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Hygiene and Environmental Health Module: 5. Institutional Hygiene and Sanitation

Study Session 5  Institutional Hygiene and Sanitation

Introduction

In this study session you will be introduced to the public health importance of various local institutions, such as schools, prisons, offices, clinics, Health Posts, churches and mosques. We will consider the essential hygiene requirements for these establishments and enable you to relate this to your own locality. In addition, this session introduces you to planning and making follow-up assessments of the hygiene status of these institutions.

Learning Outcomes for Study Session 5

When you have studied this session, you should be able to:

5.1  Define and use correctly each of the key words printed in bold. (SAQ 5.1)

5.2  Identify the local institutions that require attention for hygiene. (SAQ 5.2)

5.3  Describe the public health importance of public institutions. (SAQ 5.3)

5.4  Explain the basic hygiene requirements of institutions in your locality. (SAQ 5.4)

5.5  Describe the activities needed for planning the promotion of hygiene and sanitation in local institutions. (SAQ 5.5)

5.6  Identify the tools that are needed for institutional inspection. (SAQ 5.6)

5.1  Scope of institutional hygiene

Public institutions are those that provide social, educational and religious public services to the general population. They include schools, nursery homes, clinics, Health Posts, prisons, jails, churches and mosques. You may have some or all of these in your locality. These are the focus of institutional hygiene. However, there are other sectors of service such as shopping centres, mill houses, slaughterhouses and traditional markets that may also require your attention.

Children attending school, patients attending Health Posts and other people seeking services are vulnerable to various diseases, accidents and stresses. Protecting the health of all these people is essential from a public health point of view. The promotion of basic hygiene is very important in these local institutions.

5.2  Public health importance of institutional hygiene

The public health importance of local institutions is considered to be an extension of healthful housing. These institutions are places where people spend much of their time outside their home. The satisfaction of their physiological and psychological needs, and protection against infections and accidents, depend on the way hygiene is promoted in these local institutions. It is possible for these institutions to be the focal point for epidemic diseases such as diarrhoea and measles due to poor hygiene.

5.3  School hygiene and sanitation

When we say schools, we mean kindergartens, primary schools (first and second cycle), and high schools, all of which could be present in your locality (Figure 5.1).

An elementary school
Figure 5.1  An elementary school in one of the rural areas of Ethiopia. (Photo: Abera Kumie)

5.3.1  Public health importance of school hygiene and sanitation

School children spend about one third of their time either in schools or doing school assignments, during which time they may be exposed to a variety of physical, social and psychological harm. Schools provide an ideal opportunity to detect poor hygiene practice by children.

The water supply and sanitation conditions of schools have become a public health concern in recent years. A Ministry of Health report in 2007 about school hygiene in Ethiopia indicated that the majority of surveyed primary schools did not have access to drinking water sources or adequate sanitation facilities for handwashing and excreta disposal. School dropouts are observed among female students due to a lack of latrines with facilities for menstrual hygiene. The report also found that the hygiene knowledge of the prevention of communicable diseases was poorly understood by students.

Other studies in Ethiopia among school children indicate that upper respiratory infections, skin infections, abdominal discomfort, eye infections, gastro-enteritis (diarrhoea) and tonsillitis are the commonest ailments for school clinic visits. Helminthic infections such as ascariasis and hookworm are prevalent because of the prevailing poor personal hygiene and waste management in the school and home environment.

The provision of school hygiene and sanitation ensures the rights of students to acceptable hygiene practices, safe water supply, latrines and a healthy school environment in general. The impact could have further beneficial effects, for example:

  • Healthy environments facilitate more effective learning.
  • Opportunities for students to gain life-long positive hygiene behaviours.
  • Opportunities for increased school enrolment, retention and attendance for girls.

5.3.2  Components of school hygiene and sanitation

  • You have been a school student at some time in the past. What were the components of school health services in your time?

  • You might have various memories of events. Your classroom teacher might have checked your personal hygiene. You might have learned about trachoma and face washing in science class. Someone might have reminded you to use the latrine and wash your hands afterwards.

