/journal.pone.0124688
Risiro, J. 2014. An evaluation on the implementation of environmental education program at
Mutare Teachers' College in Zimbabwe. International Journal of Innovative Research
and Development, 3(1), 264-271.
Rosemarin, A., Ekane, N., Caldwell, I., Kvarnstrom, E., McConville, J., Ruben, C., & Fogde, M.
(2008). Pathways for sustainable sanitation: IWA Publishing.

22
 ACCEPTED MANUSCRIPT

Sarkar, M. 2013. Personal hygiene among primary school children living in a slum of Kolkata,
India. Journal of Preventive Medicine and Hygiene, 54, 153-158.
Shaibu, S., and Phaladze, N.A. 2010. School health: the challenges to service delivery in
Botswana. Primary Health Care Research & Development, 11, 197-202. doi:
0.1017/S1463423609990417
Shrestha, A., and Angolkar, M. 2014. Impact of health education on the knowldge and practice
regarding personal hygiene among primary school children in urban area of Karnataka,

PT
India. Journal of Dental and Medical Sciences, 13(4), 86-89.
Shrestha, A., and Angolkar, M. 2015. Improving hand washing among school children: An
educational intervention in South India. Al Ameen Journal of Medical Sciences, 8(1), 81-

RI
85.
Silo, N. 2013. The plight of sanitation managment in selected schools in Botswana - A critical
concern. European Scientific Journal, 9(2), 12-26.

SC
Stedman-Smith, M., DuBois, C.L.Z., Grey, S.F., Kingsbury, D.M., Shakya, S., Scofield, J., and
Slenkovich, K. 2015. Outcomes of a Pilot Hand Hygiene Randomized Cluster Trial to
Reduce Communicable Infections Among US Office-Based Employees. Journal of
Occupational and Environmental Medicine, 57(4), 374-380. doi:

U
10.1097/jom.0000000000000421
Taghizadeh Moghaddam, H., Bahreini, A., Ajilian Abbasi, M., Fazli, F., & Saeidi, M. 2016.
AN
Adolescence health: The needs, problems and attention. International Journal of
Pediatrics, 4(2), 1423-1438. doi: 10.22038/ijp.2016.6569
Tran, D., Phongsavan, P., Bauman, A., Havea, D., and Galea, G. 2006. Hygiene Behaviour of
Adolescents in the Pacific: Associations with Socio-demographic, Health behaviour and
M

School Environment. Asia-Pacific Journal of Public Health, 18(2), 3-11. doi:

10.1177/10105395060180020201
UN. 2017. Clean water and sanitation: Why it matters. Retrieved from
D

http://www.un.org/sustainabledevelopment/water-and-sanitation/.
UN. 2015. Transforming our world: the 2030 Agenda for Sustainable Development -
TE

A/RES/70/1. Retrieved from

https://sustainabledevelopment.un.org/post2015/transformingourworld/publication.
UNICEF. 2012. Water, sanitation and hygiene (WASH) in schools. New York: UNICEF
EP

Retrieved from https://www.unicef.org/publications/files/CFS_WASH_E_web.pdf

UNICEF/ WHO. 2015. Progress on sanitation and drinking water - 2015 update and MDG
assessment. New York: UNICEF/WHO.
Vivas, A., Gelaye, B., Aboset, N., Kumie, A., Berhane, Y., and Williams, M.A. 2010.
C

Knowledge, attitudes, and aractices (KAP) of hygiene among school children in

Angolela, Ethiopia. Journal of Preventive Medicine and Hygiene, 51(2), 73-79.
AC

Watson, J. A., Ensink, J. H. J., Ramos, M., Benelli, P., Holdsworth, E., Dreibelbis, R., &
Cumming, O. 2017. Does targeting children with hygiene promotion messages work?
The effect of handwashing promotion targeted at children, on diarrhoea, soil-transmitted
helminth infections and behaviour change, in low- and middle-income countries. Tropical
Medicine & International Health, 22(5), 526-538. doi: 10.1111/tmi.12861
WHO. 2017a. Adolescents: health risks and solutions - Fact Sheet. Retrieved from
http://www.who.int/mediacentre/factsheets/fs345/en/.
WHO. 2017b. Clean water and sanitation: Why it matters. Retrieved from
http://www.un.org/sustainabledevelopment.

23
 ACCEPTED MANUSCRIPT

WHO. 2017c. Health for the world's adolescents: Mortality, morbidity and disability in
adolescence. Retrieved from http://apps.who.int/adolescent/second-decade/section1.
WHO. 2015. Key facts from WHO/UNICEF Joint Monitoring Programme 2015 report.
Retrieved from http://www.who.int/water_sanitation_health/monitoring/jmp-2015-key-
facts/en/.
Wijk, C.V., and Murre, T. 1995. Motivating better hygiene behavior: Importance for public
health mechanisms of change. New York: UNICEF.

PT
Wilkinson, D.S., Rounds, K.A., and Copeland, V.C. 2002. Infusing Public Health Content into
Foundation and Advanced Social Work Courses. Journal of Teaching in Social Work:
22:139-154. doi: 10.1300/J067v22n03_10

RI
World Bank. 2005. The handwashing handbook: a guide for developing a hygiene promotion
program to increase handwashing with soap. Water and sanitation program.

SC
Washington, DC: World Bank.
World Bank Group and UNICEF. 2017. Sanitation and water for all: How can the financing gap
be filled? A discussion paper. Washington, DC: World Bank.

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Highlights

• Study explored hygiene education, personal hygiene practices among learners and
environmental sanitation in primary schools
• Hygiene behaviours and knowledge in the study area are unsatisfactory
• Boys exhibited sub-optimal hygiene behavior when compared to girls
• Majority of learners dispose solid waste in proper solid waste disposal facilities

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• hygiene behavior intervention to focus more on the boy-child to promote better hygiene
behaviors

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