Child-based sanitation promotion
From interviews with the principals and teachers at the six selected schools it was clear that the schools followed the national curriculum related to hygiene and no separate formal component on hygiene education and sanitation was included in the curricula.
However, 6 weeks of observations at the six schools did identify a number of general environmental hygiene promotion activities taking place outside the classroom across all schools. In six schools, the emphasis was on teaching children practical skills such as daily cleaning of classroom and weekly cleaning of schoolyards. In one secondary school, students participated in weekly cleaning of the school latrine and in keeping the road leading to the school free from garbage. During the observations and from interviews with schoolchildren it was clear that no practical instructions were given to the children on how to use a latrine.
Based on in-depth interviews with the parents and responses from the children, no child-focused sanitation promotion activities were identified as ongoing at the community level. Village health workers and village heads were identified as the main actors responsible for community-based sanitation promotion. However, none of them performed any such activities targeting children during the time of the study [36
Latrine infrastructure and availability at school
All six schools had latrine facilities which were located within the school compound and all had gender segregated compartments. Each compartment was designed with separate areas covered by a roof for defecation and separate urinals without a roof.
The location of the latrine depended on the size of the school compound. It was observed that two schools with large compounds had their latrines located in a secluded area where the earth path to the latrine was slippery, especially in the rainy season. In the remaining four schools with a small compound, the latrines were located nearby the classroom with a concrete path leading to the latrine. Only two out of the six schools had separate latrines for the staff. In general, each school had only one latrine with two or four pits serving between 67 and 247 children. At all schools, children were allowed to use the latrine during class times.
Observations also showed that the school latrines lacked essential materials and items allowing for proper use. For example, no anal cleansing materials, soap or waste baskets were seen at any of the schools.
Observations at the individual schools showed that the latrines were inadequately cleaned and therefore appeared dirty and in poor hygienic condition. The latrines had a strong smell of urine, especially at the end of the school day, the floor was dirty from soil and waste materials, and flies were abundant. Four of the six schools were found to have feces continually present on the latrine floor during the week of observation.
Latrine infrastructure and availability at home
It was observed that children had limited opportunities to use a latrine at home, with only eight out of 20 households visited having a latrine. Four of these had the latrine connected to a septic tank with a structure made of a concrete roof, walls and floor. All latrines were located a few meters away from the main house. All households with a latrine connected to a septic tank had a door at the entry to the latrine and water, soap and toilet paper were available. The other four households also had a latrine but with very simple construction, including three pit latrines and one over-hanging fish-pond latrine. These latrines were made of local material and did not have a door. No water was available and the paths leading to these latrines was narrow, slippery and observed to be difficult to access and use in the rainy season, especially for small children. During the home visits, it was observed that the latrines floors were littered with fecal matter, soil, waste and a lot of flies present. Only two of the latrines were found to be well maintained.
Contextual appropriateness of latrine
Through observation at school and home, we found that the residents, including children, preferred to urinate and defecate in the open. There seemed to be no stigma associated with this traditional practice and open urination and defecation were socially acceptable at village level. Regarding open defecation, the parents and children commonly stated that "everybody here does the same, all villagers practice similarly" (ai cũng đi như thế, cả làng đi như thế). Therefore, based on our observations, "hygienic" defecation means to either defecate into the stream that will carry the feces away, or dogs took care of children's feces. This attitude might be one reason for not having a latrine at home.
According to several parents in highland as well as lowland, the concept of a latrine is perceived to come from the urban areas or the city where living conditions are better-off or considered as part of a 'civilized world' (thế giới văn minh). A septic tank is perceived as a sign of a better-off family in the village who has regular visitors and represents a higher social class in the local area.
Responding to the question of why many children practiced open urination and defecation in the village, a mother of grade 4 female student replied that "Go to the stream.... Local people and children here do the same, go to the stream".
Through observation and interviews with local people, we found that it was collective perception that open defecation is common practice at the village level.
