Gender and WASH Practices in Schools: Photovoice Research from Southwest Cameroon

Jennifer A. Thompson and Rachel Lawerh

Introduction

Figure 1: Photograph of a water barrel taken by research participants with the caption, “There is no water in school, and that which is there is not good for drinking. It’s very dirty” (Mixed1). Buea, Cameroon. Reproduced with permission from research participants.

The photograph in Figure 1 peering down into a water barrel was taken by a group of students as part of a photovoice study at a secondary school in Buea, Cameroon. This blue barrel features prominently in students’ photographs, sometimes explicitly as a feature of water access at school and other times implicitly as part the school’s everyday waterscape. The students explained that the water stored in this barrel is used for cleaning the school and that the water smells bad when stored for too long. One group asked, “What kind of water is this?” Students’ concerns about water quality provoked much discussion about the connections between water, sanitation, and hygiene (WASH) in school and the inequities in how students navigate these realities.

The WASH challenges at this particular school in Cameroon are not unique and reflect major structural inequalities in global health and education. Research by Ashu et al. (2021)—also in the city of Buea—identified schools with only two water points for approximately 700 students, presenting significant limitations to water access and basic hygiene like handwashing. Country-wide, only 34% of schools in Cameroon have access to basic drinking water and only 39% of schools had access to basic sanitation (UNICEF 2020). These figures echo similar concerns about WASH in schools in under-resourced areas in the Global South and North (UNICEF 2022). According to UNESCO (2016), approximately half of primary schools in Africa do not have access to drinking water and one-third of primary schools do not have toilets, with more acute situations in rural areas.

WASH issues are deeply linked with social inequities in global health, with important repercussions for education. Access to reliable WASH services and facilities in schools is a critical factor for supporting and advancing education and wellbeing outcomes. In addition to the importance of access to potable water for drinking, the availability of water on school premises facilitates sanitary hygiene practices and school cleanliness, all which support the health, wellbeing, and experiences of students and staff at school. For example, research in Cameroon found that when there is unreliable access to water in school, students may also be sent out of class to collect water for the maintenance of the school grounds (Thompson 2017). Reliable access to sanitation in schools includes both access to basic toilet facilities as well as considerations of safety and dignity, and how toilets are maintained. For example, research in Eswatini and Zimbabwe documents student concerns about school toilets and sexual and gender-based violence (Mitchell and Mothobi-Tapela 2004). Additionally, WASH in schools has taken on new urgency in the context of the COVID-19 pandemic with an intensified focus on handwashing.

However, despite the importance of WASH in schools, there remains uncertainty about the effectiveness of school-based WASH interventions. McMichael’s (2019) systematic review of WASH interventions in low-income countries found some evidence that school-based WASH interventions can improve WASH knowledge, attitudes, and behaviors and improve health-related outcomes such as reduced diarrheal and other hygiene-related diseases among students. However, this review found mixed evidence about whether WASH interventions improve student enrollment and attendance. An earlier systematic review of over 5000 studies found no existing studies (at the time) that could attest to whether single sex toilets improve girls school enrolment or attendance, in part due to a lack of sex-disaggregated data (Birdthistle et al. 2011). Other randomized control trials assess the effectiveness of WASH programming but often offer limited insight or explanation about why particular interventions succeed or fail. Despite calls to include young people in health promotion programming (Aceves-Martins et al. 2019), little research about WASH in schools seems to involve young people. There remains a dearth of evidence about what young people experience, think, and know about WASH in schools.

Unpacking WASH: The need for more comprehensive understandings of WASH

Given these uncertainties, critical global health scholars identify conceptual gaps within fairly narrow understandings of WASH (Curtis et al. 2011; Marshall and Kaminsky 2016; McMichael 2019; Workman et al. 2021). While hygiene was meant to be a major bedrock in the domain of public health, water and sanitation have long been considered within the realms of engineering and infrastructure, which have historically favored and financed technological developments. Hence, much WASH research in schools quantifies water and sanitation facilities and concludes that schools lack adequate WASH facilities (Abanyie et al. 2021; Agol et al. 2017; Appiah-Brempong et al. 2018; Ashu et al. 2021; Morgan et al. 2017). As critical scholars suggest, infrastructures and technologies are important but also not enough. Building toilets in schools can help to ensure adequate student to latrine ratios, for example, but these interventions do not ensure that water and soap accompany the toilet, that the toilet is used correctly, and that handwashing takes place. While the Millennium Development Goals saw enormous investments in water and sanitation technologies, less attention has been paid to understand and address the social practices and complexities of WASH (Marshall and Kaminsky 2016; Nunbogu and Elliott 2022). In short, the H in WASH (hygiene) has been historically been overshadowed within the WASH sector overall (Curtis et al. 2011) and in the WASH sector in Sub-Saharan Africa (Akpabio and Takara 2014). Curtis et al. (2011) suggested that social inequalities combined with a lack of political will has gravely under-funded and under-prioritized hygiene promotion:

Perhaps because hygiene does not require clever new technologies or products, or perhaps because it is a domestic and personal issue largely affecting women and children, and perhaps because it concerns the neglected diarrheal and respiratory diseases (still the two biggest killers of children), hygiene is still very much overlooked in public health. (312)

