Journal of Public Health in Africa 2023; volume 14(s2):2540
School sanitation and student health status: a literature review
Anita Dewi Moelyaningrum,1 Soedjajadi Keman,2 Hari Basuki Notobroto,2 Soenarnatalina Melaniani,2
Lilis Sulistyorini,2 Ferry Efendi3
1Doctoral Program of Public Health, Faculty of Public Health, Universitas Airlangga, Surabaya; 2Public Health
Faculty, Universitas Airlangga, Surabaya; 3Department of Community Health Nursing, Faculty of Nursing,
Universitas Airlangga, Surabaya, Indonesia
Abstract
Introduction. UNESCO 2019 said that Indonesia’s education
has ranked 54 to 120 countries. The Sustainable Development
Goals (SDGs) contain goals 4, target 4a, indicator 4.a.1. Quality
education can be achieved with basic drinking water during school
hours, basic sanitation facilities, and basic handwashing facilities.
School sanitation is covered at targets 3, 4, and 6 of SDGs. The
objective of this review is to identify school sanitation, determina-
tion of disease, and students’ health status-related school sanitation.
Correspondence: Anita Dewi Moelyaningrum, Doctoral Program of
Public Health, Faculty of Public Health, Universitas Airlangga, Kampus
C, Jl. Mulyorejo, Surabaya, Jawa Timur, 60115, Indonesia.
Tel.: +62.315920948- Fax: +62.315924618.
E-mail: anita.dewi.moelyaningrum-2022@fkm.unair.ac.id
Key words: health status; school sanitation; students.
ci
Acknowledgments: the authors would like to thank the Faculty of
Public Health Airlangga University, Faculty of Public Health
er
Universitas Jember, and also Beasiswa Pendidikan Indonesia for sup-
porting the research.
m
Contributions: all authors contributed to the design of the study, draft-
om
ing, review, and editing. ADM, builds the idea, presentation, and analy-
sis of data; SK, HBN, LS, analyzed the data; SM, FE, build the method.
All the authors approved the final version to be published.
-c
Conflicts of interest: the authors declare no potential conflict of interest.
on
Funding: the research was supported by the Faculty of Public Health
Airlangga University, Faculty of Public Health Universitas Jember, and
N
also Beasiswa Pendidikan Indonesia.
Ethical approval and consent to participate: not needed.
Availability of data and material: Data and materials are available by the
authors.
Informed consent: the manuscript does not contain any individual per-
son’s data in any form.
Received for publication: 2 December 2022.
Accepted for publication: 8 February 2023.
This work is licensed under a Creative Commons Attribution
NonCommercial 4.0 License (CC BY-NC 4.0).
©Copyright: the Author(s), 2023
Journal of Public Health in Africa 2023; 14(s2):2540
doi:10.4081/jphia.2023.2540
[page 56] [Journal of Public Health in Africa 2023; 14(s2):2540]
Materials and Methods. This research was based primarily on
a literature review. Boolean technic was used to define the key-
words. The database used for the searching within these documents
were School Sanitation, Health, and Students. Data were found
from search engines PubMed, Science Direct, Springer, and
Google scholar. The literature review of this search was done by
the publication range 2019-2022. The search data were conducted
on 8 October 2022, which Acquired 7 articles that meet predefined
criteria.
Results and Discussions. Schools’ sanitation was identified in
ly
water supply, drinking water supply, rest room, sanitary facilities,
toilet/ latrine, hand washing facilities, cleaning policy, clean and
on
functional toilet, Water Sanitation and Hygiene Programs, and the
knowledge of sanitation. The effect of health-related school sanita-
tion was gastrointestinal illness, diarrhea, cholera, dehydration,
e
cavities in teeth, undernutrition, stunting, soil-transmitted
us
helminths, intestinal parasitic infection, toothache, decay missing,
filled permanent teeth status, and health status of students.
Conclusions. School sanitation affected the student health sta-
al
tus, absenteeism at school, and students’ concentration. Sanitation
facilities are suggested to include laws and policies.
Introduction
School sanitation is a concern of the global community.
Therefore, it is one of the goals in the Sustainable Development
Goals (SDGs). The SDGs had seventeen goals that should be
reached in 2030. The vision for drinking water, sanitation, and
hygiene in schools is shown in SDGs 3, 4, and 6. Goal number 3
had 38 targets about health that should be reached. Goal number 4
is about universal access to basic drinking water, single-sex basic
sanitation, and basic handwashing facilities in schools, and goal
number 6 is universal access to safely managed drinking water
services, safely managed sanitation services, and handwashing
facilities with soap and water.1
Quality education is a human right. Every child should get it.
Quality education mentioned in goal 4 of SDGs will be achieved
when the school meets target 4a, indicators 4.a.1 said that quality
education is achieved when there have good drinking water, sani-
tation, and hygiene in school. Schools are places that have the
potential to affect the health of students because students spend
more time every day at school than at home. There are many activ-
ities for all day at school, consequently, should fulfill the require-
ments of hygiene and sanitation to support the student’s health.
The research about sanitation showed that sanitation decreases the
risk of disease,2-4 reduces death and disability, and effected the life
span, especially in a child,5 and sanitation can use as a predictor of
fever and abortus in pregnant women in Indonesia.6
There is much research shown about sanitation in the house-
hold, but there isn`t identification of how the school sanitation and
health status to the students. It may cause low attention to school

