Healthful School Environment: A Comparative Study of Public and Private Primary Schools in Ogun State, Nigeria

Methods: The study was a comparative cross-sectional survey of Private and Public Primary Schools in Ogun state, Nigeria conducted between February and May, 2014 in Ogun State, Nigeria using a multistage sampling technique. Participants in the study were interviewed using a structured questionnaire, which was administered by a trained interviewer. Data collected was analyzed using the SPSS version 20.0.


Introduction
Healthful School Environment is one of the interrelated aspects of the School Health Programme. The concept "Healthful School Environment" denotes all the consciously organized, planned and executed efforts to ensure safety and healthy living conditions for all members of the school community. A healthy school environment (physical, biological and socio-cultural) serves as a major determinant of health and greatly infl uences the individual's level of intellectual growth and development.
The objectives of a Healthful School Environment are to create a healthy and safe learning environment in the school, provide adequate safe water supply and sanitation facilities for use in the schools. The physical school environment encompasses the school building and all its contents including physical structures, infrastructure, furniture and the use and presence of chemicals and biological agents; the site on which a school is located and the surrounding environment including air, water and materials with which children may come into contact, as well as nearby land uses, roadways and other hazards [1]. The American Academy of Paediatrics defi nes a 'healthful school environment' as one that protects students and staff against immediate injury or disease and promotes prevention activities and attitudes against known risk factors that might lead to future disease or disability [2]. WHO estimates that between 25% and 33% of the global burden of disease can be attributed to environmental risk factors. About 40% of the total burden of disease due to environmental risks falls on children under the age of 5 years [3]. Respiratory infections are the most common among all diseases in children and pneumonia is the primary cause of childhood mortality worldwide. Indoor and outdoor air pollution may be to blame for as much as 60% of the global burden of disease brought by respiratory infections [4]. Diarrhoeal diseases, the second most global illness affecting young children and a major cause of death in lower income countries, are closely linked with poor sanitation, poor hygiene and lack of access to safe and suffi cient supplies of water and food [5]. Each year nearly two million children die of diarrhoeal diseases caused by unsafe water supplies, sanitation and hygiene. Interventions such as simple hand washing have been shown to reduce sickness from diarrhoeal diseases by up to 47%, and could save up to one million lives [5].
Malaria, the most deadly of mosquito transmitted diseases kills over one million people each year, the majority of these deaths occur in African children [6]. In endemic areas, 60% of all school children may suffer from malaria [7]. Standing water and poor waste management in schools increase the risk of vectors breeding and spreading near the school environment [1]. Schools sited adjacent to pools of water and wetlands are more susceptible to mosquito-borne diseases.
In high income countries, road traffi c injuries are the most common cause of death among children aged 5-14 and account for approximately 10% of deaths in this age group. In low and middle income countries, they are the fi fth leading cause of death in the same age group behind diarrhoeal diseases, lower respiratory infections, measles and drowning [8]. Therefore, schools located near busy roads or water bodies, landfi lls, construction sites have increased risks of these types of injuries. Falls and injury within school grounds can occur as a result of poorly maintained schools or poor construction management.
Human excreta are the biggest source of disease producing organisms including parasites, bacteria and viruses. Success in eliminating faecal material from the school environment is dependent on: informed and responsible students, supervision of young pupils, a fence or structure to stop animals from defecating in areas where children play, toilets conveniently located-reliable, clean, odour-free, private and well maintained [9]. Separate facilities for girls can reduce dropout rates during or before menses [9]. Baseline information on School Health Programme as reported in most parts of the country is poor [10][11][12]. This study was therefore designed to assess the school environmental health services in both private and public primary schools in Ogun state Nigeria. This has implications in the environmental health care of the school children and protects students and staff against immediate injury or disease and promotes prevention activities and attitudes against known risk factors that might lead to future disease or disability

Study area
The State has Twenty (20) Local Government Areas (LGA). Each LGA is headed by an Executive Chairman. It has three (3) Senatorial Districts and is divided into four (4) geo-political

Study design
The study design was a comparative cross sectional study that assessed the School Health Programme in Public and Private Primary schools in Ogun State.