When hygiene is addressed, many interventions tend to focus on biological disease transmission pathways and behavior change interventions, with handwashing tending to receive the most attention (Curtis et al. 2011). Behavior-change interventions have been critiqued for relying largely on cognitive approaches such as rationale choice theory and social learning theory, which posit that increasing an individual’s knowledge will change their actions. This assumption about a linear relationship between knowledge, attitude, and practice still informs the design of much public health programing, often leaving socio-cultural, environmental, and structural factors unaccounted for (Launiala 2009). At the crux of this problem is the focus on individual behavior and responsibility for change. This focus neglects to consider how WASH issues are multidimensional, multi-scalar, and culturally embedded (Workman et al. 2021). Simply knowing about the benefits of handwashing does not necessarily lead to increased incidents of handwashing (Curtis et al. 2011). Questions about social norms and inequities need to inform more comprehensive and critical views of hygiene and its role in WASH and health promotion. Regarding WASH in Sub-Saharan Africa, Akpabio and Takara (2014) and Zakiya (2014) call for more qualitative, local perspectives in order to understand the social and cultural complexities around WASH.

One significant social dynamic in WASH is gender, and more specifically gender inequalities. Women and girls are disproportionately affected by WASH issues. The field of gender and water highlights how gendered divisions of labor, norms, and expectations often leave women and girls with more responsibility for water-related work such as fetching water, cleaning, and care (Coles and Wallace 2005), including in Cameroon (Thompson et al. 2011; Thompson et al. 2017). Regarding sanitation, it is widely acknowledged that a lack of access to toilets disproportionately affects girls and women. The last decade has seen an explosion of research and programming on putting menstrual hygiene management (MHM) onto the WASH agenda (Sommer et al. 2015; WHO/UNICEF 2022) and identifying the need for schools to have separate sex latrines with locks on doors for privacy, an adequate water supply, and discrete waste disposal (Morgan et al. 2017; Parkes and Heslop 2013). This research highlights complex, sensitive, and under-documented intersections between violence against women and girls and poor WASH access (Nunbogu and Elliott 2022; Sommer et al. 2014). Yet when it comes to WASH in schools, there seems to be scant literature about gender and other WASH practices (other than MHM) more broadly.

In order to develop a more comprehensive understanding of gender and WASH in schools, participatory and action-oriented research approaches offer opportunities to shift whose voices are informing WASH conversations and the difference that research participation can make in research participants’ lives and communities. Community-based research seeking to understand women’s WASH experiences has used qualitative methods such as in depth interviews (Abu et al. 2019; Pommells et al. 2018), focus group analyses, and visual research methods such as photovoice (Bisung et al. 2015a; Bisung et al. 2015b). Participatory visual methodologies have also been used for addressing issues related to gender and health with young people in the context of global education (Mitchell et al. 2017) and WASH (Virgi and Mitchell 2011). For example, photovoice invites participants take photographs to identify, represent, and analyze issues in their lives (Catalani and Minkler 2010; Wang et al. 1996), including within health promotion (Evans-Agnew and Strack 2022). These approaches shift from viewing young people as victims of their situations to agents and social actors with important knowledge and capacity to produce change (D’Amico et al. 2016). Aligned with action-oriented approaches to research, participatory visual methodologies can be considered a type of ‘research as intervention’ that strives to go beyond simply studying or understanding the world to engaging in questions about action and the ways in which research might also contribute to social change (D’Amico et al. 2016). In this paper, we investigate young people’s WASH concerns through participatory visual methods in the context of a secondary school in Cameroon, and how a gender lens can help deepen understandings of WASH in schools. We begin by presenting practice theory for conceptualizing WASH beyond behavior models.

Practice theory

Theories about social practice have been gaining traction in the social sciences as a way to transcend the seemingly irreconcilable structure-agency debates. As noted earlier, behavior change models relying on economic rational choice models position individuals as consciously responsible for what they do and for therefore changing their behaviors, while often disregarding larger contexts and histories of inequity. More macro-level approaches to structural inequities often inadequately account for social change. Practice theory attempts to work around these incompatibilities by collapsing the micro vs. macro dichotomy to focus instead on practice as the unit of analysis (Shove et al. 2012; Strengers and Maller 2014).

Noting earlier iterations of practice theory (Bourdieu, Giddens), we draw on a so-called second generation of practice theorists (Reckwitz 2002; Schatzki et al. 2001; Shove 2003, 2014). Here, practices involve the “routinized way in which bodies are moved, objects are handled, subjects are treated, things are described, and the world is understood” (Reckwitz 2002, 250, emphasis added). Schatzki et al. (2001) described practices as organized constellations of materially mediated human activity, or the “nexus of doings and sayings” (Schatzki 2012, 14). Practices can involve everyday normalized activities that become habitual, implicit, and unquestioned, like cooking, consuming, working, taking care of oneself and others. Here tastes and values become embedded within practices. People are seen as hosts or carriers of practices, not autonomous decision-makers, and practices all depend on a range of constitutive social, cultural, and material elements. Second-generation practice theorists explicitly consider materiality (including bodies, objects, technologies, and infrastructures) alongside social elements such as knowledge, thought, discourse, and agency. Shove et al. (2012) theorize practices as composed of three interconnected elements: Meanings (symbolic meanings, ideas, and aspirations); competences (skill, know-how, and technique, including knowledge); and materials (things, technologies, tangible physical entities, and the stuff of which objects are made) (14). Applications of practice theory in health and in sustainability have tended to focus on reducing unhealthy or unsustainable practices, such as smoking (Blue et al. 2016), alcohol consumption (Hennell et al. 2020), and resource consumption (e.g. energy) (Shove 2014). We take up practice theory in health promotion to explore the gendered construction of WASH practices in schools through the perspectives, concerns, and experiences of young people.

