Universal access to drinking water, sanitation and hygiene (WASH) as outlined in the 2030 sustainable development goals (SDG) agenda, remains a public health challenge in schools worldwide (Ahmed et al., 2021, United Nations, 2015). The 2030 vision for WASH in schools is enshrined in SDGs 3, 4 and 6. SDG 3 calls upon United Nations (UN) member states to sustainably work towards ending water-borne diseases such as cholera, typhoid and dysentery. SDG 4 calls for universal access to basic drinking water, single-sex basic sanitation, and basic handwashing facilities in schools. Additionally, SDG 6 calls for universal access to safely managed drinking water services, safely managed sanitation services and handwashing facilities with soap and water (United Nations, 2015, UNICEF and WHO, 2020, UNDP, 2021, WHO, 2019, Ahmed et al., 2021). SDGs also call upon UN member states to work towards ending open defecation and to pay special attention to the needs of vulnerable populations such as individuals with limited mobility (UNDP, 2021, Rebelo et al., 2019).
Although several SDGs are specific about WASH, none is explicit about oral health, making it a neglected issue on the global health agenda (Benzian et al., 2021). Yet, oral diseases are one of the major non-communicable diseases affecting over 3.5 billion people (Bernabe et al., 2020). About 10% of the global population is affected by severe periodontal (gum) disease, which often results in tooth loss (WHO, 2021, Baiju et al., 2019). Besides, there are 530 million cases of dental caries/tooth decay/cavities among children, the majority of whom live in low and middle-income countries (LMCs), where provision of dental services is limited (WHO, 2021, Batwala et al., 2007). The major risk factors for dental carries among children are unhealthy diet high in sugar, use of tobacco, harmful use of alcohol and poor oral hygiene (WHO, 2021, Abbass et al., 2019).
In relation to WASH, only three-quarters of secondary schools (74%) and two-thirds of primary schools (66%) globally had a basic water service in 2019 (UNICEF and WHO, 2020). Limited access to a basic drinking water service at school affected 584 million children, among whom, 297 million were in schools that had an improved source with no water available, and 287 million were in schools with no water service (UNICEF and WHO, 2020). Almost half of the children in schools without water service lived in low-income countries. Access to basic sanitation in schools is also a challenge. Overall, 63% of schools globally had access to a basic sanitation service while 71% of secondary schools and 60% of primary schools had a basic sanitation service. Limited access to a basic sanitation service in schools affects 698 million children, among whom 331 million are in schools with improved sanitation facilities that were sex-disaggregated or not usable, and 367 million had no sanitation service at all. Almost a quarter of the children in schools without a sanitation service lived in low-income countries (UNICEF and WHO, 2020). The World Health Organisation (WHO)/United Nations Children's Fund (UNICEF) Joint Monitoring Programme 2019 global estimates indicated that only 57% of schools had a basic hygiene service while 25% neither had hand hygiene facilities nor water at the school premises (UNICEF and WHO, 2020). About 40% of children whose schools had no hygiene service lived in the least developed countries (UNICEF and WHO, 2020).
