Water, sanitation, and hygiene (WASH) are fundamental to human development and wellbeing. The World Health Organization /United Nations Children’s Fund (WHO/UNICEF) Joint Monitoring Program (JMP) for water supply and sanitation estimates that, in 2015, 663 million people lacked improved drinking water sources and 2.4 billion lacked improved sanitation facilities [1
]. Unsafe and insufficient quantity of drinking water, inadequate sanitation, and unimproved hygiene account for 7% of the global burden of disease and 19% of child mortality worldwide [2
]. The era of the Millennium Development Goals (MDGs) from 2000–2015 had specific targets for “improved” access to drinking water supply and “basic sanitation”; however, coverage fell short of the sanitation target [1
]. Still today, many schools and households in low- and middle-income countries (LMICs) lack adequate and safe WASH services, compromising people’s health and wellbeing [5
]. For example, in 2012, UNICEF reported that only 51% of schools in LMICs, had access to adequate water and 45% had access to sanitation facilities [6
]. The lack of reliable access to safe and sustainable WASH infrastructure, in conjugation with related hygiene and sanitation behaviours, remains a major public health problem [7
]. In LMICs, each year, 1.5–2 million children die from WASH-related diseases and many more are debilitated by illness, pain, and discomfort [12
]. While the majority of deaths occur in children below the age of five years, the burden of disease among schoolchildren is considerable [13
]. Approximately 74% of the health burden in schoolchildren in LMICs is due to intestinal helminth infections and 60% of the mortality is linked to infectious diseases such as schistosomiasis, soil-transmitted helminthiasis, and trachoma [14
]. Approximately 88% of diarrhoeal diseases and 47% of soil-transmitted helminthiasis are due to WASH issues in LMICs, which in turn cause malnutrition and impair food intake and nutrient absorption [10
The heavy metals such as arsenic and lead introduced into drinking water primarily by dissolution of naturally occurring ores, minerals, and industrial effluents are public health problems. Arsenic is one of the most dangerous trace elements and is predominantly found in rocks, soils, and natural water. The studies reported that arsenic affects the organs and systems in the body, including skin, heart, respiratory organs, and kidney consequently leading to cancer of the lung, kidney, and bladder [17
]. Similarly, lead, another heavy metal, acts as an anti-essential trace element, highly toxic cumulative element in the human body and is widely distributed in soil and groundwater [18
]. For neurological, metabolic, and behavioural reasons, children are more vulnerable to the effects of lead compared to adults [20
Nepal faces a plethora of problems related to WASH issues [21
]. In 2015, the World Health WHO/UNICEF JMP reported that 92% of the Nepalese population had access to improved water, and hence, met this specific MDG target [1
]. However, it remains to be determined whether the water classified as improved is safe for consumption. Sanitation coverage was 46%, while 37% of the population were still practicing open defecation, causing serious risks of environmental contamination, such as to open water sources [1
]. At the unit of the school, 61.9% had at least one toilet facility. Water supply facilities are not adequate to meet and maintain sanitation requirements in most of the schools [24
]. According to data from the Department of Health Service in Nepal, about 3500 children die each year due to water-borne diseases [25
]. Intestinal parasitic infections and diarrhoeal diseases due to inadequate WASH are the principal causes [26
]. The most common intestinal helminths among Nepalese children reported are Ascaris lumbricoides
, hookworm, and Trichuris trichiura
, with manifestations that include malnutrition, iron deficiency anaemia, malabsorption syndrome, intestinal obstruction, and impaired physical growth [27
]. There is a large body of evidence indicating that WASH interventions improve health and lead to significant reductions in both the severity and prevalence of diarrhoea and helminthiases [5
]. Several studies investigated heavy metals, such as lead and arsenic. With regard to lead, a study reported high concentrations (15–35 µg/L) in drinking water samples collected from different parts of Nepal [30
]. Meanwhile, a study investigating the quality of groundwater, especially in the Terai region, revealed high arsenic content [31
]. Furthermore, some studies have revealed high concentrations of arsenic in shallow tube wells (<50 m depth) with reported arsenic concentrations of up to 10 µg/L [32
The project entitled “Vegetables go to School: improving nutrition through agricultural diversification” (VgtS) is a multi-country study that seeks to deepen the understanding of whether school vegetable gardens, nutrition, and WASH interventions might lower the incidence of intestinal parasitic infections among schoolchildren and reduce malnutrition. Five countries are involved: Bhutan, Burkina Faso, Indonesia, Nepal, and the Philippines. The study protocol for Burkina Faso and Nepal has been published elsewhere [34
]. The specific objectives of the research presented here were: (i) to assess WASH conditions at the units of the school, households, and community; (ii) to conduct a baseline appraisal and identify gaps from which to identify priority needs and required interventions; and (iii) to analyse the association between water contamination and WASH predictors at the household level. We examined the water quality (physiochemical characteristics, microbiological contamination by thermo-tolerant coliforms (TTC), and heavy metals content), and sanitation and hygiene conditions at schools, households, and communities of the sampled children.