Methods

Situating the study

This study took place as part of the first author’s doctoral research exploring gender and water in Southwest Cameroon in collaboration with a local women’s organization, Changing Mentalities and Empowering Groups (Thompson 2017). This fieldwork involved women and men from four communities in participatory visual methodology workshops about water. However, we faced challenges recruiting youth through community-based processes, partly because many young people attended school and were not available to attend the workshops (held on weekdays to accommodate community members). The school-based study presented in this paper was conducted simultaneously but not included in the first author’s doctoral thesis. While the WASH facilities in this school have likely changed since the time of fieldwork (2014), the data remain pertinent expressions of youth concerns about WASH in schools.

As co-authors of this paper, we each have different relationships and roles with the research process and data. The first author, a White university-based researcher from Canada (who was a doctoral student during fieldwork and a postdoctoral fellow at the time of writing) spent one year living in Cameroon during which time she was actively involved in designing and facilitating the research workshops with young people. She draws on her experience working with participatory visual methodologies at the community level in Cameroon as well as in several other African contexts, including Sierra Leone, Ethiopia, Kenya, and Mozambique. The second author, an international student from Ghana completing a PhD at a Canadian university, brings a background in public health research and programming in various health areas, including sanitation. She drew on her community-based experience in the context of Ghana across sexual reproductive health, family planning, WASH, and maternal health programs to interpret the photovoice data. Together, we bring our complimentary and distinct professional and lived experiences with the theory and practice of gender and with water and sanitation in different African contexts to engage critically with the data produced through this study. During data analysis and writing, we worked collaboratively to make sense of the data and met regularly to share the interpretations, questions, and tensions that we were seeing in the data.

The photovoice workshops

The research workshops were conducted at a secondary school in the city of Buea in Cameroon’s Southwest Region. Twenty-four students between 15 and 22 years old (9 girls and young women and 15 boys and young men) worked in small groups (four to six students) to take photographs and make short videos in response to the prompt "Water: Challenges and solutions." The groups, designed to elicit gendered perspectives, included two girls’ groups (abbreviated here as Girls1, Girls2), three boys’ groups (Boys1, Boys2, Boys3), and two mixed groups (Mixed1, Mixed2).^[1] Two 3-hour workshops were facilitated at the school, outside of class hours, by the first author and a teacher. The first workshop focused on photovoice where each group worked with digital cameras and took between 8-10 photographs in and around the school grounds. The groups printed their photographs on a portable photo printer, arranged the photographs on a poster, and wrote photo captions. Each group presented their poster and analysis to the group, and the other groups had opportunities to respond. These group presentations and the discussions that followed were recorded. The second workshop focused on participatory video, where each group produced a short "no-editing-required" video. Unfortunately, due to technical issues, most of the video files were lost. This paper therefore focuses exclusively on the photovoice data that include 61 participant-produced photos arranged on seven posters, and recordings of the presentations and discussions. The study was approved by the Ethical Review Board from the first author’s university, and by the school administration. Prior to the workshops, participants and their parents or guardians provided informed consent for their participation. After the workshop, participants gave consent regarding the use and publication of their photographs for research purposes.

Analysis

Our analytical framework brings together three lenses: a participatory lens that prioritizes the issues and stories that participants choose to tell with their images; a practice theory lens that explores the materials, knowledges, and meanings of WASH practices; and a gender lens attends to social differences and relations in the roles, knowledges, and lived experiences of participants. We began with a preliminary content analysis to identify the WASH concerns that young people depicted in their photos. From this analysis, we identified the different school-related WASH practices discussed. To develop more detailed understandings of each practice, we systematically organized the data in a spreadsheet to analyse how each participant group addressed the three constitutive elements of practices (materials, knowledges, and meanings). This process allowed the isolation of different WASH practices and their elements, and a gender analysis of the trends and tensions that emerged across the groups (girls’ groups, boys’ groups, mixed groups).

Results

First, we present an empirically grounded conceptual framework that differentiates diverse types of WASH practices in school. Second, we demonstrate the role of gendered experiences, knowledges, and norms in the construction of these different WASH practices.

WASH as a collection of practices in context

Young people’s concerns about WASH in school integrated multiple overlapping practices. Photographs depict for example drinking water, handwashing, water collection, water storage, school cleaning, waste disposal, toilet use, bathing, and infrastructural maintenance. Each of these practices is distinct yet also entangled and constituting the complexities of WASH practices in school. Drawing on the idea that practices can be inherently understood as bundles of practices (Shove et al. 2012), Figure 2 presents a diagram depicting how WASH in schools is a collection of practices. This discursive move provides a clear visual representation for unpacking and making explicit the multidimensional nature of WASH. WASH in schools might certainly involve more practices than discussed by the young people in this study. For example, drawing on the literature, we also include menstrual hygiene practices and financial practices in the diagram, despite how the youth in this particular study did not explicitly discuss these practices. The outer ring of the diagram emphasizes the importance of social, cultural, political, economic, institutional, and environmental contexts in understanding the particularities of different practices.

