Access to water, sanitation and hygiene (WASH) for persons with disabilities in school settings: A call for research

Abstract

Improving access to water, sanitation and hygiene (WASH) services in school settings is critical in addressing access disparities experienced by persons with disabilities. As such, the Sustainable Development Goals (SDGs) established ambitious targets which aim to achieve universal access to water and sanitation by 2030. Despite this, access to inclusive WASH services in schools remain a big challenge in many resource-constrained settings. This review seeks to examine access to WASH for persons with disabilities in school settings. We undertook a review to identify a wide range of evidence from peer-reviewed sources. We identified only two studies, and they revealed environmental, social and institutional barriers that negatively affect persons with disabilities’ access to WASH services. We concluded the review with a call for urgent attention to build on this knowledge base as well as practical steps to improve WASH service provision in school settings in low- and middle-income countries.

Keywords:

• Access
• persons with disabilities
• review
• schools
• water and sanitation

Introduction

The United Nations Sustainable Development Goals (SDGs) established ambitious targets which aim to achieve universal access to water sanitation and hygiene (WASH) (i.e. SDG6, for both household and institutional settings) by 2030. The SDGs further call for systematic attention to gender equality and the empowerment of persons with disabilities in relation to the implementation of the new Agenda. Thus, the SDGs recognize equitable and adequate access to WASH in schools for vulnerable and marginalized populations such as persons with disabilities as a major priority for promoting health and wellbeing. Despite this call, access to inclusive WASH services in schools remains a big challenge in many resource-constrained settings. Recent reports indicate that 47% of schools in sub-Saharan Africa do not have any form of water facility, and 33% do not have any type of sanitation facility (WHO/UNICEF 2018). The lack of WASH facilities and other inclusive services have led to high school dropout rates among persons with disabilities (Groce et al. 2011). For instance, 90% of children with disabilities do not attend school, and this situation is more pronounced among disabled girls who often drop out of school due to lack of access to disability-friendly water and sanitation facilities (Groce et al. 2011). Thus, achieving equitable access to education in many low-and middle-income countries will imply building new and upgrading WASH facilities in schools as well as ensuring that such facilities are disability-friendly, gender sensitive, and provide safe, inclusive and effective learning environments for all.

We undertook a scoping review to examine access to WASH for persons with disabilities in school settings. Databases searched included Embase, Global Health, Medline and Scopus. The literature was searched using keywords related to WASH, disability and schools. Relevant articles were selected based on English articles that focused on WASH for school children with disabilities in school environment. There was no restriction on publication period and methodological designs in order to identify a wide range of evidence on the topic. Only two qualitative studies were identified, and they revealed three broad barriers: (a) environmental, (b) attitudinal, and (c) institutional barriers. Given the limited number of studies identified, we believe it is important to make an urgent call to the research community to increase knowledge base and improve the quality of life and wellbeing of persons with disabilities especially in school settings.

Access barriers

Physical/environmental barriers

The built environment posed a major challenge in accessing WASH facilities in schools. Specifically, students with physical disabilities faced difficulties in accessing latrines due to barriers such as steep and rocky pathways, narrowed doorways and high ramps that prohibited the use of wheelchairs (Erhard et al. 2013; Zaunda et al. 2018). Similarly, long distance to latrines, slippery floors of latrines, height of hand washing facilities, and the lack of disability-friendly hand pump to collect water are physical barriers encountered by those with mobility impairments (Zaunda et al. 2018). These barriers often compelled students with disabilities to employed strategies such as reducing food and liquid intake to decrease the need for use of latrines in schools, waiting until they are at home, practicing open defecation and keeping quiet or avoiding the need for water (Erhard et al. 2013; Zaunda et al. 2018). Further, these barriers have negative health implications to the individuals and the school settings at large. For instance, slippery latrines and the absence of supporting handles often forced students with disabilities to touch urine or feces on the floor as they are unable to squat due to their physical conditions (Zaunda et al. 2018; Erhard et al. 2013). Consequently, this makes students highly susceptible to diseases as well as risk of accidents.

