This study was carried out in Buea, the Regional capital of the South West Region of Cameroon. Buea has a total of 31 secondary schools which are either public or privately owned. Ten public general education secondary schools, three public technical education secondary schools, eight boarding secondary schools and ten day private secondary schools were used (Figure 1).

This study was a descriptive cross-sectional community based study and was carried out from November 2017 to June 2018.

Secondary school students in the Buea Health District make up the study population; the sample size for this study was 384 students. The sample size was determined using the Cochrans formula for sample size determination (Eng, 2003):

Where n= sample size; Z= = 1.96 (standard normal value at 95% confidence level); p= estimated proportion of an attribute that is present in the population = 50%. e= precision of the event of interest = 0.05 

Probability proportionate to size sampling was used to determine the number of students to sample in each of the four secondary schools in the Buea Health District (Table 1).

An ethical clearance (2018/0198/UB/SG/IRB/FSH) was issued by the IRB of the Faculty of Health Sciences of the University of Buea. Administrative approval was sought from the department of Public Health and Hygiene, Faculty of Health Science, University of Buea. Later, approval was sought from the Regional Delegation of Public Health for the South West Region, Heads of the various schools. Direct observation and a well-structured questionnaire were the tools for data collection and a consent form was signed by participants who accepted to take part in the study.

Statistical software’s SPSS V20 and Microsoft Excel 2013 were used to analyze the data. The analyzed data was presented in tables and bar charts. Bivariate analysis was computed using chi-square test to assess the relationship or association between variables. During analysis, P-values of less than or equal to 0.05 was considered statistically significant, while P-values of more than 0.05 was considered not to be statistically significant.

Demographic characteristics of selected secondary schools in the Buea Health District

This study involved four secondary schools, two public and two private. The majority of participants (290, 75.5%) were students from public secondary schools and most of them (356, 92.7%) attended day session, while some (28, 7.3%) were boarding school students. A greater number (314, 81.1%) were participants from schools with fence, which offers a secured space for students. Among the schools, the oldest school building was 42 years and the most populated school had 1600 students. The average student per class ratio was 76-100 students per class. From observation, most of the schools were dirty, majority of the students who drank water from the tap were  using  their  hands  and a greater proportion did not  wash their hands before drinking while just a few washed their hands before drinking directly from the tap.

Water sources in secondary schools

Among the two types of schools, their main water sources were public tap (Camwater). Most 197 (51.3%) [95% CI: 46-56] of the students reported that their tap were functional at the time of study; and 187 (48.7%) [95% CI: 43-53] reported nonfunctional taps. Public secondary schools had a higher respond rate,182 (62.8%) [95% CI: 56-68], of functional taps. Using Public tap as the main source of water was significantly associated with the type of school (X²=62.239, P=0.000) (Table 2).

Majority, 133 (34.6%) [95% CI: 29-39], of the participants reported having alternative sources of water (Borehole, community water) and 251 (65.4%) [95% CI: 60-70] reported not having alternative water sources in school. Private secondary schools had a higher respond rate;  72(76.6%)   [95%  CI:  67-85]   reported    to    have alternative water sources (Borehole, community water). Using alternative water sources (Borehole, community tap water) was significantly associated with the type of school (X²=96.800, P=0.000) (Table 2).

Closeness of WASH facilities to the toilet in secondary schools

The results show that (285, 98.2%) [95% CI: 96-99] of public secondary schools and (68, 72.2%) [95% CI: 62-81] of private secondary schools do not have basic WASH facilities (wash stand, wash hand bolls, soap) closer to the toilet for use by the students as shown in Figure 2.

Different methods of waste disposal in secondary schools

Half (146, 50.3%) [95% CI: 44-56] of the respondent from public secondary schools reported of burning dirt and (59, 62.4%)[95% CI: 52-73] from private secondary schools reported  of   dumping   dirt   for  HYSACAM  (Hygiene  et Salubrite du Cameroon) to carry away as presented in Figure 3.

Reasons why students do not wash their hands after using the toilet in schools

A greater percentage (126, 43.6%) [95% CI: 37-49] of students from public secondary schools and a majority (59, 62.6%) [95% CI: 52-73] from private secondary schools said water scarcity is the reason why they do not wash their hands after using the toilet and 2.9% from public secondary schools and 3.1% from private secondary schools  said they always forget to wash their hands after using the toilet as presented in Figure 4.

Reasons why students do not wash their hands before eating during break

The result shows that (116, 40.2%)[ 95% CI: 34-46] of students from public secondary  schools and  (49, 52.2%) [95% CI: 41-63] of students from private secondary schools do not wash  hands  before  eating  during  break because of water scarcity and a lesser percentage 5.9% of the students from public secondary schools and 4.6% from private secondary schools said crowded tap is the reason they do not wash their hands during break before eating as presented in Figure 5.