Inclusion criteria
All fully registered Public and Private primary schools in the selected LGAs

Exclusion criteria
All schools that are not fully registered in the selected LGAs All schools operating a boarding system in the selected LGAs

Sample size
A prevalence of 40.4% of Private Schools compared to 31.0% of Public Schools [14] was used to estimate the sample size using the formula for comparative study proportions between two groups [15].

Stage II
In each Local Government Area selected, 60 Public Primary Schools and 60 Private Primary Schools were recruited into the study by listing all the Public Schools and all the Private Schools and then randomly selecting 60 each into the study.

Data collection process
The Instruments for Data Collection: a self-administered semi-structured questionnaire for the Head Teachers and an Observational Checklist for the Schools were pre-tested in ten (10) Public and ten (10) Private Primary Schools in Ibadan North East Local Government and modifi ed as appropriate. Twenty (20) Research assistants were recruited and trained in the correct use of the Questionnaire and the Checklist for the Project. Identifi cation tags with pictures were issued to the Research Assistants to facilitate School Entry.
School entry was made by approaching the Head Teacher and the Project carefully explained to them. Once the Head Teacher consented by signing the Informed Consent form, he/she was given a copy of the Questionnaire to fi ll in the presence of a Research Assistant who explained grey areas when necessary. At no point would the Head Teacher be left to fi ll the Questionnaire alone. Two other Research Assistants would then inspect the School with the Observational Checklist to assess practice of School Health Programme usually in the company of a Teacher nominated by the Head Teacher or alone. Both Instruments were subsequently collected and stored and the consenting Head Teacher thanked for the cooperation. Data was collected over a three (3) month period.

Analysis of results
Quantitative Data collected was checked for errors, cleaned, entered and analyzed using the SPSS version 15.0. Data was summarized with proportions and means and presented using frequency tables. Inferential statistics to test for associations between variables was done using the chi-square test. T-test was used to compare the difference between the mean knowledge scores of the Public and Private Schools' Head Teachers.
Observational Checklist was essentially used to measure Practice of School Environmental Health Programmes in the Schools. Hospital, Sagamu. Approval was also obtained from the Permanent Secretary of the Ogun State Ministry of Health and the Local Government Authorities of Sagamu, Abeokuta-South and Ado-Odo/Ota Local Governments respectively. Written informed consent was obtained from all the participants after study objectives were explained to them. They were assured that participation was voluntary and they would incur no loss if they decided not to participate.

Ethical consideration
Study participants were assured of strict confi dentiality and this was indicated on the questionnaire. Data collected was only used for research purposes and was kept confi dential on a password protected computer. Research assistants were also trained not to disclose the information divulged by the respondents during the interview. Anonymity was assured as names or any other personal identifying information was not required from subjects. Those who declined from the study were politely dismissed.

Socio-dermographic characteristics
The overall mean age of all the Head Teachers was 45.7± 9.9 years. The Socio-demographic Characteristics of the respondents is as shown in table 1.