We note that limited access to clean water in school is clearly beyond students’ control. At the time of research, water in urban areas of Cameroon was partially privatized and managed by a consortium of foreign private companies, which had failed improve water supply systems or adequately communicate the privatization arrangement to the public (Thompson 2017). Yet students lived the repercussions of these failed national and multinational policies daily. In their narratives, many students seemed to have lost faith that their school could adequately respond to their WASH needs and sought alternative explanations for their situation, from God’s will to the government, and the hope that the researcher might help to explain a lack of water access in their school. Given the need for constructive WASH dialogue that includes many of the different actors involved and those most impacted by WASH issues, this framework offers a fluid and accessible tool (that could be adapted in include diverse other WASH practices) for making visual and differentiating WASH practices. This diagram can also facilitate a corresponding dialogue about gendered social inequalities related to these practices in various contexts.

Figure 2: A conceptual framework for contextualizing and differentiating WASH practices in schools

Through our analysis across and between practices, a number of structural trends emerged related to the institutional context of schooling. First, the same material resources repeatedly entered student narratives, including the school’s water storage tank, stand tap, toilet block, and buckets. As we will elaborate, the shared nature of these common resources all featured significantly in photographs and discussions. This perspective offers a distinct view of WASH in school as a bundle of collective practices that rely on shared materials that belong to the school, compared to for example practices such as energy consumption or driving that involve more individualized ownership of things (such as homes and cars). Second, identifying which materials sustain each WASH practice also highlighted the absence of clean water, which is essential for all WASH practices. Most young people’s concerns revolved around a lack of water, or problems associated with poor quality water. For example, each of the seven groups commented on the lack of clean drinking water at school and its impact on their health. Pointing to a close-up photo of brown water in the blue barrel (much like the image in Figure 1), one girl said: “And here … see the water? That was what I was saying. … You can see how dirty it is. It is not good for drinking” (Girls2). The students raised their health concerns from drinking contaminated water, from stomach problems and diarrhea to cholera and typhoid, and even death. Photos depict plastic bottles filled with murky water and students doubled over with their hands clutching their stomachs with looks of pain on their faces and being taken to the hospital after drinking dirty water. One group reported purchasing packaged juice in the absence of water or to avoid drinking water they believed was of bad quality: “Because of no water, students have to use 250 francs to buy juice” (Mixed1). All groups lamented the lack of good quality water available on campus, and their inability to drink water safely while at school. While drinking water might be an expected priority focus for WASH in schools, the rest of the data extends beyond drinking water to nuance the gendered social complexities of other WASH practices in schools.

Gendered WASH practices in school

While mixed groups tended to present more collaborative and balanced views of WASH issues in schools, clear gendered patterns clearly emerged across the single-gender groups. In general, girls’ groups shared more detailed knowledge and concern about hygiene-related practices and boys’s groups tended to focus on infrastructural break-down and repair. Additionally, as these gendered patterns emerged in the exchanges between youth, their gendered knowledges and priorities also became contested as sources of disagreement. However, to begin, all students agreed that some WASH practices in school were undisputedly tied to institutional discipline.

WASH as discipline and being a good student

In their narratives, young people emphasized the relationship between school discipline and student labor in collecting water and cleaning the school campus. Many students refer to cleaning as punishment assigned by the school principal or DM (Discipline Master) for being late or for bad behavior. Photo captions read: “She is punished to clean the toilet for crime committed” (Girls1); “When I came late to school, I was punished to look for water to clean the campus” (Boys2); and “When [the students] came late, the school master asked them to do some cleaning” (female student). In other words, WASH practices meant to support health promotion were coupled with institutional disciplinary practices. The students themselves also portrayed proper WASH practices and cleanliness as self-discipline, and criteria for being a “good” or “older” or “more advanced” student. All students thought that the younger students needed to be educated about proper WASH techniques. The students draw attention to the role of discipline imposed by the school and self-discipline in terms of adopting particular morals and values that seem to underpin the privileged status of being students.

Hygiene as gendered care

In the context of unreliable water access on campus, concerns about cleanliness also entered all student narratives. From handwashing to cleaning school toilets, ideas related to hygiene and sanitation featured strongly across the work. However, a close analysis of which groups discussed which WASH practices and in what ways revealed that girls’ narratives offered richer and more informed insights about hygiene and sanitation compared to narratives put forward by groups of boys.

Specifically, girls had more to say about hygiene practices related to cleanliness and in the form of advice about how to avoid or manage dirt or bacteria. Here, girls tended to position themselves through socialized roles as caretakers of the school environment with a focus on the health and wellbeing of other students. Girls’ narratives emphasized their knowledge of what they considered good hygiene practices through photographs portraying the correct and incorrect ways to use the materials required for hygiene, such as taps and buckets. For example, one photograph of a student drinking water directly from a tap is captioned “Bad manner of drinking water” (Girls1). One girl explained:

This is very bad! This is the tap that everybody is using. This is the tap where we drink water. You can’t come, then you open the tap and put your mouth [on it to drink]. It is very, very bad. Please, students, do not do that. (Girls1)

Both girls’ groups also acknowledged the multiple uses of water and how different waters are used for different purposes. For example, they specified that water unfit for drinking or handwashing can be used for other WASH practices like cleaning classrooms or ‘watering’ the compound (a practice where water is sprinkled on the ground to alleviate dust). Many of the girls’ narratives shared concerns for other students on campus, and in particular the younger students. During the discussion, one girl commented:

After dumping the [garbage], when there is no water for you to wash your hands. Especially [younger] children, they will just take it directly to the [trash bin] and go and buy something to eat, [without] washing their hands. That will cause stomach problems.