Our study revealed several WASH challenges at the unit of the school, household, and community in the districts of Dolakha and Ramechhap in Nepal. Indeed, our data provide evidence of inadequate drinking water availability at the main water sources in the schools surveyed. Moreover, water samples subjected to chemical and microbial tests revealed considerable faecal contamination. The access to “safe” water coverage from improved water sources in 12 schools was, in fact, not safe for consumption. Contamination of water samples with >100 TTC CFU/100 mL was detected in about one-third of the water samples obtained from schools. Furthermore, due to inadequate availability of drinking water at 14 schools, children obtain drinking water from other locations where safe drinking water consumption is not guaranteed.
Linking observational WASH assessment, out of all the surveyed schools, more than a quarter of schools had no sanitation infrastructures with a regular water supply available for anal cleansing. The conditions of latrines were poor and lacked essential hygiene materials (e.g., soap). Moreover, none of the schools had separate handwashing stations in close proximity to the sanitation infrastructure for handwashing. Additionally, none of the schools had any allocated budget for purchasing toilet-cleansing supplies. Another challenge identified by our study is insufficient coverage of improved/sanitary latrines and handwashing stations within the schools. The majority of schools did not meet the national student-to-toilet standard set by the Government of Nepal where one latrine per 50 students and at least one set of handwashing stations for a set of latrines (one for boys, one for girls) were recommended [24
]. To improve this ratio, the school committee or parents’ associations might focus their efforts also on building an adequate number of toilets for girls and boys. In addition to latrines, building more urinals for boys (which have considerably lower costs than latrines) could also be beneficial for schoolchildren. We found that the surveyed schools had usually one or two water taps available at a school for handwashing, and these were located at central places, far away from latrines. The findings of this study regarding WASH in schools are consistent with evidence on WASH in schools in Nicaragua where schools were without adequate sanitation infrastructures and handwashing facilities, highlighting several WASH challenges [39
]. Similar observations have been made in South Africa where the majority of the schools had access to unhygienic pit latrine and had one water tap, which was mostly located at a central point on the school premises [41
In terms of WASH at the unit of household, more than half of the households had access to an improved water source and sanitary infrastructure. However, water quality was typically not suitable for drinking in 112 households (20.0%). The water qualities from stored household samples were found to be worse than the water samples from the community source. This might be due to further contamination during transportation, storage, and point-of-use at households. This finding was consistent with the evidence from meta-analysis that reported the association of supply type with faecal contamination of source of water and household stored drinking water in LMICs [29
In the case of water quality of the samples obtained from the community, more than 30% were contaminated by TTC with maximum coliform count of >100 CFU/100 mL, with drinking water quality standards exceeded in 14 (32.5%) water sources. This finding is consistent with a prior study conducted in the communities of Kathmandu valley and Myagdi district of Nepal, where a maximum TTC of 267 CFU/100 mL had been reported [42
] and where 27.3% water sources were contaminated with TTC, respectively [17
Our survey included the examination of the physicochemical quality of water samples. Importantly, most of the physicochemical parameters were within national thresholds, except for turbidity. Some of the water samples showed high turbidity (>10 NTU), which might be due to the discharge of domestic effluents and runoff from agricultural activities. In turn, this might call for adequate and proper treatment of water before consumption [40
]. The pH was within the national standard (6.5–8.5). The schools, households, and communities mostly had a natural water source, and hence, pH levels were expected to be in this range. Similar observations have been reported from studies conducted in Myagdi district and Dharan, where pH levels of 7.6 were reported [17
When drinking water leaves a water point (e.g., tap), a residual free chlorine of about 1 mg/L is recommended, and similar levels are recommended for points-of-use during consumption [44
]. In our study, none of the stored water samples from schools and households had detectable residual free chlorine of 1 mg/L, even though chlorine solution had been distributed free of charge by various relief organisations after the April 2015 earthquake. The possible explanation for the low levels of detectable residual free chlorine might be that the aftershocks due to the earthquake were still quite frequent during the survey period, and hence, the chlorine promotion programme might have received only little attention, or people may dislike the odour of chlorine or they might regard chlorination as being an extra form of work during an emergency period.