Your concern as a healthworker is the need to check systematically:

  • health-related policies in schools
  • hygiene
  • safe water supply
  • sanitation.

We will discuss these and other aspects of the school environment in turn.

Health-related policies in schools

All schools should be aware of the importance of school hygiene and sanitation for their students. Promotion of hygiene, organising hygiene/health clubs, having a clean school compound and supervising classrooms for their cleanliness are some of the items that require the attention of the woreda and kebele school authorities. The implementation of policy statements must take into account the availability of human resources and materials.

Promoting hygiene

Teaching students about health focuses mainly on the dissemination of hygiene information aimed at changing or modifying their behaviour. Health information is usually incorporated within various school subjects such as science, biology, home economics and physical education. However, teaching aimed at changing the behaviour of students is not part of the traditional education system. There are ways to fill this gap. Setting up and supporting health or hygiene clubs in schools, and the effective involvement of the Health Post, are important. You can take an active role in this by regular inspection and advising the school community in your area. You can take an active lead in coordinating and involving existing local health facilities in the promotion of school hygiene and sanitation. Detailed information on how to plan, organise and deliver health messages for school health promotion is found in the Health Education, Advocacy and Community Mobilisation Module.

The benefits of personal hygiene practice have been discussed in Study Session 3.

  • Which components of personal hygiene are most important to students?

  • Keeping the body clean, face and handwashing, wearing clean clothes, foot hygiene, and nail care are all important to students.

Healthy school environment

The physical and aesthetic values of the school environment and physical buildings need to satisfy the physical, physiological and psychological development of students. The important aspects of a safe and healthful school environment are:

  • Adequate classroom space to avoid crowding. The Ministry of Health recommends: 2 m2 per student at kindergartens; 1.11 m2 per student at primary school; 1.26 m2 per student at secondary schools.
  • Classrooms with adequate daylight and ventilation; the proportion of window to floor area should be 25%.
  • Classrooms that protect students’ vision through the appropriate distance between the blackboard and the first line of seats.
  • Dimensions of desks and chairs that match the students’ physical development.
  • The location of the school should be free from any potential physical and chemical hazards (e.g. free from noise and air pollution).
  • Playing areas for physical exercise.

You should work in collaboration with the appropriate experts of the woreda education office for the satisfaction of the above needs. This can be discussed at the kebele cabinet meetings.

Provision of drinking water

Many students may walk hours to get to school. The provision of safe water for drinking and personal hygiene is important and there needs to be adequate facilities in proportion to the number of students. The Ministry of Health advises one water tap per fifty students. Low-cost water fountains and water taps arranged in a water trough design are acceptable for schools. They should be mounted at the appropriate height from the ground surface to match the height of the students (Figure 5.2). Water availability should be about five litres per day per student and water must be available throughout the school day. A water storage tank may be necessary to provide water reserves and satisfy the demand at peak hours. The sullage (wastewater) that results because of handwashing must be drained to a seepage or soak pit, or ditch.

Drinking taps and handwashing basins
Figure 5.2  Drinking taps and handwashing basin arrangements in a school. (Photo: Wasse Shiferaw)
Provision of latrines

The provision of latrines is also extremely important. In addition, separate latrines for girls and boys need to be provided to encourage girls to continue their education. The usual type of latrine at schools is a communal dry pit latrine equipped with a vent.

School latrines should meet the following requirements:

  • They must be located away from the classroom in order to avoid interfering with the students’ learning process. They must be reasonably accessible.
  • They must be well-maintained and agreeable to use. They should provide privacy and security.
  • The dimensions of the latrine must be adequate to accommodate the storage needs for three to five years. You will learn more about this in the waste management sessions later in this Module.
  • There must be handwashing facilities near the latrine (Figure 5.3). Handwashing with soap after using the latrine and before lunch must be encouraged.
  • There should be separate latrines for male and female students. Latrines for teachers must be separated as well.
  • There must be a bucket with water and a jug inside female latrines. This is essential for cleaning the bottom for female students during menstruation.
  • In primary and secondary schools, there should be one latrine for every 30 students and one urinal for every 50 male students.
  • Latrines should be hygienic to use and easy to clean. Students themselves should participate in daily cleaning of the latrine. The hygiene/health club should take the leading role in the maintenance of latrine cleanliness.
School latrines with water container
Figure 5.3  School latrines with water container and handwashing facilities. (Photo: Abera Kumie)
Provision of solid waste management facilities

