Wash Practices in Schools, Cameroon

This study investigated the influence of Water, Sanitation and Hygiene (WaSH) management on the bacteriological quality of students’ palms in some schools within the Bamenda municipality, to serve as baseline data for strengthening of hygiene management and health policies in schools. The study employed a descriptive cross-sectional approach with data generated through questionnaires, swabbing of the palms of selected students and doorknobs, as well as culturing of the swabs for microbial identification. SPSS version 16.0 was used for data analysis and Chi-square test to determine significant differences in the level of bacteria on the palms of participants by gender. None of the schools met WHO standards, and the gap between toilet usage and hand washing after defecation was very significant (p < 0.0001). Bacteria isolated included: Staphylococcus spp (63%), Escherichia coli (31%), Enterobacter sp (10%), Bacillus sp (10%), and Coliforms (5%). Two Fungi species: Yeast (10%) and Moulds (3%) were also isolated. The content of the curriculum, teaching and assessment mechanism for the WaSH programme management in schools was found to be in need of greater attention, schools and local governments focus on it being below expectation.


I. INTRODUCTION
Studies in developing countries show the threat to urban health posed by microbial contamination and associated increase in waterborne enteric diseases [1]. Cameroon's urban areas largely echo this pattern, with acute water shortage worsening the sanitation situation. In the context of scientific developments on medication and vaccines, it needs to be stressed that prevention deserves greater advocacy, given the emergence or re-emergence of new/old microbial and viral pathogens. The case of Covid-19 has brought mankind to this, highlighting the need for systems take up heightened preventive measures. School environments instance vivid disease transmission by contagiontouching of objects, bodily and post-faecal interactions-as well as the fact that proper hygiene management significantly responds to these pathogenic paths.
Assob et al. [2] in their Buea (Cameroon) study highlight a 61.33% prevalence of faecal-oral parasites in street food vendors and Akoachere et al. [3] and Awah et al. [4] document the biological pollution of wells, backwaters and rivers from poor domestic and industrial waste management. The Bamenda Health District records confirm the prevalence of waterborne diseases, including occasional cases of cholera [4]. Yet, water provision and sanitation facilities have not been upgraded relative to the rapid population growth [5], which raises the risk factor in health and the environment. Most educational institutions in Cameroon lack or only have water in short supply and inadequate, poorly managed toilet facilities compound the deplorable hygiene practices. The curriculum for the management of school WaSH programme needs greater attention; the teaching and assessment mechanism of hygiene education in schools lack the practical component. These growing structural health concerns, particularly in schools, necessitate school-based studies for better understanding of the stakes.
Allegranzi and Pittet [6] have compared different hand hygiene methods in hospital settings but little has been published on the effect of hand hygiene vis-à-vis the bacterial contamination of hands in schools. This study was therefore conducted to bridge the gap in the management of hygiene and sanitary practices in secondary schools and thereby provide baseline data to facilitate governmental efforts at improving and creating safe, healthy, inclusive, and equitably resourced educational environments.

A. Study Site
Where this study was carried out, the Bamenda Urban Municipality of North West Region is on the Western Highlands of Cameroon, between Latitudes 5 o 40' and 7 o North of the Equator and Longitudes 9 o 45' and 11 o 10' East of the Prime Meridian. It is bounded by Akum to the east, Bambui to the North, Bafut to the west and Bali to the south. The largest and closest municipality to Nigeria and the Western Region of Cameroon, Bamenda ( Fig. 1) has witnessed rapid population growth, projected to double in 2030 and triple in 2050 [5]. In 2010 Bamenda population stood at 322,889 with a density of 104.3 inhabitants per km 2 [7] and growth rate of 7.95%, above the national average of 5.6%. Understandably and projecting an early return to normalcy from the on-going conflict in Anglophone Cameroon of which Bamenda is a part, the number of school-goers rose, with record more than thirty secondary schools of private and public status for each of the three subdivisions of the municipality. The student concentration multiplies the chances of disease propagation, especially since enough focus has not been directed to waste and/or sewage treatment beyond garbage disposal efforts, as garbage recycling techniques are non-existent and untreated sewage is randomly discharged into the environment [5].