sanitation. The pandemic COVID-19 teaches us how the impor-
tance of school sanitation to support the sustainability of school
activity, including sanitation facilities. Poor school sanitation is
still a problem around the world. There are only three-quarters of
secondary schools (74%) and two-thirds of primary schools (66%)
globally had basic water services in 2019, and only 57% of schools
had a basic hygiene service, while 25% neither had hand hygiene
facilities nor water at the school premises.7
The objective of this research is to identify school sanitation, the
determinant of disease of school students related to school sanitation,
and the student health status related to school sanitation. It will encour-
age improvements in school sanitation which can further accelerate
the achievement of SDGs goals number 3, 4, and 6 in 2030.
Materials and Methods
The research was primarily based on a literature review.
The first stage is identification, screening, eligibility and
included (Figure 1). Reference books were published, as well as
academic articles, books, and websites related to the keywords.
Data were found from search engines PubMed, Science Direct and
Springer, and google scholar. Boolean technic was used to define
the keywords. The database used for the searching within these
documents were School Sanitation, Health, and Students. Data
were found from search engines PubMed, Science Direct,
Springer, and Google scholar. The literature review of this search
was done by the publication range in 2019-2022. The article
should be in full text (n=1.503), and then the language should be
international and open access. The search data were conducted on
8 October 2022, and acquired 7 articles that meet predefined crite-
al
ria.
ci
er
Results
Sanitation and hygiene support each other. Hygiene didn’t
m
implement without sanitation facilities. School sanitation facilities
om
should be provided by the school to fulfill the right of children and
reach the SDGs goals target number 3,4 and 6 which said that
health, quality education, and sanitation. The coverage of health
-c
for all in target 3 of SDGs should be implemented at schools. It
means that all the facilities that can support the health student were
on
very important. Education quality can achieve when the students
are healthy and satisfied at school. Education quality is the goal
SGDs target 4. Basic sanitation at schools is important to support
N
healthy students. Basic sanitation at schools, such as water supply,
toilet, and hygiene facilities, supports not only the student’s health
but also the satisfaction of students while they learn at school.
The research analysis of the article can explain how sanitation
correlates with the health of the students. Seven articles meet pre-
defined criteria, which analyze the school sanitation condition and
health of students, the determinant of disease of school students
related to school sanitation, and the student health status related to
school sanitation. Some research showed that school sanitation
should be a requirement of the standard of school sanitation. The
articles involved a large population of students and combined
many methods. Randomized Controlled Trials (RCTs) with a pop-
ulation aged between two and 18 years old.8 Their research analy-
sis about comparing rinse-free hand washing (hand sanitizer, gel,
foam, hand rub) with conventional hand washing using soap and
water. The pandemic COVID-19 made some schools use rinse-free
hand washing to control the transmitted disease than using soap
and water.
[Journal of Public Health in Africa 2023; 14(s2):2540]
Article
Sanitation programs are often tried implementation at schools
to improve the achievement of sanitation. Some research was an
analysis of school sanitation with intervention. The sanitation pro-
gram is called Fit For School (FIT).9 They tried to analyze the
implementation of the FIT program, integrating school health and
water, sanitation, and hygiene intervention which had implementa-
tion in the 3 countries, i.e. Indonesia, Cambodia, and Lao PDR.
The non-randomized clustered controlled trial and follow-up of
two years in the public elementary schools involved 1847 children.
Another school sanitation program is called School garden.10 The
programs analyzed intervention programs, including the school
garden, nutrition dan water, sanitation and hygiene (WASH),
which involved 682 children aged 8-7 years from two schools ran-
domly allocated to one or three interventions.
The school’s sanitation can improve student health. Some
research analyses the association between water, sanitation, and
hygiene (WASH) services and the health status of basic-level stu-
dents ranging from sixth to eighth grades. The method we’re using
is the causal-comparative research design. There were two groups
consisting of 2 schools; each group improved and unimproved
WASH facilities at school. The 768 respondents were analyzed in
univariate, bivariate, and multivariate.11 The other research with an
analysis of 1,869 schools was conducted in Kampala, Uganda,
ly
with a cross-sectional design and conducted the cross-sectional
on
survey, which was analyzed with a Poisson regression model to
identify the factor of water, sanitation, hygiene, and health status
of students (see Table 1).12
e
School sanitation
us
Basic water is substantial in life. People couldn’t have a decent
life without water. Schools should provide water for students all
the time while they are at school. Basic drinking water and water
for sanitation are important things to decrease transmitted diseases.
The research showed that schools did not provide a hygiene-
enabling environment, no learning materials, policies, and
resources, and also the lack of access to sanitation on hygiene and
health.13
The other research showed that said that rinse free handwash-
ing, such as using hand rub, hand sanitizer, gel, and foam reduces
Illness-related absenteeism in school, but it may have identified a
small yet potentially beneficial effect.14 During the pandemic situ-
ation, some schools had a program to use hand rub, hand sanitizer,
gel, foam, etc., while traditional hand washing had barriers to use
at preschool and school children. Rinse free hand washing was
implemented to substitute the lack of water when doing the hand
washing. Although rinse-free hand washing reduces illness-related
Figure 1. Flow diagram.
[page 57]
Article