Girls were concerned that younger children might get sick because of improper hygiene technique and know-how, for example, around cleaning practices and disease prevention. This assumed caretaking role focuses on creating a particular order through instilling collective discipline about the ‘right way’ to engage in various WASH practices, and also in correcting younger students.

While the groups of boys also discussed hygiene and cleanliness, their narratives tended to focus on more individual concerns such as personal impacts or woes and how they could access water to meet personal needs such as drinking, handwashing, and bathing. Boys were concerned about getting sick from drinking unsafe water or getting their clothes dirty from carrying water on their heads. The boys were also more likely to focus on handwashing as a practice in and of itself with implications for their own health. One photo depicts a boy trying to wash his hands with brown-colored water, with the caption “Dirty water used to wash hands leading to some diseases like cholera and rashes” (Boys1). When the girls’ and mixed groups discussed handwashing, they more likely connected handwashing with other practices such as cleaning and drinking water. One mixed group photo depicts two students dumping waste into a bin:

Sometimes in the morning, students come to school … they need to clean their classes, clean the surroundings. After they do that, they will not have water to even clean their hands. And when they are writing on their books, it gets very dirty and sometimes their hands stink. (Mixed1)

Within their hygiene concerns, girls addressed the issue of cross-contamination related to shared WASH objects. For example, one girls’ group raised their concern about health issues when students use waste collection buckets for water collection or handwashing. They explained their photograph in Figure 3:

We are seeing a girl, a young lady, carrying a bucket. She is throwing that into the trashcan, but … in my own view, it is not good because some students are using this same bucket to mop the floor and others are using the same bucket to wash their hands. It can give them a stomachache. (Girls1)

Figure 3: Photograph of a girl dumping trash into a garbage bin at school, taken by research participants with the caption, “She is cleaning the campus” (G1). Buea, Cameroon. Reproduced with permission from research participants.

In this and other narratives, girls emphasized their knowledge of how the practice of cleaning can introduce hygiene concerns through either exposure or through cross-contamination. They were concerned about younger students’ cleaning practices and accidentally ingesting unclean water while mopping, again highlighting the importance of care and being careful.

See the water here, you can see how dirty it is. It is not good for drinking. Little children in Form One and Form Two, the way they use the water to go and do mopping. They are not scared… they are not careful with what they are doing… it can even get into their mouth because when they do the work, they play a lot. (Girls2)

After the group of girls presented the photograph in Figure 3, the participants from other groups in the workshop had questions. Some girls asked for clarification about how throwing out the garbage could lead to stomach problems. The boys, however, overtly challenged girls’ expertise and concerns. One boy commented:

If she makes a statement here by saying that the same bucket is used … to [clean] refuse and … taken again to the tap, it is wrong. Because, I believe that in every institution, they have rules and regulations […The] trashcan is where we put dirt and bucket is what we use to help us carry water. So, if you take a trashcan and take it toward the tap, it means you are a fool!

This boy—supported by a chorus of agreement amongst the other boys—dismissed girls’ concerns and argued that the scenario presented by the girls was trivial or even unrealistic. The boys seemed to scorn the idea that students might mistakenly use the wrong bucket and went on to explain that “it means you do not really know what makes you a student” and that using the wrong bucket to collect water was “not normal.” He reinforced his view of implicit WASH techniques that he thought should be expected of students and that any deviations were out of the norm. The boys seemed to assume that students should and do follow certain norms, and that it seemed illogical and inconceivable that anyone would act out of these stated norms. Yet girl’s photographs make room for deviations, variance in practice, and the realities of life as a student; that some students may be in a rush or perhaps “stubborn” (questioning rules) or unaware of the norms and rules. We suggest that gender roles often place girls as responsible for cleaning practices (at home, and perhaps also at school) such that girls might be more in-tune with sanitation practices and notice the different uses of buckets in school. Yet in this instance, the boys refuted the legitimacy of this gendered knowledge.

Gendered infrastructures

A gender analysis of participants WASH concerns also highlighted gendered knowledges and priorities related to water and sanitation infrastructures. In general, boys’ narratives emphasized infrastructural break-down and repair, through photographs of infrastructural problems. For example, boys’ groups were more likely to photograph the school’s water meter, broken taps, and other taps and pipes on the school compound. The boys perceived the broken tap as preventing students from proper handwashing and toilet flushing:

Many students feel lazy to go right to the tank to fetch water and pass right here [by the broken tap] before going to the toilet. So, I think that… if there was this head of the tap, it would be easy. … The distance is not far, you just fetch water here and use it, before and after [using the toilet]. (Boys1)

Another group of boys posited that taps became broken because students over-tighten them. While water infrastructures also featured in the photographs of girls’ and mixed groups, infrastructures took on more focused and explicit levels of significance in each of the boys’ groups’ narratives, including how boys thought infrastructural problems could be solved.