B. Study Design
Approved by the Institutional Review Board of the Catholic University of Cameroon, Bamenda and the Regional Delegation of Public Health, consent for this study was from both the school authorities and focal students. Based on an updated list of the municipality schools from the Regional Delegation of Secondary Education, the study employed a descriptive, cross-sectional design. The municipality was carved out into five sections (north, south, east, west and centre) and one school randomly selected from each. A total of 249 students from these schools were selected and stratified into respective cycles (First cycle, aged 10-15 and the Second cycle, aged [16][17][18][19][20]. Within each cycle they were further stratified according to the two sexes. Two data collection modelsquestionnaires and experimental methods with palm and door swabswere employed.

C. Questionnaire Survey
The questionnaire, with designated response options [8], had five sections which respectively required demographic information, students' sanitary habits, the hazards present, risk assessment, and the measures to control the hazards and reduce risks. An observational checklist documented the sanitary conditions of the schools, sources of water supply, sanitary facilities (including toilets and tap water) and other disease-related environmental factors (waste disposal, and vector breeding around the school premises).

D. Swab Sample Collection Methods Preservation and Transportation
Wetted sterile swabs immerged in sterile water were swiped over fingers and the palm of each student's dominant hand of all participating students and on the most frequently used doors; the swab sticks were then sealed in their tubes and stored in a cool box at 4 o temperature and moved within an hour to a research laboratory at the Phytobiotechnology Research Foundation Bamenda. There the swabs sticks were immediately put in a fridge.

E. Culture Media Preparation
The microbes on the swabs were cultured in Nutrient Agar and MacConkey Agar, prepared as guided by the manufacturer, and sterilized at 121 °C in an autoclave for 15 minutes. For sterilization, all glassware was passed over a flame.

F. Culture Technique and Incubation Period
The swab sticks and Petri plates for cultures were assigned specific codes and inoculated by sterile techniques, streaking the swabs onto the Petri plates containing MacConkey Agar and Nutrient Agar before covering and incubating the plates for 48 hours at 37 °C.

G. Characterization, Identification, and Confirmation of Isolates
Pure cultures were picked through streak plaiting with a loop and subjected to Gram staining catalase test, coagulase test for suspected growth isolates being presumptively identified by morphological, cultural, and biochemical characteristics. The results were compared with the standard bacteria characteristics expressed in Bergey's Manual of Systemic Bacteriology [9].

H. Data Analysis
The statistics were set to a frequency distribution with percentages displayed on tables and graphs. The Chisquared test carried out established the association between categorical variables. P-Values less than 0.05 were considered statistically significant on a 95% confidence interval. The statistical analysis was conducted using SPSS (statistical package for social sciences) version 16.0.

A. Socio-demographic Characteristics of Respondents
A total 249 students of whom 146 (58.63%) were boys and 103(41.37%) were girls. with a preponderant age bracket of 10-15 years (Fig. 2) participated in the study, males being greater because 50 of the random sampling students came from an all-boys school. Some 99 (39.8%) of the students were from Day government school (GBHS Bamenda and GBHS Atiela); 59(23.7) from a Mission Boarding school (SHC); 44 (17.7%) from a Holiday school (HSHS) and 47 (18.9%) from a Lay private school (LCC) (Fig. 3).

B. Sanitary Habits of the Students
The surveyed schools each had at least one toilet facility, pit latrine being most common. One toilet block with an average of three compartments or drop holes served both the male and female students. The gender-segregated toilet compartments serving many students had better ratios in private (LCC, HSHS and SHC) than in the government (GBHSB, GBHSA) schools, but none met the WHO standard ratio of 1:25 for girls and none provided male urinals, anal cleansing materials, or accessibility for the physically challenged; water was absent, inadequate or in inconsistent supply and defecation on toilet floors or in the open field was common.
The frequency of toilet usage and the hand-washing practice after toilet usage (Table 1) indicate more frequent use of toilets in private schools than in government school. Gender further varied the frequency of toilet usage, 33.6% (49/146) of males always using the school toilets whereas only 3.4% (5/103) females used the toilets regularly. By the statistical test, students of the 10-15 years bracket used school toilets more often than those 16-20 years (p<0.005). However, 62.2% of students indicated using school toilets occasionally, i.e., when hard-pressed, if water was available, or on days of general campus cleaning. Hand washing facilities were available in all the schools but located far the toilets and lacked water. No school provided soap for students' hand washing and only 108 (43.4%) and mostly 10-15 year old males (65.9%) washed their hands after toilet usage. The gap of toilet usage and hand washing after defecation was significant (p-value < 0.001).