Discarded paper and cartons are the usual type of waste at schools. There could also be chemical wastes from school laboratories. Schools should have the following facilities:

  • Waste bins/buckets in each classroom and teacher’s office. Waste bins may be placed in the school compound where deemed necessary (around corridors, playgrounds).
  • Waste disposal pit at an appropriate location; a local incinerator can be used if the amount of school solid waste is significant.
Classroom sanitation

The cleanliness of the classroom is vital for a good learning process. Students should be involved in the maintenance of classroom cleanliness on a daily basis. The floor of the classroom should be smooth to reduce dust (Figure 5.4). Dust and cracks in the floor must be avoided because these are good hiding sites for biting animals such as the chigger (also known as the chigger red bug or harvest mite).

Classroom sanitation
Figure 5.4  Classroom sanitation: smooth floor, physical suitability of seats and desks, and adequate light and ventilation. (Photo: Abera Kumie)

5.4  Prison hygiene and sanitation

Detention homes such as prisons and jails, including temporary arrest facilities, must be hygienic. The transmission of communicable diseases such as diarrhoea, relapsing fever, scabies and typhus fever could be possible due to crowding and poor sanitation in prisons. The following provisions are important to check:

  • Sanitation promotion: the strict nature of the prison requires some form of local organisation that could be actively involved in cleaning the interior rooms and compound. A sanitation committee can organise this with the guidance of the authorities of the prison. Its duty is to plan and execute a sanitation day at least once a week. Room and compound cleaning, clothes washing and personal hygiene are some of the priorities to maintain the health of detainees.
  • The presence of any possible epidemics in a prison must be checked through regular prison inspection.
  • Access to safe water, showers, clothes washing stands, latrines and solid waste disposal facilities are essential in a prison.
  • An insanitary interior of the prison is attractive for insects such as cockroaches, fleas, lice and bedbugs. Inspection of new prisoners’ clothing and bodies for the presence of these insects must be done when they arrive. High standards of personal hygiene through frequent body washing, maintenance of clean premises and clean clothes should be enforced.
  • The rooms for detention should have an adequate supply of indoor light and fresh air. The surface area of windows should be a minimum of 10% of the floor area in order to admit daylight and adequate air.
  • Overcrowding must be controlled as much as possible. Overcrowding leads to the transmission of many communicable diseases.
  • Periodical hygiene education on selected relevant topics is important in order to maintain the healthy behaviour of prisoners.

5.5  Health facilities

There may be different types of local health facilities in your area, such as Health Posts, private and public clinics and health centres. The benefit of health facilities is well understood. However, the risks associated with health facilities are not always well understood by patients and the general population. Health facilities generate infectious wastes, needles and other sharps that are potentially harmful. The possibility of acquiring infections is another concern. The sanitation provision that you have learned about healthful housing in Study Session 4 is also applicable in these institutions. In particular, you should be aware of the following requirements for the Health Post you are working in:

  1. Healthcare waste must be properly segregated, collected and disposed of. Needles, other sharps, contaminated linen, gauze, cotton and similar items must be disposed of by burning. The ash and unburned items must be properly handled and buried in a designated pit.
  2. Liquid and semi-liquid wastes (placenta, blood, vomit, secretions) must be disposed of in a placenta pit.
  3. Wastehandling facilities such as latrines, an incinerator and a placenta pit must be available, depending on the type of health services provided. Latrines should be clean, comfortable and pleasant to use.
  4. Water supply and plumbing (water tank, handwashing facilities) are very important for good personal hygiene practice among healthworkers and patients.