absenteeism at school, there is a small beneficial effect over tradi-
tional hand washing with running water and soap and also it can be
harmful to health and the environment.15-17 Hand washing with
running water and soap is the best way to control the transmitted
disease, especially at school. The lack of water is the reason why
the students didn’t wash their hands after using the toilet.18
School is the place where students spend a lot of time every
day. They interact with friends, objects, and the environment at
school. The frequency of hand washing is important. Some
research showed that hand washing with soap could reduce the dis-
ease,19 and the frequency of handwashing also correlates with a
decrease in the disease.20,21 The water for handwashing should be
required for the quantity and quality of clean water.
The restroom was an important facility at school. The lack of
water in the school restroom affected students’ condition. The rest-
room should be clean every time. The policy of cleaning the sani-
tation facilities had an important thing in the sustainability of san-
itation facilities. The policy had the main role of making the sani-
tation facilities clean. The cleaning policy, which supports sanita-
tion, was very important. The research showed that undernutrition
was associated with the lack of a school restroom cleaning poli-
cy.22 The policy is important to the sustainability of the program
sanitation.23 Poor planning impacts the sanitary service.24 Many
factors influence the making of water policy, such as interests,
access to information, habits, and customs.25 Sometimes, the exist-
ing policy is not effective in promoting appropriate sanitation.26
School sanitation programs help the sanitation implemented well.
Programs should be supported with policy.