Importance of the study

The Sustainable Development Objective (SDG) 6, envisages by 2030, access to adequate water, sanitation and hygiene services for all. The inadequacy of these services in the school environment will hamper the achievement of this goal, so far many secondary schools in the developing countries do not have adequate WASH facilities and the consequences for educational performance are established (WHO, 2000; UN, 2014). This study was  carried  out to assess WASH practices in public and private secondary schools in the Buea Health District. The WASH program in schools contributes to a safe school environment, healthier students in school and a better result. Adequate WASH facilities and activities in secondary schools will reduce the number of WASH related diseases (diarrhoea, typhoid, cholera, malaria, and hepatitis), absenteeism and school dropout which improve on the educational system and nation building at large. This study identified weaknesses related to WASH practices in secondary schools and proposed strategies to improve on WASH activities in secondary schools in the Buea Health District.

Availability of WASH facilities in secondary schools in the Buea Health District, Cameroon

Many of the students were from schools with secured space (Fence) which is in line with the WASH guideline in schools by WHO (2009) stating the need for secured space in schools which prevent intrusions by animals and other persons. The main source of water for drinking in schools is Camwater, the conventional distribution network. The available water complies with the drinking water standards required by the Cameroonian legislation for potable water. A good number of public secondary school does not have basic facilities (wash stand, wash hand boll and soap). From observations made, most toilets in secondary schools in the Buea Health District were found to be dirty, doors open and some toilets do not have door, no privacy for the students when using the toilets. This aspect is not in line with the WASH guideline for schools in low- cost setting by Adams et al. (2009), they stated that toilets should be kept clean and doors always closed to avoid transmission of diseases and toilets should have doors for users’ privacy and protection. The student / toilet ratio was as high as (160/1) far above the recommended standard by WHO in 2009 (1 toilet for 30-50 students). Many public and private secondary schools in the Buea health district had just two water points supplying a population of 700 students and more which was far above the recommended standards (150-200 students/ water point) (WHO, 2009). Most secondary schools do not have cleaners and the absence of cleaners and cleaning equipment, contributed to the dirty school environment and dirty toilets, which consequently become areas where students can easily contact pathogenic germ and various infectious diseases. The girls/ boys separate aspect of toilets was respected, the security of the girls are not ensured in most schools due to unhealthy toilets students are practicing open urination and defecate to meet their needs, in line with a study conducted in Yaoundé by Annie-Claude and Dieudonne (2017) stating that unhealthy sanitary toilets will cause users to carry out malpractices like open urination. Most  public  schools and private schools do not have toiletries and hand washing facilities closer to the toilets as recommended by WASH standard for schools in low-cost settings (Adams et al (2009).

WASH practices in secondary schools in Buea

Water scarcity was the main reason for poor hand washing practices by students in secondary school as a greater part of students from public schools and private schools indicated that water scarcity is the reason they do not wash their hands before eating during break and after using the toilet. Lack of basic WASH facilities like wash hand stands and soap in schools contributed to poor hygienic practices among students. Dirty toilets were one of the reasons why most students practiced open urination. The result in line with a study conducted by Guinan et al. (2002) stating that most schools lack latrines and safe water for drinking and hygienic practices, which eventually leads to absenteeism and high dropout rates in schools. Lack of basic facilities will force student to carry out poor hygienic practices like open defecation and urination. A good number of public secondary schools disposed their waste by burning and a majority from private secondary schools dump for HYSACAM (Hygiene et salubrite du Cameroun) to carry away.

This study revealed that most secondary schools in the Buea Health District lack the necessary facilities needed for the implementation of water, sanitation and hygiene activities. A greater proportion of the students do not practice water, sanitation and hygiene activities in schools due to lack of basic materials like soap, toiletries and also water scarcity.

From the findings of this study, we therefore recommend that: the government should review policies about WASH in schools to enable establishment of adequate facilities in all public and private institutions before they go operational; multi sectorial collaboration is needed (ministries of education, health, public works and finance) and should support schools with the building of modern toilets, wash handstand with taps and other WASH related facilities; a department should be created in schools to ensure the implementation of WASH related activities, especially the cleanliness of school toilets; schools associations should collaborate and make available  facilities  like   soap,   toilet   tissues   and  even construction of modern toilets in schools; WASH education should be emphasize at all levels of the school program, more emphasis on practical classes; schools should employ cleaner who will be taking care of the school environment and the toilets; students should be encouraged to take active part in the implementation of WASH activities in schools; schools with water scarcity issue should construct or make available alternative water sources (Boreholes, reservoirs) for use in case of non-availability of the main source.

The authors have not declared any conflict of interest.

The authors are grateful to Prof. Nsagha Dickson Shey and Prof. Verla Vincent for their support during the course of this research. They are also grateful to the lecturers of the department of public health and hygiene for their support.