Attitudinal (social) barriers

Privacy is a major concern as latrines in schools are either without doors or locking doors (Erhard et al. 2013; Zaunda et al. 2018). The lack of privacy was commonly experienced by students with visual impairments in inclusive schools, as they may be afraid that latrines without doors or locking doors could result in other students watching them or invading their privacy when using a latrine. Further, persons with disabilities are often stigmatized in schools and therefore may not be consulted about their needs in designing water and sanitation facilities (Zaunda et al. 2018). Additionally, due to persistence of negative stereotypes of children with disabilities, students with disabilities often do not articulate their challenges in accessing water and sanitation facilities in schools (Zaunda et al. 2018).

Institutional barriers

Existing policies and guidelines to ensure implementation of and access to water and sanitation facilities for children with disabilities are often not given the needed attention. In many low- and middle-income countries, this situation may due to the inadequate resources or lack of motivations to adhere to policies on the provision of disability-friendly facilities in schools. In particular, a study in Uganda indicated that school teachers and administrators regarded the provision of more classrooms and books as the main priority over the provision of disability-friendly WASH in schools (Erhard et al. 2013).

Gaps and future research

Several research gaps were identified in the review process and in the studies that could be explored in future research. First, access to WASH for persons with disabilities in school settings is underexplored. This limited research may not be surprising in that persons with disabilities have largely been neglected as a major population in public health attention (Krahn, Walker, and Correa-De-Araujo 2015), including improved WASH systems in schools (Redman-MacLaren et al. 2018). Nevertheless, given the SDGs’ emphasis on “leaving no one behind” in ensuring universal access to WASH by 2030, more research in needed to achieve this goal. Specifically, data on the perspectives of WASH users (i.e. persons with disabilities) is needed as evidence suggest that their involvement in the design and decision-making process could potentially reduce access inequities (Zaunda et al. 2018).

Second, the two studies utilized qualitative approaches to articulate key stakeholders’ perspectives and the experiences of school children with disabilities in accessing WASH services. We argue that future research could employ alternative qualitative approaches such as arts-based methods (e.g. photographs and drawings). These approaches may provide a better understanding of key aspects of the physical, social and political environment and how they affect access to WASH in school. In particular, recent studies show that the use of drawing and photovoice could potentially reveal rich perspectives about children with disabilities’ experiences in relation to physical barriers and facilitators to participation and accessibility to services (Eisen, Cunningham, and Campbell 2019).

Third, there is lack of disability disaggregated data in the existing evidence. This could hinder a comprehensive understanding of the unique WASH needs of the individual’s disability type (i.e. physical, sensory and intellectual disabilities). Thus, as persons with disabilities are not homogenous groups, their experiences in accessing WASH may differ based on the type of impairment. For instance, persons with vision and hearing impairment encounter difficulties in accessing WASH information, whereas those with intellectual disabilities may not be able to comprehend such information. For all these types of impairments, it will be more appropriate to design WASH policies and interventions that target their specific needs. Recent intervention studies on handwashing hygiene from the lens of school children with intellectual disabilities is a promising step (Choi, Wong, and Chung 2012; Lee and Lee 2014; Lee et al. 2015; Walmsley et al. 2013).

Fourth, existing evidence tend to predominantly focus on a deficit-based approach—i.e. the challenges persons with disabilities faced in accessing WASH facilities, and the concomitant negative health outcomes. There is a need for further research to use a more strength-based approach that focuses on when and how WASH can positively influence health outcomes for children with disabilities in schools. Finally, the nascent evidence is not theoretically grounded. The use of access and social theories as well as those in the field of disability (e.g. social and medical) may be useful in understanding areas that need policy interventions. This is especially crucial if we are to avoid “opaque observation” (Dreibelbis et al. 2013).

Conclusion

Improving accessible and inclusive WASH services in school settings is critical in addressing access disparities experienced by children with disabilities. Although very few empirical studies were identified, the review revealed environmental, social and institutional factors that negatively affect persons with disabilities’ access to WASH services. In view of these emerging insights, we call for an urgent attention to build on this knowledge base as well as practical steps to improve WASH service provision in school settings in low- and middle-income countries.

Acknowledgements

The authors conducted this research as part of a Canadian Institutes of Health Research Planning and Dissemination Grant and the Kwame Nkrumah University of Science and Technology College of Health Sciences Early Career Grant.

Additional information

Funding

This work was supported by Kwame Nkrumah University of Science and Technology College of Health Sciences Grant.