There have been commendable efforts by the Ugandan government and implementing partners to improve oral health and WASH behaviours of school-going adolescents and young adults (WHO, 2016, Ministry of education and sports, 2017). For instance, in 2017, the Ugandan Ministry of Education and Sports (MoES) adopted and contextualized the UNICEF three-star approach to stimulate effective WASH behaviours amongst the learners (Ministry of education and sports, 2017). The three-star approach ensures that healthy habits are taught, practised and integrated into daily school routines (UNICEF and GIZ, 2013, Ministry of education and sports, 2017, Wagner and Samuelsson, 2019, Duijster et al., 2020, Mukherjee and Alam, 2017). Besides, MoES and UNICEF developed national WASH standards which require each staff and learner in Uganda to have access to 1.5 litres of safe drinking water per day, and separate toilets for all girls and boys and children with disabilities, with at least one toilet for 40 learners (UNICEF, 2020). Besides, schools are required to provide one hand washing facility with soap and water per 40 learners. Other critical requirements included regular health education on WASH, food safety and hygiene, proper solid waste and excreta and waste water management, and provision of menstrual hygiene facilities (UNICEF, 2020). Similarly, the government of Uganda in collaboration with WHO developed the national oral health policy (2007) to provide a framework for the prevention of oral diseases. The policy emphasizes the need for schools to undertake oral health education, periodic screening of school children and training teachers on oral health education and promotion (Ministry of Health and WHO, 2007). Despite the existence of the different interventions and standards, the status of WASH and oral health in Uganda remains suboptimal. About 87.5% of primary and 93.5% of secondary schools have access to basic drinking water, 90% of primary and 95.5% of secondary schools have single-sex sanitation facilities, and just 40.9% of primary and secondary schools have hand hygiene facilities. Only 42% of learners in Uganda are enrolled in schools with basic handwashing facilities (Government of Uganda, 2020). Data on oral health remains limited.
Improved WASH is a right for every learner as it has enormous benefits (WHO, 2019, Han et al., 2020). Safe drinking water promotes regular hydration which in turn improves the cognitive performance of learners (Masento et al., 2014). Safe and usable WASH infrastructure coupled with good practices reduces the incidence of infectious diseases including COVID-19 (Skolmowska et al., 2020, Yigzaw et al., 2021), and diarrhoeal diseases such as typhoid and dysentery (Taddese et al., 2020, Azhar et al., 2021). Improved WASH behaviours reduce absenteeism from school, health and wellbeing of learners and to uphold the dignity of the learners (WHO, 2019). There is evidence that the WASH behaviours that children learn and practice at school are likely to be the norm in society when they become adults, and that children who practice the desired WASH behaviours are more able to integrate sanitation and hygiene education into their daily lives, and are effective messengers and agents of change within their families and the wider community (Bartram et al., 2009). Besides, access to safe WASH infrastructure is associated with better educational outcomes such as performance and better WASH-related behaviours (Thakadu et al., 2018). Similarly, good oral health alleviates pain, discomfort, disfigurement and even death, and promotes quality of life (Spanemberg et al., 2019).
There has been considerable attention towards WASH in schools both globally and locally (Government of Uganda, 2020, Ministry of Education and Sports, 2021, Sommer et al., 2016, Sommer et al., 2021, Hennegan et al., 2018). However, the focus has been directed towards meeting the sanitation and hygiene needs of adolescent girls and young women, particularly menstrual hygiene management (AGYW), and less attention to the young boys. Adolescent boys and young men (ABYM) have unique oral health, and sanitation and hygiene needs that should be addressed based on their social class, disability, ethnicity and age (Bell et al., 2013, Cavill et al., 2018, Kato-Wallace et al., 2016, Amin et al., 2018, WHO, 2000). Failure to understand the sanitation and hygiene needs and behaviours of ABYM is likely to negatively impact sanitation and hygiene promotion when they turn into men. Yet, it is reported that men compared to women, often exhibit unfavourable sanitation and hygiene behaviours (Kwiringira et al., 2014). For example, men are less likely to practice hand hygiene during critical moments such as before and after using a toilet, are less likely to use a toilet facility even when available, are harder to engage in sanitation and hygiene promotion activities, and often practice unfavourable sanitation practices such as open urination and defecation (Lopez et al., 2019, Cavill et al., 2018). Unfavourable sanitation and hygiene behaviours of men have been attributed to their desire to slow the rate of pit filling, having more time for open urination and defecation, greater mobility of men, lack of shame about open defecation and lack of toilets at workplaces (Chambers and Myers, 2016, Coffey et al., 2014). The limited focus on the WASH needs and oral health of adolescent boys and young men (ABYM) in educational settings is likely to “leave them behind” during the attainment of the SDGs. It was against this background that we established the WASH behaviours and oral health status of school-going ABYM. Our findings can be used to inform WASH in schools related policies and programmes.