Adequate water supply and proper waste disposal
Dust bins and waste paper baskets were available in Public Schools and 123 (68.3%) Private Schools. This was a statistically signifi cant fi nding. (X 2 = 46.946, P= 0.001). About half of the respondents in both groups in Public and Private Schools respectively use a bore hole or a mono pump as their source of water supply. However there is a signifi cant difference in how Public Schools and Private Schools make use of well water (X 2 = 33, P= 0.001). Signifi cantly more of the Public and Private Schools respectively had their water source >200meters outside the School (X 2 =10.982, P=0.004). Eighty-one percent of the Schools in this study practiced open dumping or burning as their method of waste disposal. The Public Schools use this signifi cantly more than the Private Schools. (X 2 = 46.22, P= 0.001).
Water closet/ septic tank was used by most of the Public Schools and Private Schools. Signifi cantly more of the Public Schools practiced surface (bush/water) method of waste disposal (X 2 = 58.013, P= 0.0001). Gender differentiated toilets were absent in 66.1% of Public Schools and 52.2% of Private Schools (X 2 = 7.186, P= 0.007). It was also observed that soap for hand washing was unavailable in 87.2% and 55.6% of Public and Private Schools studied (X 2 = 44. 186, P= 0.001).    administrators, as well as for rest, relaxation and recreation [16].
In this study 78% of the total number of Schools studied had some form of water supply even though about 52% of this was from bore holes/ mono pumps. This is high compared to the 46% reported by the Federal Ministries of Health and Education in their assessment of availability of water supply in schools [17]. This fi gure however represents a national average as primary, secondary and universities were involved in the study. It is also higher than the fi gures in another related study in Rivers State where 35% of the schools had water supply [18]. It is also better than the 17.3 %, 2.6% and 0% reported in Edo State [14], Imo State [19] and Zaria in Kaduna State [20], respectively. It should be noted that the Zaria study involved only one school, however majority of schools in the developed countries have adequate water supply [4,5].
In this study, sources of water were found within and less than 200 meters outside the school in 66% of the schools studied. This was acceptable as the Universal Basic Education (UBE) strategic plan had stipulated that clean water supply should be within 500 meters of the school [21]. The Rivers [18] study reported that 40% of the schools had their water supply within 200 meters of the school premises while most of the schools in the Imo study lacked water within 500 meters from the schools [19]. Poor water supply means that activities that involve its use such as hand washing, cleaning, fl ushing of toilets and even drinking would suffer and indirectly create unhygienic environment for the pupils. They will also become exposed to accidents and unnecessary hazards in their attempts to obtain clean water outside the school premises. practiced open dumping of refuse as against the Private School that did not [22]. All the schools in the Rivers study (100%) practiced open dumping and burning [18]. The results were also similar in the studies in Edo [14], Imo [19] and Zaria [20]. Open dumping provides excellent breeding sites for fl ies, rodents and reptiles. Huge piles of waste will constitute an environmental nuisance. They also serve as breeding grounds for mosquitoes when they contain broken bottles, plastic, cans etc. Children will also suffer from cuts and bruises when they play around the piles of rubbish and hence must be discouraged.
Only 39% of schools studied have functional toilets. This is made up of 23% Public Schools and 77% Private Schools. These fi ndings are better than that done in Rivers State where 25% of the schools studied had functional toilets [18]. There were no toilet facilities for children's convenience at all in the study done in Imo State [19]. Similar study in Edo State showed that 40% of the schools studied have functional toilets and was distributed as 13% Public Schools and 87% Private Schools [14].
Similar fi ndings were reported from the study at Obio-Akpor Local Government Area [23] and in Ikenne [22]. They showed absent functional toilets in Public Schools. Absence of toilet facilities suggests increase in unsanitary methods of sewage disposal with contamination of the hands and environment with faecal matter leading to more cases of diarrhoeal diseases, helminthiasis and possible disease epidemics from water contamination. Studies on school toilets in the UK [24] have corroborated this. It has also been reported that unsanitary toilets lead to an increase in urinary tract infection in children as they tend to hold back from voiding urine as at when due [25].