Regarding heavy metals, fortunately, our investigation revealed acceptable levels of arsenic contents in all 16 water samples from school drinking water sources, indicating no significant threat to people’s health. This finding is in line with a study conducted in hilly parts of the Myagdi district, where values of arsenic are reported to be within the NDWQS [17
]. Other studies conducted in Asia (e.g., Cambodia) showed higher levels of arsenic (0.13–0.2 µg/L) and lead (0.1–0.3 µg/L) in drinking water [45
The high values of TTC are indicative of polluted drinking water sources or drinking water vessels, and of inadequate sanitary integrity of the water source and vessels [40
]. Such contamination may be due to construction defects, poor sanitation, poor hand hygiene, and open defecation by freely roaming animals and humans in close proximity to open water sources [40
]. In our study, the microbiological analyses of water samples revealed the presence of TTC in 193 water samples with 81(42.0%) of these samples having a TTC >100 CFU/100 mL, which calls for urgent treatment. Of note, despite households reporting that they obtain water from improved sources, faecal contamination was still observed in some of these. Yet, this water was being consumed by schoolchildren. Additionally, some improved water sources in the community were also not free from faecal contamination. This observation highlights that “improved” drinking water sources, considered safe by the global monitoring framework and burden of disease analyses, may entail health risks at some sources [21
]. Cross-contamination at leakage points in old pipes, back siphoning, and drainage systems had been reported by a study conducted in Myagdi district and mountainous parts of Nepal [17
]. Our findings of water contamination with TTC might be also linked to garbage discarded in open spaces in close proximity to drinking water points, open defecation practices, or cross-contamination between water supply and sewage systems.
The practice of open defecation was still common in the study region. Indeed, 17% of the households surveyed reported open defecation. However, this percentage of households practicing open defecation is considerably lower than what has been reported by WHO/UNICEF JMP in Nepal, where 37% of the rural population reported to practice open defecation [1
]. This difference might be explained by the fact that temporary latrines were constructed immediately after the April 2015 earthquake with Dolakha district being the epicentre [51
]. It should also be noted that some VDCs of the Dolakha district had declared the states of “open defecation-free”.
Re-growth of TTC in drinking water sources occurs at temperature above 15 °C, in the presence of sufficient bacterial nutrients and the absence of free residual chlorine in the water [44
]. In our study area, some sites were located in settings where the average temperature is above 15 °C. Of note, we found that more than 85% of the households where TTC was present reported no treatment of drinking water, while only 13.5% reported treatment. Boiling was the most frequently known water treatment procedure; however, boiling alone might not confer full protection from TTC. The finding of boiling as the main known water treatment procedure is in line with a previous study conducted in rural Nepal, where 15% of households consistently boiled water before consumption [52
]. Additionally, poor maintenance of sanitation facilities and inefficient disinfection are other likely reasons for the observed TTC contamination in our study.