C. Hazards Present and Risk Assessment
The hazard and risk assessment ( Table 2) are indicated by students exchanging clothing and other items, besides their drinking habits. Commonly (27.7%) of students exchanged clothing and footwear, 38.2% saying they did so only occasionally. Females 10-15 years and 16-20 years respectively had 45.0% and 34.8% prevalence of exchange and only 34.1% of all students said they did not exchange school clothing with their mates. Chi square test shows a significant difference (p-value 0.005) between the groups of students as far as the exchange of clothing is concerned. All the participants (100%) in the study indicated that they do not bath before going back to class after sports.

D. The Practice of Exchanging Materials and Food in School
Most of the students 237/249 (95.2%), irrespective of age and sex, exchanged materials and food in school. The Fisher exact test performed showed a p-value of 0.06, greater than 0.05. Thus, the exchange of materials was insignificant. In the study, only 2.8% of students were not exchanging clothing, 5 students (2%) saying they only did so sometimes.

E. Presence of Taps and Drinking Habit of Students
The survey confirmed that all the participating schools had school taps for students to drink. However, among students who did not wash their hands after toilet usage, up to 69.09% used their hands to drink water from the school tap (Fig. 4).
As indicated in Table 2, 52.2% of students did not drink from school taps, 46.6% drank using their hands and 1.2% sucked directly from the tap. Of reporting females, 65% of the 10-15 age group and 65.2% of the 16-20 age group drank from school taps using their hands; 54.5% males of 16-20 years and 20.9% of 10-15-year also used their hands to drink. However, 79.1% of males of the 10-15 year bracket reported not drinking from the school tap with the Fisher exact test showing a p-value of 0.000.

F. Provision of Waste Bin in School
Paper, empty plastic wrappings, empty cans, and plastic bottles comprised common waste observed in the schools. Most schools (60%) lacked both safe waste disposal methods and appropriate waste disposal systems, littering their campuses, streets, empty spaces outside their premises or using open ditches. Only 40% used private waste collectors and waste pits, some using communal waste pits outside their premises. One school alone used composting for gardening.

G. Cleanliness of the School Surrounding
An observational Checklist determined the cleanliness of the school surroundings and classrooms. Classrooms and surroundings not littered with solid waste, observable human, or animal faeces, cleared wastewater drains, wastewater not contaminating the surroundings marked up the school as clean. LCC and HSHS reported fairly clean, SHC clean and the rest not clean. By another checklist, most sales food courts were poorly constructed, with no handy hand washing structure. In private schools, discipline masters and sanitation prefects controlled food sales but government schools were not so organized.

H. Measures to Control Hazards and Reduce Risk
More boys than girls bathed before school in both age groups (Fig. 5), with 90% of 10-15 year-old females attesting to bathing before classes against 83% of [16][17][18][19][20] year-old girls. For both age brackets, proportionately the same attested to only bathing if they were early (6.3%) or did not bathe at all before classes (10%). Males who only bathed when they were early were far fewer (02.2%) and belonged to the 10-15 years brackets.  More boys took breakfast than girls (Fig. 6), all 10-15 year-olds (100%) and 81% of the 16-20 year-old boys; 86.3% of girls 10-15 years and 69.6% of 16-20 year-old girls ate breakfast. While boarding students ate breakfast in the refectories, day students indicated that they were given money for snacks in school when they missed breakfast at home.   WTR =When they remember. Fig. 8. Taking water from home to school among students.
As per Fig. 8 more female students of 10-15 years took water from home to school (36.3%) than those 16-20 years old (21.7%). Slightly more of the 16-20 year old girls only brought water to school if they remembered (47.8%) than the 10-15 year ones (43.8%). More girls of the 16-20 age brackets (30.4%) attested to not taking water to school at all than the 10-15 year old girls (20.0%).

