Anal cleansing is a taboo subject that is often overlooked by researchers and program staff.

The SWASH+ Project conducted focus groups with male and female 12- to 15- year-old students in rural Kenya and collected data from teachers and parents to understand students’ anal cleansing practices and beliefs.

Anal Cleansing in Rural Kenyan Schools

[Students reported using several materials for anal cleansing: schoolbook paper and leaves were cited as the most frequently used while in school.

All students in the focus groups felt guilty about tearing up schoolbooks because they were forced to lie to teachers about why pages were missing and they were ruining learning material. Students agreed that toilet paper was the best material to use, however, it is rarely purchased or made available for use. Of the 114 head teachers interviewed, 111 (97%) reported never providing materials for anal cleansing (McMahon, 2011).

The SWASH+ study revealed generational differences in anal cleansing practices. Focus group participants reported the elderly, adults and some young children had no shame about using leaves to wipe but adolescents found this embarrassing.

Students reported asking their parents to buy toilet paper however, parents often refused because they questioned the effectiveness and utility of toilet paper, which they never or rarely used and they consider expensive and prone to tearing.

Students reported never discussing latrine use or defecation with friends or family. Parents stated that they had never been trained on how to use a latrine and many had no home latrine.

Because they engaged in open defecation – and almost always used leaves that were an arm’s reach away – there was never an opportunity to train their children on latrine use or how to use materials other than natural materials.

Focus groups also confirmed many students were confused about how to wipe. Students reported that younger children did not know how to properly wipe or use the latrine, creating unsanitary latrine conditions. If school latrines are unsanitary and are not properly maintained students are much less likely to use latrines.

The practice of wiping feces on walls is so common that students refer to it as ‘writing on the wall.’ Younger children were reportedly unashamed of using leaves or hands to wipe, or scooting on grass to clean their bottoms.

Focus groups also confirmed many students were confused about how to wipe. Students reported that younger children did not know how to properly wipe or use the latrine, creating unsanitary latrine conditions. If school latrines are unsanitary and are not properly maintained students are much less likely to use latrines.

The practice of wiping feces on walls is so common that students refer to it as ‘writing on the wall.’ Younger children were reportedly unashamed of using leaves or hands to wipe, or scooting on grass to clean their bottoms.

Adding new and clean latrines at school increases student’s use of latrines for defecation. However, students’ risk of bacterial contamination and sickness increases if concurrent improvement to hand hygiene and provision of anal cleansing material is not provided.

A recent SWASH+ study found the addition of new sanitation facilities to the hygiene promotion and water treatment intervention greatly increased children’s risk of having any E. coli and high levels of E. coli on their hands.

The percent of students with E.coli on their hands increased from 37% at baseline to 90% at follow up in schools that received new latrines. Anal cleansing materials, education and handwashing with soap are necessary components to school WASH (Freeman, 2012).

Social responsibility played a significant role in the older students’ desire to wipe and to wash their hands after using the latrine. Students often were concerned that they may spread illness or make friends ill. Emotional factors motivated students to wipe, including a desire to avoid shame because of soiled clothing or smelliness.

After analyzing the research, the SWASH+ team recommended making anal cleansing materials available and teaching children how to use them, providing water and soap near latrines, encouraging school officials to ensure adequate materials are available, and working to educate parents about the importance of anal cleansing.

ReferencesMcMahon, S., Caruso, B., Obure, A., Okumu, F., & Rheingans, R. (2011). ‘Anal cleansing

practices and faecal contamination: a preliminary investigation of behaviours and conditions in schools in rural Nyanza Province, Kenya.’ Tropical Medicine and International Health. 16(12), 1536- 1540.

Freeman MC, Greene LE, Dreibelbis R, Saboori S, Muga R, Brumback B, Rheingans R. (2012) ‘Impact of school-based hygiene promotion and sanitation interventions on pupil hand contamination in western Kenya: a cluster-randomized trial.’

Photography by CARE/Brendan Bannon. Photo essay by Julie Straw; edited by Malaika Cheney-Coker.

SWASH+ is a five-year applied research project to identify, develop, and test innovative approaches to school-based water, sanitation and hygiene in Nyanza Province, Kenya. The partners that form the SWASH+ consortium are CARE, Emory University, the Great Lakes University of Kisumu, the government of Kenya, and the former Kenya Water for Health Organisation (KWAHO), and Water.org. SWASH+ is funded by the Bill & Melinda Gates Foundation and the Global Water Challenge. For more information, visit www.swashplus.org.