The interviewer: Well, which latrine the people here like to use?
The female parent: (laugh)
The male parent 1: generally speaking, if you go to the rural, you like to....
The male parent 2: open, like to go in open (tự do, đi tự do)
(FGD with parents of secondary student)
Latrine use by schoolchildren
Table describes the latrine use pattern of the schoolchildren. About half of the children reported urinating (55%) and defecating in the open (53%). Out of 319 schoolchildren responding to the question "Where did you defecate yesterday?", 170 children reported 'in the open', 140 'in the home latrine' and only eight (3%) used the school latrine. Observations made at the school settings and during child interviews confirmed the low use of the school toilets for defecation. At the six schools, latrine use practices were observed for more than thousand children and only 19 children were seen to use the school latrine for defecation. Furthermore, only seven of the 24 children selected for home visits and in-depth interviews reported ever having defecated in the school latrine. The analysis of the children's diaries describing their sanitation practices over a one day period also indicated that latrine use was not a common practice among the children. Only 23 out of 243 children reported having used a latrine either at home or at the school. The overwhelming preference for open defecation was clearly supported by our observations in the community and household settings.
In-depth interviews with children indicated that they found it more comfortable and convenient to defecate in the open, not least because of more fresh air. A grade 7 male child explained "I prefer defecating in the bush because it is a cool and convenient place". Another grade 7 female child explained why she preferred to defecate in the stream "I like to defecate into the stream because it will make it [excreta] flow away".
Results from the school-based questionnaire survey found limited differences in latrine use between boys and girls (Table ). Likewise, no differences were found among children attending schools located in lowland as compared with highland areas. However, there was a difference in latrine use among children attending secondary and primary schools, with older children reporting more frequent use of latrines at school and home (Table ). For example, only three (5%) and 19 (31%) out of 62 grade 1 schoolchildren reported to have urinated in the school latrine and defecated in the home latrine the previous day, respectively. In comparison, a higher proportion of latrine use was noted among grade 7 children, with 42 (29%) and 73 (51%) out of 143 children reporting to have used the school latrine for urination and home latrine for defecation the previous day, respectively.
"Popular knowledge" among schoolchildren of latrines
Among the 24 children participating in the in-depth interviews, only six who lived in the lowland area highlighted latrines as a mean to prevent the spread of diseases or as a way of protecting the environment from "pollution". These six children emphasized that open defecation may cause germs to spread and could make people sick. A grade 7 female child using a latrine at home described the importance of latrine use as to "avoid germs". She further explained that "germs from feces could be transmitted by flies to food and then people could be sick from eating the food".
Additionally, five children explained that latrines were important to avoid bad smell and dirtiness around the homes and in the community. Among grade 1 children mainly living in the highland (coming mainly from the Xa Phó ethnic minority group), 11 of the 24 children participating in the in-depth interviews could not think of any reason as to why a latrine would be of importance.
Child perception of hygienic latrines
From the in-depth interviews it was noted that the children perceived a hygienic latrine associated with cleanliness. In their perception, a hygienic latrine should have water to flush and should be cleaned on a regular basis. As explained by a grade 4 male school child "The floor of the latrine must be clean, urinating and defecating places must be clean, with water to flush, no flies and no fecal matter on the floor".