Water storage practices. Notably, all of the boys’ groups photos feature the school’s elevated water storage tank. The tank was a focal point in workshop discussions as many students questioned the quality of water in the tank and the school’s water storage practices (Figure 5).

Figure 5: Photograph of a water storage tank taken by research participants with the caption, “Dirty tank from which dirty water flows” (Boys1). Buea, Cameroon. Reproduced with permission from research participants.

One boy echoed a concern that was common among all participants about whether or not the tank had been cleaned and what could be done about it:

Since I came to this school, I have never drunk water from that tank. I was told since they have placed it there, they have never washed the tank. So, I just feel afraid. That is why I had to carry out this research in order to try to see if we can really change…something can be done about it. (Boys1)

Girls also expressed concern about the quality of water in this tank. One girls’ group photographed the school’s stand tap as a more reliable drinking water source than the tank:

In my own thinking, I don’t think they have cleaned [the] tank since they bought it. I do not know. So, most of the students, they will likely use this [other tap] because it is more preferable. (Girls2)

The students doubted the quality of water in the storage tank. When their teacher tried to insist that the water was “very, very clean,” his authority on the matter was apparently unconvincing based on students’ skeptical reactions during the workshop.

The storage tank also became a focal point of discussion for the ways in which the boys represented the problem. In their photos, every single boys’ group photographed themselves climbing the tank’s metal rebar structure. Sometimes the narrative for climbing was because the tap (at ground level) was broken, and someone had the climb the tank to collect water. Other times, the boys climbed the structure to indicate the need to clean the tank. Some boys also noted the risk and physical danger of climbing up the tall structure to collect water. Other boys seemed to climb the structure simply to talk about the importance of the tank at school. The girls’ and mixed groups also photographed the tank but did not depict themselves climbing its structure.

One photo in particular sparked contestation from the girls. The photo depicts a boy half-way up the metal structure, leaning back onto the structure and looking out over the school compound with holding his mobile phone to his ear, as if making a call. This group of boys featured their entire photo narrative on the story of this student climbing up to the tank, discovering a broken tap and tank that needed to be cleaned, and then calling repairmen to fix the problem. The boys explained:

This guy … tried to call to see if there is any way they can get him water [from] out of campus because there was no way to have water in campus... After doing that, he had to now say ‘Okay. What happened?’ He now called the manager who is in charge of the tap. You understand me? (Boys2)

After this group presented their story, the girls challenged the need to climb the tower to make phone call: “So, the picture here, [where] the guy is climbing up. Yes, do you wish to tell me that there is no network down [on the ground]? [Students laugh].” The boy justified his phone call:

As a repairer right, when you have a [repair, like the] engine of a car, you have your phone with you … because when you are working, you have to see [the] faults and… communicate with somebody … For instance, the guy standing there, he asked someone to go and bring some [tools…] He called the person and said ‘Ei, there is another fault so you have to buy these [parts] and replace it here.’ That is the reason why he called [from] up there. It doesn’t mean that there was no network.

The girls also questioned why the boys used their mobile phones during the workshops given that the school forbids the use of mobile phones on campus. While it is likely that the boys may have been taking advantage of lenience around school rules during the research workshop, the boys also wanted to present their views of a solution to infrastructural breakdown.

Toilet practices. Conversations about gendered infrastructures and experiences also emerged in relation to toilets. Almost all groups raised issues related to toilet practices, mostly to emphasize a shared concern about how the school toilets are often left in disconcerting unsanitary conditions. A mixed group explained: “Sometimes you even come to toilet, and you see urine inside the bucket. That was what happened here. There was urine inside the bucket. You cannot use it because it will make the place stink more” (Mixed1). One group of girls noted, “It is good to clean the toilet before using it” (Girls1). Yet this cleaning requires water, which is not always available on campus. One boy explained: “Students are forced by their own knowledge to get water out of school campus to clean the toilet before using it to avoid diseases like cholera” (Boys3). Unclean toilets are clearly and undeniably a health concern for the entire staff and student body.

Yet gendered knowledges and experiences around toilets were also contested during the workshop. One photograph of a toilet stall in the school compound, taken by a group of girls, was challenged by the boys. In the photograph caption, girls emphasized how girls are more impacted by unclean toilets (Figure 4).

Figure 4: Photograph of a toilet taken by research participants with the caption, “The misuse of the toilet by the students and the effect is that it causes disease to girls when relieving yourself” (Girls2). Buea, Cameroon. Reproduced with permission from research participants.

One girl explained:

If you can see … the toilet is dirty, nasty. … All the girls, like, when we want to [defecate] or [urinate], we [squat] down. The odor from it, when it's not yet washed, it is very dirty and it is not good for our health, especially us the girls. Boys they stand-up [to urinate] so it is very dangerous, mostly for girls. (Girls2)

While unclean toilets certainly affect all students, in this moment, the boys denied that girls were disproportionately impacted. One boy interjected:

The boys too, when they go to … [much noise in the room], they still sit[/squat], so they are exposed too. So, when you talk about toilets, you talk of [it as] mostly a girl’s problem but boys are exposed.