Table 1. The school sanitation, disease, and health status relate to school sanitation.
No Title Author Population School sanitation Consequence Health status
Pubmed

1. Rinse free hand wash for Zachary Munn et al. 30,747 participants Water supply Poor handwashing Students gastrointestinal

ly
reducing absenteeism among Illness
preschool and school children

on
Science Direct
2. Diarrhea, malnutrition, Stephanie 15 public schools, Water supply Poor handwashing Diarrhea
and Dehydration associated O Sangalang et al. primary and

e
with school water sanitation secondary
and Hygiene in metro Manila,
Philippines: Across sectional study
schools students
us Handwashing with soap Diarrhea, Cholera
before eating and defecation
al
Lack of water in the school restroom Dehydration
Cleaning policy Lack of cleaning policy Undernutrition
ci

at school restroom
er

Number of school restrooms Diarrhea, stunting,

undernutrition
m

Springer

3. WASH and diarrhea-related Ommy 1,781 students,

om

sanitation Mushota et al. aged: 14-19 years

and hygiene intervention on
students' knowledge in a
-c

resource-limited setting
4. Fit for school-based water Denise 1847 children Clean and functional Soil-transmitted
on

sanitation and hygiene program Duijster et al. toilet at school helminths

to improve child health: results
from a longitudinal study in
N

Cambodia, Indonesia,
and Lao PDR
5. Nutritional and health status
of children 15 months after
integrated school garden, nutrition,
and water interventions:
a cluster-randomized
control trial in Nepal
Google Scholar
Lack of WaSH Decay, missing, and Filled
Permanent Teeth (DMFT)
Sharesta et al. 682 children Water, sanitation, hygiene Intestinal parasitic infection,
aged 8-7 years (WASH) program parasitic infection, anemia,
stunting, intestinal
protozoa infection,
soil trans, and mitted
helminth infection

6. Effect of School water Sharma et al. 768 students Water sanitation and sanitary Improve hand hygiene practice Health students status
sanitation and hygiene hygiene Facilities
on health status among
basic level students in Nepal
7 Water, Sanitation and Hygiene Ssekamate 1,869 school Safe drinking water and sanitation facilities Oral health (cavity, toothache)
Behaviours and the oral health
status of school-going adolescent
boys and young men in
Kampala Uganda Lack of wash Cavities cause mental health

[page 58] [Journal of Public Health in Africa 2023; 14(s2):2540]