Gender differentiated toilets were available in 41% of the schools and 59% in the Private Schools. In a study assessing toilet facilities in secondary schools in Jos North LGA, 54% of the schools had gender differentiated toilets [26]. Studies in Kenya [27] and Ethiopia [28] have reported that toilet differentiation can lead to more school attendance by girls especially if they are clean, safe, secure and private. Soap for hand wash was available in 29% of schools as at the time of study and 78% of the schools were Private Schools. This was similar to the study in Edo state where soap was present in 33% of the schools studied and 88% of them were Private Schools [14]. Others studies reported absence of hand washing soaps in the schools [18][19][20][21][22]. The study is a sharp contrast to that in the Schools in the Bloomberg Health District of London where 75-78% had soap and water for hand washing [24]. Hand washing has been described as the single most effective way to prevent the spread of infections [29]. WHO had recommended a ratio of 1toilet to a maximum of 30 pupils [30]. In this study, only 14% of the schools met this WHO requirement and 84% of them were Private Schools. While this fi nding is very poor, others studies were much worse off and reported abysmal ratios [22][23][24]. An insuffi cient toilet/pupil ratio contributes to overuse, fi lthy conditions and a consequent return to open defecation around schools, or absenteeism in order to use a home toilet [31].
Schools with strong walls and roof were 56% of the total schools in this study. Out of this, 65% were Private Schools. Less than 1% of the schools were completely dilapidated. This is contrast to the schools studied in Rivers where 25% were dilapidated but 50% had strong walls and roofs. One school in the Rivers study had no building at all and the students sat under a shade [18]. It is important to note that the environment in which learning takes place is an important factor in the learning process [32]. Ventilation was adequate in 81% of the schools and controllable in 71%. This is similar to another study that reported adequate ventilation in 85% of schools but differed by reporting controllable ventilation in 35% of the schools studied 110 . Others reported inadequate and uncontrollable ventilation [18][19]. Seventy-two percent of the Schools had good lighting while 61% had intact ceiling. The Rivers study reported 85% with good lighting and 60% of the schools there with intact ceiling. These studies are in contrast to the one that reported an abysmal 2.2% of schools with good lightning and poor ceiling of its buildings [19]. Very little teaching and learning would be on going in these schools.
Pupils were completely seated in 83% of schools studied. The Private Schools accounted for 57% of this number. This study found pupils sitting on the fl oor in 27% of the schools in the study population. This is in contrast to the study in Bonny in which pupils were completely seated in 55% of the schools and on the fl oor in 45% of the schools [18]. The results are poorer from the study in Obio-Akpor where pupils were completely seated in 11% of the schools and were on the fl oor in 89% of the schools in the Local Government [23]. Sitting comfort has been identifi ed as one of the factors that affect learning [33].
Children in these schools would fi nd learning diffi cult and uninteresting. Teachers too would be very frustrated and would do very little effective teaching.
Complete school fence was present in 59% of the schools in this study. Of this number, 70% were Private Schools. This is in contrast to the schools in the Rivers [18], study that reported 10% of the schools as completely fenced and the study in Imo [19] in which none of the schools were fenced. Again 9% of the schools in this study had a safety patrol team and 66% of this were Private Schools. This is in contrast to the studies in Rivers [18] and Imo [19], where patrol teams were totally absent in all the schools. Primary school fencing and gates serve two principal purposes, namely preventing the unauthorized departure of children and keeping out people seen as a threat to young children [34]. For these reasons primary schools in the UK tend to implement even tighter security than other types of schools particularly in relation to personnel access [34]. All Schools in the State must be properly fenced to provide some degree of security to staff and children while they are within the school premises. This should be a requirement for school registration. Government should provide schools with necessary funding to ensure that all staff and pupils are seated and that basic amenities such as clean water, gender differentiated toilets with hand washing facilities are available in all public schools.
The study shows that the environmental health situation in Nigerian school care is poor. There is the need for patrol teams to inspect and monitor the activities of the schools in the state in Nigeria and other developing countries. Security has become a major issue in school health care in Nigeria right now and schools have to be more conscious of this. Still fresh in our memory is the abducted Chibok girls. Fencing and patrol teams are no longer options but necessities. They would at least serve as a line of defence. School security in the UK now revolve around the Head Teacher as the Chief Offi cer but supported by the Staff, pupils and the community under the 'Schoolwatch' schemes [35].

Authors' Co ntributions
KOT participated in the study design and conducted data collection. OEA conceived the study theme, participated in the study design, supervised data collection and prepared the fi nal manuscript. KOT was involved in Data collection and analysis.
ALL authors read and approved the fi nal manuscript.