Again, the boys rallied to dismiss the girls’ concerns and points of views as invalid. In this instance, the classroom teacher intervened to stand with the girls and assert that girls are, in fact, more exposed, to which the participants replied “yes, sir” in chorus. These two interventions (by the boys, and then by the teacher) demonstrate how gendered knowledges are not neutral but contested and connected to knowledge hierarchies.

Discussion

Seeking the perspectives, experiences, and voices of young people helps to nuance, socially situate, and broaden the spectrum of school-based WASH practices. Young people in this study help to present more complex and contextualized views of WASH in schools, based on lived experiences of “sayings and doings” (Schatzki 2012, 14) that constitute WASH practices that are not typically captured by structured and pre-determined survey instruments. Young people’s points of view raise critical questions and tensions, and point to insights that need to be accounted for in the design of interventions to address WASH in schools.

Putting the H back into WASH: Questions about cleanliness and schooling

Youth’s photographs and narratives drew attention to the need to differentiate between WASH practices and to allocate more explicit attention to hygiene. These students were clearly well versed in germ theory, cross-contamination, and how invisible risks can lead to disease. Young people, and in particular the girls, took this study as an opportunity to share their knowledge on proper and improper WASH techniques and how to navigate WASH challenges in school, such as how to use brown and grey water sustainably for cleaning. All of this points to taken-for-granted assumptions about cleanliness that underpin conceptualizations of hygiene in the global health sector. The Center for Disease Control (2022) refers to hygiene as “behaviors that can improve cleanliness and lead to good health” (para 1, emphasis added). For the World Health Organization (2021), hygiene refers to “conditions or practices conducive to maintaining health and preventing disease, especially through cleanliness” (para 1, emphasis added). Yet concepts of cleanliness are not universal and therefore not operationalized in the same way across contexts. For Shove (2003) and others, ideas about cleanliness are socially constructed, cultural, and dynamic over time. The classic anthropological work of Mary Douglas (1984) framed dirt as “matter out of place” (41), connected with belief systems about order and disorder. Indeed, ideas about hygiene and cleanliness have been used to systematically exclude, marginalize, and exert control over particular groups through racist and colonial belief systems (Workman 2019; Bashford 2004).

These dynamic and yet potentially discriminatory considerations of cleanliness are important for understanding WASH practices, particularly in school systems which often aim to discipline and produce certain types of citizenship. Young people’s focus on school rules as well as on shared WASH resources in schools reinforces the institutionalized nature of WASH in schools. This focus may differ from WASH issues in households and communities because schools are institutions with particular structures, objectives, and modes of functioning. Does the coupling of cleanliness and discipline in schools create stigma around cleaning practices? In what ways do school disciplinary regimes reinforce or create gendered discrimination around WASH practices? And how do different concepts of cleaning and cleanliness align or differ within WASH interventions in other social, community, and organizational environments? Ideas about cleanliness are not always or necessarily harmful and can offer positive social resources. Research on cleanliness discourses in the UK found that hygiene played a constructive role in healthcare sites, helping nurses to manage uncertainty, to establish symbolic capital, and to construct and maintain boundaries (Brown et al. 2008). In this study, we suggest that girls’ approach to addressing hygiene and cleanliness through collective care for the community offers a critical entry point for countering discriminatory approaches to hygiene interventions.

Gendered knowledges

Conceptualizing hygiene as a practice is also helpful for presenting WASH issues as routinized “nexus of sayings and doings” (Schatzki 2012, 14) that are deeply rooted in gendered structures, relations, and power. The findings show how WASH practices are gendered and even stereotypical in ways that might reinscribe normative tropes linking femininity with care and masculinity with technology. This reinforces how differently positioned subjectivities (in this study, girls and boys) see different things, focus on different things, and offer different kinds of explanations about why certain practices matter. We observed different gendered logics, to the point that young people could not agree about how to represent WASH issues. The research activities were not designed or intended as a debate. Yet, there was an argumentative component to the discussion, perhaps amplified through the workshop location in the school, a formal site of education where knowledge is typically evaluated as correct or incorrect. Discussing gendered knowledges and representations of WASH issues elicited quite frustrating gender dynamics. For example, the boys did not consider cleanliness and hygiene as “water” issues and criticized girls’ photographs as not highlighting “water resource management.” The boys even chastised the girls for their choices of representing water issues on the school campus. This concern was unfounded given that the focus of the research prompt was intentionally broad, such that young people could represent water issues that mattered to them. One boy antagonized: “Why did you decide to emphasize only … the school?” Another boy interjected:

I think you are getting this wrong because … you did this stuff on schools. As students, you must always learn to improvise. … Just because you say you are in school [does not mean] everything is just concerning the school.

This questioning—and almost suppression—of girls’ experiences and perspectives continues to run through the discussions. Challenges from the boys seemed, at times, relentless. Yet in these discussions, the girls worked continually to assert the legitimacy of their points of view, even when it was clear that the line of questioning was unfounded.

We emphasize the school because we decided to carry out the research only here in school. If you go outside to carry out the research, then you can say that you have emphasized outside. … We emphasized mostly in school because we have done the research here in school.

These moments of contention demonstrate both gendered points of view and knowledge hierarchies. Gendered knowledges are not neutral, but actively contested and negotiated.