In terms of KAP on WASH among schoolchildren, results indicated that 97% of the students reported washing their hands solely with water when soap was not available and 97.3% reported using soap and water for handwashing if soap was available. Of note, the presence of soap and water is crucial for schoolchildren for handwashing in that it might form a sustained habit of proper handwashing. Similar findings of the importance of the availability of soap and water were reported in studies conducted elsewhere such as in Nepal, Bangladesh, Nicaragua, and Kenya [39
In terms of knowledge of water-borne diseases, children had a general awareness that dirty water can cause ill-health. Yet, the exact types of water-borne diseases and transmission pathways were poorly understood, thus confirming previous observations made in South Africa where the schoolchildren from rural schools were reported to have a disparity of knowledge on water-borne diseases [41
]. It follows that the provision of adequate resources and long-term behaviour change in children to form a sustained habit of hygienic behaviours such as washing hands with soap, including awareness regarding water-borne disease with its mode of transmission, should be initiated in the VgtS study site of Nepal. There was a lack of access to sufficient quantities of water and soap at the unit of both school and households that impedes personal hygiene [56
]. WHO recommends minimum availability of 100 L of water per capita per day for all purposes [59
We found a significant association between the presence of TTC contamination of drinking water and domestic animals freely roaming within the households compared to households where domestic animals were kept outside. This might be due to faecal contamination of water sources by domestic animals. Such faecal contamination of drinking water and possession of different types of livestock was also reported in studies conducted in Burkina Faso and Rwanda [61
]. We observed inadequate washing of drinking water storage containers, containers having no lids, or lids not fitting properly, and drinking water cups left on dirty grounds, as well as kitchens in close proximity to animal sheds. Similar observations have been made in a study conducted in Botswana, where the drinking water containers were kept without lids [64
Our study has several limitations. First, there was a huge challenge posed by the April 2015 earthquake. Around 20% of households could not be visited due to frequent aftershocks and post-earthquake emergency crisis. A number of villages had been severely destroyed, and hence, it was not possible to obtain water samples from all the schoolchildren’s households. Second, water quality analysis was carried out during the spring season only, thus the observed results might not represent the drinking water quality over the whole year. Third, although having found standard residual free chlorine in some samples, TTC was high. This might be explained by the time required to destroy bacteria, which depends on the type of bacteria, but as we did not further isolate bacteria, we are unable to investigate this issue further. Fourth, the results from selected school, household, and community water sources in the two districts of Dolakha and Ramechhap may not be considered to be representative for other parts of Nepal. Fifth, the self-reporting of diarrhoeal episodes among children’s caregivers may not be accurate. However, this is the standard procedure.
Despite these limitations, our study provides a baseline for the status of WASH indicators at selected schools, households, and communities in two districts of Nepal. We rigorously assessed water quality, including physicochemical, microbiological, and heavy metal contents, using Delagua kit and flame atomic absorption spectrophotometer. Information about self-reported morbidities helped for timely referral of children to health care delivery centres. Meanwhile, the analytical approach taken (i.e., multivariate analysis) allowed for adjustments of potential confounders, such as educational attainment of caregivers, socioeconomic status, and regional differences.
We found that about one-third of water samples obtained from selected schools and households in two districts of Nepal were unsafe for drinking. The microbiological characteristics were critical for some samples, which indicates a public health risk. Although the physicochemical parameters of the water samples collected were within permissible limits, disinfection with chlorine prior to supply, as recommended by the NDWQS, is required to maintain water quality at the source. Regarding point-of-use, contamination of drinking vessels by domestic animals freely roaming inside the houses is a concern. Households’ drinking water was mostly from improved sources; however, regular monitoring of water quality in different seasons is recommended to generate evidence regarding water quality throughout the year.
Water source protection strategies (e.g., proper fencing of domestic animals, maintenance and proper disposal of human and animal faeces) should be promoted. When school budgets do not allow for WASH improvements at schools, parents and community organisations might provide resources to ensure healthy school environments. Regular inspections are required to identify causes of contamination and to determine the risk of future contamination. In turn, mitigation measures can be implemented, such as maintenance and operation of water supply systems by the school administration, household caregivers, and other community stakeholders. Additionally, engaging the communities to take responsibility for management of water sources may also be an appropriate strategy to improve the quality of community water sources. Promotion of hand washing with soap and safe disposal of faeces must be encouraged at the unit of the school. More emphasis should be placed on water treatment. Hygiene training programmes at schools should be incorporated into the school curriculum.
Our study gathered helpful baseline WASH information at school, household, and community levels. In order to create better conditions for the VgtS project, specifically nutritional and health-related objectives, the results will be useful to design and implement a complementary WASH intervention package for targeted schools. As the VgtS project in Nepal has involved the Ministry of Education as a key stakeholder, the model of interventions implemented in these pilot schools could be readily replicated nationwide. There is a need for ensuring safe WASH in schools, households, and the communities to improve children’s health and wellbeing. The study has therefore a potential to impact on the public health in the surveyed districts and schools, and also beyond.