I. Laboratory Methods and Culture Techniques
While Table 3 shows the characterization of the isolated bacteria in this study according to cultural, morphological and biochemical characteristics, Table 4 describes the characteristics of the isolated fungi from the students' palms and school door handles. Yeast and Mould as well as five bacterial colonies (Enterobacter, Staphylococcus spp, E. coli, Bacillus spp, and Coliforms) were isolated from these palms and door handles.  The colony was white and woolly. The hypha was thick and non-septate. The Columella was round. The sporangia were filled with spores.

F2
The colony was white and mucoid. The hypha was thick and septate, with no sporangia. They appeared as single cells and in colonies of several spherical cells.

K. Summary of Bacteria and Fungi Isolate Prevalence Students' Palms by Gender and Age
Indicated in Fig. 14

IV. DISCUSSION
In this pilot cross-sectional study, an attempt was made to understand the gaps in the management of hygiene and sanitary practices in five randomly sampled public and private schools within the Bamenda municipality. The socio-demographic information of respondents provided the characteristics of the study population where the age range of the sampled students were 10-15 and16-20, coinciding with the expected secondary and high school levels of Cameroon students. The boys-only included sampled schools scaled up the male students' ratio. Three major indications in the study relate fact that the school toilet structures do not meet WHO standard ratio, the general inadequacy of the WaSH facilities, and the practice of exchanging body contacting utilities and items, all three components seen as health hazards especially as they breed or spread bacteria and fungi that are pathogenic.
The WHO ratio of one toilet to 25 girls, one toilet and a urinal to 50 boys [10] was indicated as unmet by any of the schools. True, private schools were better than the public schools whose toilets were mostly constructed by Parents-Teachers Associations (PTA) which also undertook other school projects. The unmet WHO standard toilet to student ratio restrict students' stooling, cause stool retention, dysfunctional voiding and promote disease spread. This connects with the general inadequacy of WaSH facilities, their dysfunctional status and non-promotion of soap and water usage along with the gap between stooling and hand washing and consequent faecal contamination vectoring diseases through the spread of differentiated pathogenic bacteria and fungi.
Evidently, however, students are unlikely to use the toilet when there is a queue, particularly during the planned breaks [11], indicative of the importance of proper studenttoilet ratio. This was compounded by the absence of userfriendly facilities and the non-consideration of disabled students, a negative discrimination against the vulnerable lot. Much of this explained why most students only used the toilets occasionally, when hard-pressed, when water was available, or on days of general campus cleaning. These shortcomings work against the need for children's easy access to toilets at school relative to time voiding, which is part of the treatment for dysfunctional voiding [11].
Secondly, the study found that although water, sanitation, and hygiene (WaSH) facilities were available, they were inadequate, often dysfunctional and had inadequate maintenance. Inadequate or no water partly accounted for the gap between defecation and hand washing indicated in this study. Other studies have indicated a close correlation between poor sanitation amenities and the prevalence of infection among learners and their effect on their participation in curricular activities [12]. Students defecating on toilet floors compounds the improper disposal of excreta, bringing about contaminants that breed the bacteria and fungi isolates observed in this study.
Noted to vary according to the sex, the frequency of toilet usage is low when compared with Jano's results [13] obtained from a similar study in Ethiopia which indicated up to 12% usage for females. The present study indicated relatively more students in the 10-15 year bracket using the school toilets than the 16-20 year-olds. Jano [13] also associated age factors with students of the lower age group using available toilets without looking for alternatives as opposed to students of the higher age group.
Among low income settings, hygiene campaigns have not unanimously recommended soap hand wash to prevent vendor-student pathogens transmissions. Existing regulations on street-food industry in Cameroon is poorly enforced. Assob et al. [2] in a Buea, Molyko, Soppo, Bolifamba and Muea (Cameroon) study reveals that 57.67% of street vendors had faecal-oral parasites. Related to this, Muinde and Kuria [14] showed that street vendors wash and rinse utensils only once, in the same water content and repeatedly till it becomes very dirty. These unhygienic manipulations compound with the unacceptable quality of washing water for cleaning and other operations favour student-vendor transmission [15]. Inadequacy also featured with no school in the study providing students with washing after defecation, which Ajayi et al. [16] recommend against bacteria spread.
Exchange of utilities and items was seen to have no significant difference (p-value 0.064) among the students by sex and age since only 2.8% of students were not practising exchangesone possible factor of epidemiology, hygiene and sanitation being a rapid means of micro organismal propagation and disease. Investigating the associations between hygienic behaviours and hand contamination [17] indicate bacteria of possible faecal origin as more common in people frequently shaking hands and reporting soil contact. Prasai et al. [18] investigating the microbial Load on Paper Currency and Coins, found 98.4% of currency being contaminated.
Ajayi et al. [16] report that non-sharing of personal items like towels, razors, clothing or equipment, as well as cleaning surfaces where the bare skin rubs (like exercise equipment, surfaces, common shower soap and water after work or sports) help prevent Staphylococci spread and infections. Students exchanging clothing and footwear and the poor personal hygiene indicated by 16 [16][17][18][19][20] year-olds dominated the indication for the isolates, which statistics, along with the schools differences might be due to the sampling/swabbing time, since schools were not too differentiated in sanitation facilities and practices. The staying result is that bacteria and fungi, each having pathogenic peculiarities, were prevalent in students' palms and in school facilities.
A flora of the skin, Staphylococcus spp, is a pathogen associated with community-acquired urinary tract infections and food intoxication [19]; conjunctivitis, scalded skin syndrome, toxic shock, respiratory and skin infections [16]. E. coli, another major public health concern, indicated for recent contamination with fecal matter and the possible presence of intestinal pathogens, besides the fact that some of its pathogenic strains are found predominant in enteropathogens responsible for several outbreaks of bloody diarrhea [20] and possible bacterial meningitis [21].
Total coliforms and heterotrophic bacteria serve in the evaluation the hygienic status of water; coliform group presence indicates contact with sewage [4] with low species differentiation, however. These faecal coliforms, prevalent in the digestive tracts of mammals, correlate with pathogenic organisms that have similar survival characteristics to pathogens like Salmonella and Shigella [22]. Coliforms thus indicate pathogens and associated animal wastes in water, a definite evidence of faecal contamination and risk of zoonotic pathogens [4].
Yeast and Mould may cause mycosesfungal diseases in humans, especially of yeast -which are increasingly agents of the morbidity and mortality of patients with HIV/AIDS [23] also thanks to the patients' weakened immunity.