Furthermore, gendered knowledges about WASH practices can also be sensitive or even taboo. Reading between the lines, we wonder if girls’ arguments about the importance of clean toilets for girls drew implicitly on biological differences as well as menstrual hygiene. Later, the boys insisted that if a woman did not bathe daily, she would smell, whereas a man would not. This erroneous comparison could be influenced by the stigma around menstruation being as “dirty” or “unclean” (Hennegan et al. 2019). The mixed gender groups and the presence of boys and a male teacher in the workshop may have meant that the girls felt uncomfortable discussing menstrual hygiene, a sensitive and taboo topic sometimes regarded as “women’s business” and not to be discussed with men (Mohammed and Larsen-Reindorf 2020).

Overall, girls were tenacious in the defense of their concerns, asserting the importance of their perspectives and daily experiences and struggles. They also questioned the ideas of the boys’ group, despite being unfairly told by the boys they were wrong. These gendered power dynamics are deeply rooted in the colonial systems that place women farther away from front-row male-dominated decision-making (Budig et al. 2018). Patriarchal cultural practices and norms continue to contribute to women’s unequal access to resources (Uchem and Ngwa 2014). Yet the girls confronted these hostilities and challenged these gender norms about whose voices count to ensure that they were heard. Photovoice activities provided a ‘third space’ to discuss issues and concerns that may be difficult or taboo to talk about, such as hygiene, and without the need for personal disclosure. The girls used the research platform to discuss how certain WASH practices serve as a risk to the rest of the school community, ultimately aiming to promote better health and communal living and use of shared resources.

Conclusion

This article offers three key contributions. First, practice theory serves as a productive lens for complexifying and contextualizing understandings about WASH issues in schools. While much theorizing about practice seems to take place in relatively resource-rich contexts to understand problems related to consumption (of energy, of alcohol, etc.), this study contributes an application of practice theory in the institutional context of schooling, as well as in a context with limited access to clean water. Given the need to challenge pragmatic views of hygiene (mostly as handwashing), conceptualizing WASH as a collection of practices provides opportunities for more expansive and complex interventions that take into account more diverse and intersecting practices such as cleaning, infrastructural repair, and toilet use. This plural understanding serves as an analytical tool to disrupt the assumed linearity embedded within behavior change interventions and to explore other realms of possibility.

Second, a gender analysis of WASH practices also contributes to more complex and contextualized understandings of WASH practices. Practices are gendered both in routinized ways that are implicit, expected, and taken-for-granted within society and in the related experiential knowledges and meanings associated with different practices. A gender lens elicited how the boys in this study tended to present hygiene in terms of personal, individualized concerns whereas the girls framed their hygiene knowledge in terms of collective care for others. Girls focused not only on their own personal health and wellbeing, but also on the health and wellbeing of the other students, and in particular younger students, on campus. Additionally, the study elicited nuanced discussions about young people’s gendered experiences and concerns about infrastructures such as toilets and water storage tanks. A gendered analysis of WASH practices allows deeper understandings of gendered differences in young people’s perceptions and concerns about WASH in school, critical connections between WASH practices and broader societal ideas about femininities and masculinities, and gendered power dynamics in knowledge production during the research process.

Third, participatory visual methodologies such as photovoice offer meaningful opportunities and interventions for involving young people in WASH dialogue, as members of the school community whose voices are not often included in school-based WASH research. Visual methods provide a platform for young people to identify and share their challenges from their perspectives, and to discuss their views on issues that they deem important to their health and wellbeing. As we saw in this study, visual methods also provide an opportunity for young people to look at their situations in new ways and to consider and learn from each other’s views and perspectives. These activities and dialogue offer rich and generative insight for WASH researchers as well as for WASH sector practitioners, for teachers and school administrators, and for young people themselves to engage in dialogue and action for social change in their lives and communities.

Acknowledgements

We would like to begin by thanking the young people who participated in this study, as well as their families and the school administration for their support in allowing the participants to attend the workshops. A gracious thank you to Magdaline Agbor from Changing Mentalities and Empowering Groups in Cameroon for connecting us with the school, and for much support and advice during fieldwork. Thank you to MYRIAGONE, the McConnell-Université de Montréal Chair in Youth Knowledge Mobilization, for support dedicated to article preparation. We also thank the reviewers for their thoughtful and generative engagement with our work.

Declaration of interest statement

Funding details. The fieldwork for this project was supported by a Doctoral Student Bursary from the Fonds de recherche du Québec – société et culture; a Doctoral Student Award from the International Development Research Centre; and a Jackie Kirk Fellowship from McGill University. Article preparation was support by the Grant Optimization and use of existing datasets through the support of a Student Trainee from the Reseau de recherche en santé des populations du Québec (RRSPQ).

Disclosure statement. This is to acknowledge any financial or non-financial interest that has arisen from the direct applications of your research. If there are no relevant competing interests to declare please state this within the article, for example: The authors report there are no competing interests to declare.Reference List

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1. In referring to participants, we follow participant self-identification. While participant ages extend to girls and young women as well as boys and young men, we refer to ‘girls’ and ‘boys’ in the study because this is how young people tended to refer to themselves. We also note the limitations of the gender binary as well as the risks of disclosing non-binary identities in this context. ↑