Using the randomized controlled trial in 12 schools,10 four
schools were compared with a School garden (SG) program which
specific education about fruit and vegetable, four schools with SG
programs coupled with nutrition, health, and WASH intervention,
four schools control. The data showed that the SG and control
increased in parasitic infection, anemia stunting, intestinal proto-
zoa infection, and soil-transmitted helminth infection. The other
program Fit for Schools in Cambodia, Indonesia, and Lao PDR,
showed that the school-based water, sanitation, and hygiene pro-
gram could reduce the DMFT index and cavity.9,27
There are many factors that influence students when using san-
itation facilities. The research using the Structural Equation Model
analysis showed that the cleanliness of the toilet is significant for
toilet behavior (path coefficient, 0.81).28 The cleanliness makes it
comfortable when using the toilet. The toilet is the basic sanitation
that should be existence at school. Some schools didn’t have an
adequate number of toilets and lack of knowledge and awareness
of water towards poor hygiene behavior.29
The qualitative interview with students aged 16-18 years said
that toilets were dirty, insecure, and unpleasant.30 It makes the stu-
dents refrain from drinking during school and it will be affected the
student’s health. Furthermore, students remained constantly jump-
ing up and down or moving to withhold urine and stool.
The school sanitation programs were expected to improve
school sanitation. Two articles showed that school program sanita-
tion reduces disease in school students.9,10
The sustainability of school sanitation programs should be
fully supported by the policy. The revamped toilet made the great-
est gains in students’ attitudes toward the toilet facilities.31 The
program for operation and maintenance (O&M) in a public school
in the Philippines showed that intervention schools had a higher
al
percentage of usable toilets and were fully clean than control
schools. It means that the program of school sanitation can stimu-
ci
late reaching water, sanitation, and hygiene service.32
er
m
Discussion
om
The student’s disease can cause a lack of school sanitation.
There were seven articles that showed the correlation between stu-
dent disease and school sanitation. There were gastrointestinal ill-
-c
nesses, diarrhea, cholera, dehydration, undernutrition, stunting,
soil-transmitted helminths, parasitic intestinal infection, protozoa
on
infection, cavities in students, DMFT index, and health students
status. Diarrhea correlates with poor hand washing at school in the
students.22 Students not washing their hands in school was signif-
N
icantly associated with increased odds of diarrhea (OR 1.77, 95%
CI = 1.18 to 2.65). The insecure water increases the incidents of
diarrhea among children.33
Poor hand washing among students is due to the difficulties in
finding water for washing their hands at schools. The lack of water
at schools makes the students have more diarrhea and increase
absenteeism at school. Diarrhea affects 2.39 billion people global-
ly and caused 1,655,944 deaths in 2016.34 The program of Water,
Sanitation, and Hygiene at school (WaSHS) reduces parasitic
intestinal infection cavities DMFT index.9,10,27 The Sustainability
of school sanitation programs correlated with disease. Dehydration
is associated with the lack of water in school restrooms.22 Basic
drinking water also should be provided at school. The measure-
ments via urine-specific gravity/urine test strips in the students
showed that dehydration is a condition caused by the loss of too
much fluid from the body. It happens when you are losing more
fluids than you are taking in, and your body does not have enough
fluids to work properly. Students should have good conditions for
[Journal of Public Health in Africa 2023; 14(s2):2540]
Article
learning at school. The dehydration condition in students makes
the immune drop and it increases the risk of disease. Basic drink-
ing water is a human right for all, including the students, while
they do their activities at school.
Diarrhea, stunting, and undernutrition in the students correlate
with the number of the rest room and toilets at school.22 School
restrooms had many functions. Children who did not wash their
hands with soap and water after using the toilet were likely more
exposed to fecal, so the risk of infection increased. The diarrhea
infection makes students dehydrate and increases the risk of mal-
nutrition, weight loss, and stunted growth; consequences of infec-
tion include school absence and increased risk of school dropout.
Student dehydration shouldn’t happen in the students. Dehydration
has many effects. It can cause fatigue 176 (44.78%), lack of focus
171 (43.5%), headache/dizziness 160 (40.71%), lightheadedness
117 (29.7%), muscle weakness 98 (24.94%), rapid breathing 90
(22.9%), and muscle cramps 64 (16.28%).35
The school restroom had affected the health of students. The
prevalence of dehydration among school children is high,36 and
severely dehydrated during a school day,37 even extremely high
during school time.38 Water consumption among students is low.39
Dehydration impacted students’ cognitive performance.40 At
ly
school, dehydration was associated with the lack of water in a
school restroom, and the risk of diarrhea, stunting, and undernutri-
on
tion decreased as the number of school restrooms.22 Other research
showed that stunting correlates with sanitary facilities and water
treatment.41
e
Water was the basic sanitation that should be available all the
us
time for students at schools. Without having water to wash their
hands or flush the toilet, students may have been more exposed to
feces. Consequences of fecal exposure include diarrhea, which can
cause helminth infection. Other research showed that poor sanita-
tion in school might cause helminth infection.42
The health status of students correlates with school sanitation.
The analysis showed that students from unimprovement facilities
got sickness higher than improvement facilities at a school.10 Basic
drinking water and sanitation facilities at school showed that more
than a quarter of students had a cavity in their teeth and missed
school cause of toothache.12
Conclusions
The school’s sanitation included water supply, safe drinking
water, cleaning policy, toilet function, sanitation and hygiene pro-
grams, water sanitation and hygiene facilities, which correlate to
student health such as students’ gastrointestinal illness, diarrhea,
dehydration, oral health, undernutrition, stunting, soil-transmitted
helminths, parasitic intestinal infection, anemia, cavities, DMFT
status.
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