The drawings by the children presenting the school and latrines of their "dreams" clearly indicate that children want to see functional and well-organized latrines with basic facilities. All pictures also indicated wishes for more privacy, with doors on all latrines and wall separations for urinals. In all pictures, good accessibility was also stressed with plenty of space for urination and with more than one chamber available for defecation. Finally, many children depicted hygiene amenities such as water tanks, soap and towels to be of importance to them for a good school latrine (see Additional file 1
Child perception about unappealing latrines
According to the children's explanations during the in-depth interviews, an important reason for not using latrines was related to the dirtiness and inhaling "smelly air", both at home and at schools. A range of words were used by the children to describe the status of the school latrines, in particular the smell of urine and feces, such as rất khai (a strong smell), hôi (smelly) for urine and thối (bad smell), bẩn (dirty) and rất bẩn (very dirty) for feces. A grade 1 male child explained "My school latrine is smelly, dirty from soil on the floor, much garbage and urine outside the latrine. I have defecated only one time there, very bad smell"
Lack of access was another important argument used by the older children to explain why school latrines were not preferred for urination. A grade 7 female child explained why she disliked the school latrine "There are many people waiting to use the latrine and I do not really like to use the school latrine... therefore I and many of my friends come to urinate on the hill (near the school)..."
Management of school latrines
Observations at school found that there was a scarcity of water and lack of buckets to collect and store water at latrines with five out of the six schools not having enough water to serve the latrine. It was clear that the need of water for latrines and personal hygiene purposes were inadequately addressed at the time when school latrines were designed and constructed. Through interviews with school staff, it remained unclear who was responsible for the water supply to latrines. "I do not allow them (the children) to use the latrine because we do not have water... The latrines have had no water from the time the contractor handed it over to us... when I open the door to the latrine, it is extremely dirty, and we cannot make them clean" (The principal of one secondary school).
The study found that the school management had not been involved in designing the school latrines and that this was the responsibility of external contractors. Some principals mentioned that the contractor who built the latrines was often different from the contractor building the school.
"The financial source for construction of our school latrine came from the District Construction Management Board. They only requested us to prepare land for construction. The board signed the contract with the contractors. We were allowed to supervise the construction but the Board made the final decision... We did not have the right to participate in the design..." (The principal of one primary school)
Interviews with the school managers and teachers clearly showed that all six school latrines lacked financial resources to maintain the latrines. There was no separate budget allocated for the maintenance of school latrines. Such costs had to be covered by the annual school budget. No instructions were given on how to maintain and repair the latrines provided to the six schools. The principal of one secondary school explained "We have no funds to provide toilet paper so the children use sticks for anal cleaning and it results in the latrine getting blocked".
Support provided to schoolchildren for latrine use
At the community level, no activity was found, including encouragement by the parents, guidance of children and social practices, to enable the schoolchildren to use latrines, even if the children lived in households with latrines. Open defecation in the field or hiding places such as the bush, animal-pens was seen as acceptable by family members, in particular for small children.
At schools, most teachers found it difficult to teach children how to use a latrine and language barriers made it even more difficult. According to the teachers, it was impossible to teach EMG children (e.g. Xa Phó and Dao groups) how to use a latrine correctly. Furthermore, most school staff agreed that EMG children have a low awareness of latrine use. Thus, they did not believe an EMG child to be able to use a latrine properly. A female teacher in a primary school replied when asked why they did not teach EMG children to clean latrines "Because they will not be able to... We did not teach them because they are so small/young (bé quá). They are ethnic minority people (người dân tộc). They do not know how to do. They know nothing!"
Interviews with school staff and parents clearly indicated that there was no communication between the school and home aimed at changing sanitation behavior of the children. In the established parent-child association the main task of adult household members was to focus on helping school staff mobilize the children to attend school, while sanitation practices were never addressed. According to schoolteachers, the family plays the most important role in shaping the sanitation behavior of schoolchildren. A teacher participating in a FGD explained "Teaching children hygiene behavior should be done by the family.... The school plays an important role but.... Many other factors will make decisions for children and the family context is the most important factor to shape the behavior of the children.... Teaching hygiene behavior for children is the parents' responsibility." By contrast, the parents believe that guidance on latrine use is the responsibility of the school and its staff as argued by a parent of a secondary school child participating in the FGDs "The parent (laugh): we have never tried to see the latrine of this school... Our children's activities happening there (at the school) we do not know if they use school latrine... We think our kids learnt to use the latrine at school because it is managed by the school"