V. LIMITATIONS OF THE STUDY
Sampling schools from one municipality possibly narrowed the research implications, other variables considered. The lack of hand washing facilities closes to toilets and food courts most likely played on the students' hand washing practice. In addition, the applied bacteriological methods did not quantify bacterial load; differentiation between species was low. Then too, cultural practices like the greater housekeeping roles of girls or the budding manhood of the boys might explain some hygienic occurrences rather than the assumed presence or absence of WaSH facilities. Indeed, several variables could be given interpretative causes other than those posited in this study although the interpretations only add and do not contradict the validity of the projected views.

VI. CONCLUSION
This study shows that there are gaps at various levels for school WaSH management capacity, coordination, integration, commitment, and activity harmonization. Almost all of the schools lacked adequate sanitation facilities and available facilities were poorly managed. The inadequate, inconsistent, and insufficient school WaSH facilities likely contributed to student behaviour and illpractices. Noted was the absence of stakeholders' integration to direct efforts towards appropriately synchronized school WaSH management.
From the recorded bacterial and fungi pathogens in this study, schools receive contaminants and hand hygiene methods closely relate with pathogens, exposing students with poor hygiene practices to public health risks. Action should be taken to minimise the risk, including the allocation of funds for WaSH hardware and software components in the municipality's schools, WASH-related capacity building of teachers and School management committees should include operation, maintenance, monitoring and financial management; improvement in the ratio of latrines-to-students', due consideration of the physically challenged in amenities, hygiene should constitute part of the taught curriculum along with a detailed practical cause-and-effect components. Pandemics, not excluding covid-19, remind the world of the need for organized and consistent application of WaSH in schools and our communities.