You will learn more about healthcare waste management in Study Session 23.

5.6  Public offices

Various offices are organised to serve the population, such as the kebele administrative office. It’s important to maintain a healthy office environment for the benefit of the health of the civil servants. Particular requirements include well-lit and ventilated offices/rooms, latrines, and proper solid waste management. The supply of safe water and handwashing facilities are important for the provision of personal hygiene.

5.7  Religious institutions

Churches and mosques may be present in your kebele. The need for environmental health service to the church servants on one hand, and to the attending people on the other hand, is the point of concern. The provision of a safe water supply with its auxiliaries, and the development of latrines in agreed sites should have priority. Proper liquid and solid waste management are also important areas of intervention.

5.8  Mill house hygiene and sanitation

You can find a mill house in almost every kebele. The basic principles of healthful housing are also applicable in mill house sanitation. The location of the mill house should not be a source of nuisance to the community such as from noise, flour dust and wastes. There must be adequate light and natural ventilation at the workplace. The provision of latrines, drinking water and waste management (solid and liquid waste) is important. The presence of handwashing and shower facilities is important for personal hygiene of the workers. Floor and walls should be easy to clean. The installation of an exhaust pipe for waste flour is necessary.

The safety of workers must be maintained through the proper guarding of machines, provision of personal protective devices (head cover, goggles, boots, ear plugs or muffs, working clothes).

5.9  Planning for the improvement of institutional hygiene and sanitation

There are certain planning activities that you must do in a stepwise way. The approach is the same as that used in Study Session 4 in Section 4.7, ‘Planning for the improvement of healthful housing’. The activities are briefly described below.

5.9.1  Knowing the scope of your activity

This requires the identification of institutions by type and number: schools (both elementary and high schools), prisons (both temporary and permanent prisons), health facilities (public and private clinics; you should leave the health centres and hospitals for the woreda environmental health worker), public offices (e.g. farmers’ training centres, government offices), religious institutions (both Christian and Islamic), mill houses, and other workplaces. You should only consider those that are present at kebele level.

5.9.2  Identifying the problems related to hygiene and sanitation

Problems can be identified by carrying out a sanitary inspection of each institution. Before your inspection visit you need to prepare a checklist of basic hygiene requirements that is relevant to the institutions and your local context. An example of a checklist for a school is shown in Table 5.1.

The checklist and your physical observations should provide good baseline data that is useful for analysing any problems and setting priorities. You could also use interviews and questionnaires as additional tasks for identifying problems. However, you should note that you cannot address all problems at once because they could be deep-rooted and require resources. Setting priorties based on the local situation is helpful to select the problems that can be resolved more easily.

Table 5.1  School health survey form.
No.QuestionResponse
1.0General information
1.1Date of inspection_____________
1.2Name of the institution_______________________________
1.3Number of students by sexMale:___ Female:___
1.4Address___________________________________________
1.5OwnershipPrivate or public
1.6Level of school1st cycle/2nd cycle/high school
2.0School compound
2.1 Location of school: hazards such as noise, proximity to road___________________________________________
2.2Compound sanitation: free from solid wastes, flowing liquid wasteYes/No, indicate the subject
3.0Classrooms
3.1WindowsAdequate/inadequate
3.2VentilationAdequate/inadequate
3.3LightingAdequate/inadequate
3.4Condition of classroom floorEarth/concrete/other
4.0 Water supply
4.1Is water available in the school compound?Yes/No
4.2SourcePiped/well/spring/river/pond/other
4.3Supply of drinking water and handwashing facilitiesYes/No
4.4Number of water taps_______
4.5Cleanliness around wash basinsYes/No
5.0Latrine provision
5.1 Is a latrine available in the school compound? Yes/No
5.2Type of latrinePit latrine/VIP/other
5.3Floor of latrineConcrete slab/earth
5.4Latrine available for:Students/teachers
5.5Separate latrines for male and female studentsYes/No
5.6Latrine superstructureYes/No
5.7Excreta seen around the latrineYes/No
5.8Excreta inside the latrineYes/No
5.9Can a student use the latrine in its current condition?Yes/No
5.10Number of latrine holes_______
6.0Solid waste management
6.1Is there a refuse container in the compound?Yes/No
6.2Is there a refuse container in each classroom?Yes/No
6.3Is there a burial pit for refuse?Yes/No
6.4Is there an incinerator?Yes/No
7.0Students’ personal hygiene (observe a few students)
7.1ClothingIntact/torn/clean/unclean
7.2HairClean/unclean
7.3FaceClean/unclean
7.4NitsYes/No
7.5FeetClean/unclean
7.6FingernailsClean/unclean
7.7EyesClean/unclean
7.8LiceYes/No
7.9TeethClean/unclean
7.10ScabiesYes/No
8.0Summary of main findings
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
9.0Suggestions
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

