This is a SWASH+ photo essay on anal cleansing, still a taboo subject.

1. Anal Cleansing
in Rural Kenyan Schools
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.

2. 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).

3. 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.

4. 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.

5. 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.

6. 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.

7. 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).

8. 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.

9. 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.

10. References
McMahon, 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.