5.9.3  Identifying partners that you can work with

It is useful to identify partners in order to work together and bring improvements from mutual effort. Your role is to guide the hygiene and sanitation practice in your locality. The implementation of your recommendations will be the responsibility of one of your partner organisations. These are likely to be government offices such as the kebele health office, education office or water office, school staff, school parents’ committees, traditional leaders, or police and court desks. It is also important to include authorities of religious institutions. The presence of a locally operating non-governmental organisation (NGO) could be a source of resources and expert advice.

5.9.4  Strategies for assessing and improving institutional hygiene

You need to understand the methods and tools for improving the hygiene conditions in public and private institutions. Here are some of them.

Designing the plan of action

You should have a plan of action that covers at least one year. The plan should indicate the list of activities in one column and the time in the second column (see Table 5.2). Note that the activities and time intervals in Table 5.2 are suggestions. You will need to devise your own schedule. The plan of action should be approved by the local authority or your supervisor so that they are aware of it. The local authority can provide you with better assistance if you involve them.

Table 5.2  Annual plan of action for assessing and improving institutional hygiene
Year:______
No.ActivityTime frame (suggested)
1Identify categories and number of public institutionsAt the beginning of the year (specify the time)
2Prepare survey tools(specify the time)
3Visit/inspect public institutionsMonthly
4Provide a feedback report to visited institutionsImmediately after the visit
5Discuss the findings with local authoritiesMonthly
6Hygiene education to studentsMonthly
7Discuss the main findings with the local government officialsMonthly
8Check personal hygiene of studentsEvery week on Mondays
9Discuss the hygiene status of religious institutions with the church and mosque leadersAt the beginning of the year (specify the time)
10Call and address a general meeting in order to discuss the annual performance and get feedback from the stakeholdersTowards the end of the year
12Mobilise resourcesWhenever needed
13Write reportsMonthly
Advocacy and public education

The enforcement of hygiene requirements is challenging. If a school has no latrine and you advise the school head to install latrines for students, thhe cannot do it immediately. They need time and a budget. In this case, you should emphasise the importance of latrines and encourage them to make the necessary budget allocation. You can also discuss the issue in the formal meetings which involve the local authorities. There are activities that do not require many resources. These are, for example, the establishment of hygiene/health clubs, hygiene education for students, and conducting personal hygiene inspections periodically.

Improving hygiene and sanitation services

Hygiene education and creating awareness are useful for the provision of information, but improvement of hygiene also needs facilities. The construction of latrines and safe water sources must be highlighted even if there are resource constraints. Just be aware that the provision of hardware, such as latrines, requires time and resources.

Inspection of public institutions

Inspection is a tool to identify problems, as described in Section 5.9.2, but it is also a means to design strategies for improvement. You need to make regular visits to each local public institution, at least once a year, using a checklist or a questionnaire that enables you to collect data, similar to the checklist for schools in Table 5.1. You should inform the owners or people responsible for the institution that you want to visit them at a specified date and time. Be transparent and genuine when inspecting to show that you want to help the institution to attain proper hygiene and not to criticise or fine them. You should give advice to the owners for improvement. You need to report to the kebele administrator for any sanitary violations that require enforcement.

Summary of Study Session 5

In Study Session 5, you have learned that:

  1. Institutional hygiene is important for a range of institutions in your operational area, including schools, health facilities, prisons or jails, public and private offices, and local religious institutions.
  2. It is important for public and environmental health that public institutions meet basic sanitation requirements, including: water supply, personal hygiene, provision of latrines and proper waste management.
  3. School hygiene and sanitation are especially important because children spend a great deal of time at school and they need a healthy environment to learn and grow, physically, mentally and socially.
  4. Sanitary inspection of public institutions is a method for identifying hygiene and sanitation problems. It can also be used to inform the design of strategies for improvement.
  5. In order to address the institutional hygiene needs in your area, there should be an operational plan that can be applied locally.

Self-Assessment Questions (SAQs) for Study Session 5

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 5.1 (tests Learning Outcome 5.1)

You have visited one of the schools in your locality and drawn the diagram of the front view of the main building shown in Figure 5.5. You also inspected the facilities and took the photographs below. What parts of this building and its surroundings can you see that satisfy the criteria for physiological satisfaction, disease prevention and accident prevention? List the parts of the building and its surroundings using the numbers shown, and state why they are important.

Diagram and photographs from school inspection
Figure 5.5  Diagram and photographs from school inspection. (Photos: Abera Kumie)
Answer
CriteriaParts of the school building
Physiological satisfaction

1  Window: facilitates good vision and ventilation

5  Smooth cleanable floor: avoids dust and vector breeding

4  Proper chairs and tables: facilitates proper sitting position

Disease prevention

3  Water: for drinking and handwashing for personal hygiene

6  Handwashing facility: for personal hygiene

7  Presence of latrine: for personal hygiene

Accident prevention2  Tidy compound: no bushes that could harbour snakes and rats

SAQ 5.2 (tests Learning Outcome 5.2)

Go around your kebele and list the categories and number of public institutions that require your service.

Answer

Your list may include kindergartens, 1st and 2nd cycle schools, junior high school, Health Posts, private clinics, mill house, or possibly others.

SAQ 5.3 (tests Learning Outcome 5.3)

You have learned about healthful housing in Study Session 4. What basic hygiene requirements are shared between healthful housing and institutional hygiene?

Answer

The health development of individuals, whether at home or in schools, prisons or other institutions, shares common needs. These are ensuring the physiological satisfaction, disease and accident prevention, and the psycho-social (mental) satisfaction in terms of the provision of basic hygiene and sanitation.

SAQ 5.4 (tests Learning Outcome 5.4)

The local kebele leader on the behalf of the woreda administrative office was asked to provide a licence for a private primary school. The kebele leader asks you to assist him to describe the basic hygiene requirements of an elementary school. What would you tell him?

Answer

The basic hygienic requirements of a school include: school compound cleanliness, proper solid waste management, access to safe and adequate water supply, access to adequate latrine provisions, classroom cleanliness, adequate lighting and ventilation, free from any external hazard such as noise, accident and pollution.

SAQ 5.5 (tests Learning Outcome 5.5)

You have to make a plan of action for the forthcoming year for the promotion of institutional hygiene. Briefly describe the activities that need to be included in your plan.

Answer

Firstly, identify the number, type and location of the various different institutions in the kebele. Then, plan a schedule for visits and inspections of each institution in the coming year. This will require the preparation of checklists and arrangement with the heads of the institutions concerned. The visits are followed by writing and delivering feedback reports and discussing the findings with the relevant authorities. Finally, you should decide on possible follow-up activities such as meetings, hygiene education, mobilising resources, etc.

SAQ 5.6 (tests Learning Outcome 5.6)

There is a school in your kebele that is due for an inspection of its hygiene and sanitation status. What tools of inspection will you consider using?

Answer

The inspection tools would include a checklist on which to note physical observations of the various aspects of the school environment. It could also be useful to interview the students and teachers, and possibly use a questionnaire if a more thorough survey of personal hygiene was required.