Shao et al.

BMC Public Health (2021) 21:32

https://doi.org/10.1186/s12889-020-10099-4

RESEARCH ARTICLE Open Access

Analysis of factors affecting students going

to school toilets in a rural primary school in
China
Tang Shao1, Jingjing Zhao1, Haijuan Hu1 and Qi Zhang2*

Abstract
Background: Several factors may affect students going to school toilets, but a few studies have analyzed the
reasons for students using toilets. This study aimed to use a structural equation model to understand the factors
that impacted children’s toilet behavior.
Methods: This study was performed in 12 rural nonboarding primary schools (6 schools in the northern and 6
schools in the southern regions of China). All students of the third and sixth grades (761 students) were examined.
A questionnaire on students’ toilet behavior was used. The questionnaire included 33 perceptual items based on 5
factors: toilet facilities, cleanliness, hygiene practices, peer relationship, and experience. The questionnaire also
covered the frequency of voiding and defecating by themselves. The exploratory factor analysis, confirmatory factor
analysis, and pathway analysis were used to analyze the causes of students’ toilet behavior.
Results: A statistically significant correlation coefficient of 0.300 indicated that cleanliness impacted the toilet
frequency of students. The visual experience of the overall cleanliness of the toilet had the most significant impact
on students’ toilet behavior (path coefficient, 0.81). Washing facilities and convenient handwashing had the least
impact on toilet use (path coefficient, 0.52).
Conclusion: Cleanliness was the primary consideration for students’ toilet use on campus. The visual experience of
the overall cleanliness of toilets had the most significant impact when students used toilets. No pre-survey was
conducted to test the reliability and validity of the questionnaire. Using self-reported data might be associated with
potential recall errors.
Keywords: Behavior, China, Cleanliness, Experience, Students, Toilet use

Background research, but they did reflect problems with students’

A survey of school children in developed countries toilet behavior. These studies gave every reason to be-
found inadequate toilet facilities in schools and the re- lieve that students’ hygiene might be worse in less devel-
luctance of children to use them. Data for 2005 showed oped areas. Healthy hygiene habits can be best
that 25% of students had constipation and 26% never inculcated since the early years of childhood. However,
used school toilets to defecate [1]. These data might past studies suggested that traditional didactic health
seem a little outdated due to the lack of the latest education was unlikely to be a valid route to behavioral
change [2]. The reason for this problem might be that
hygiene behaviors were rarely examined for health-
* Correspondence: [email protected]
2
Chongqing Center for Disease Control and Prevention, 8 Changjiang
related reasons for ordinary people, especially children.
Second Road, Yuzhong District, Chongqing, China
Full list of author information is available at the end of the article

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Shao et al. BMC Public Health (2021) 21:32 Page 2 of 11

In contrast, in the non-educational environment, the factors were also limited. Thus, this study aimed to use a
school’s comprehensive WASH (Water, Sanitation, Hy- structural equation model to understand the factors that
giene) interventions might significantly improve stu- impacted children’s toilet behavior. The conclusion of
dents’ hygiene [3]. According to the World Health this study also provided a reference for school health
Organization, 11% more girls attended schools when intervention. This study involved a qualitative survey in
sanitation was available [4]. The evidence on the impact two counties in rural China, one in the north and an-
of improved school washing on health and education other in the south.
was limited, but it was indeed convincing. Studies in
China and Kenya showed that school health promotion Methods
campaigns could reduce absenteeism due to sickness by Sample size and field sites
20–58%, and could also reduce absenteeism among girls This was a cross-sectional study. Referring to the re-
[3, 5]. searches on qualitative variables in cross-sectional sur-
Toilet-related behaviors were one of the most critical veys, the following formula ([13] was used to estimate
hygiene behaviors in protecting health. Healthy behav- the population parameters:
iors of using school toilets were critical because voiding
postponement incontinence was associated with a low
Z 1 − α=2 2 pð1 − pÞ
micturition frequency, urgency, and behavioral problems Sample size ¼
[6]. The data showed that children voided 2–10 times d2
per 24 h (median 5), and most (95%) avoided voiding at
a frequency of 3–8 times [7]. Children aged 7–12 years where Z1 − α/2 is a standard normal variable. As in the
in a Japanese primary school urinated about five or six majority of studies, P values less than 0.05 were consid-
times daily [8]. However, a study examined 385 Swedish ered significant. Hence, 1.96 was used in the formula (P
school children aged 6–16 years and revealed that 25% = expected proportion in population-based previous
(overall 16%) of children reported never using the school studies). This study referred to an extensive survey on
toilet to urinate, and 80% (overall 63%) never used it to the use of toilets by British students because studies on
defecate [9]. When children suppressed or ignored “full- the use of school toilets in China were limited [14]. The
bladder” signals, the risk of developing emptying distur- results showed that 40% of students never used the
bances and urinary tract infections increased [9]. A school toilet to defecate. Therefore, the value of P in the
timed voiding schedule was essential in treating dysfunc- aforementioned formula was 0.4 (d = absolute error of
tional voiding [10]. Thus, analyzing the causes affecting precision). The sample size was calculated with an abso-
students going to school toilets was necessary. lute error of 5% and a type 1 error of 5%. Therefore,
Children aged 7–15 years often based their decision to using the formula, the sample size was 369. Hence, at
relieve themselves on behavioral and social factors [7]. least 369 participants were required for this cross-
Nevertheless, a limited number of studies focused mainly sectional study.
on behaviors of students using school toilets. Some stud- When choosing schools, several causes needed to be
ies suggested several possible causes affecting students considered [1]. Nonboarding schools including only
going to school toilets. For example, one cluster ran- grades 1–6 were included. Boarding schools, schools
domized trial, including latrine provisions, evaluated the with incomplete grades 1–6, and schools including high
influence of school WASH on health and absenteeism school grades were excluded [2]. Schools with complete
[11]. Results from in-depth interviews showed that stu- WASH facilities were included referring to the national
dents would weigh multiple factors to decide whether to rural school construction standards, Code for design of
use the school toilet. The factors included physical en- school [3, 15]. Schools with a high degree of cooperation
vironmental factors (conditions, safety, privacy, accessi- among school administrators were included. Each grade
bility, and availability), social factors (norms, in rural schools had about 30 registered students, and
expectations, and responsibility), and individual factors on-site surveys had missing samples. Finally, 12 schools
(experience, routine, risk perception, and personal were included in the survey, 6 schools located in north
needs) [12]. It implied that factors such as washing and China and 6 in south China.
cleaning toilets, making them smell good, removing dirty
contaminating matter from facilities, and protecting chil- Imposing a theoretical framework
dren’s privacy might be attractive factors for students to Many students did not use the school toilet to urinate
use school toilets. and defecate [9]. The problem might be the result of a
However, some studies analyzed these causes and the combination of multiple factors. Nevertheless, previous
extent to which they impacted children’s toilet behavior. studies mostly focused on a single reason. The wide-
Studies investigating the possible factors and the priority spread impact of the cause on students’ toilet behavior
Shao et al. BMC Public Health (2021) 21:32 Page 3 of 11

in school and the independence of interaction between questionnaire were reviewed by the Ethics Committee of
the causes needed further exploration. National Center for Rural Water Supply Technical Guid-
Previous studies found that some reasons might im- ance, Chinese Center for Disease Control and
pact students’ toilet behavior in school. These reasons Prevention.
included toilet facilities ([10, 16–18]), cleanliness [19–
22], hygiene practice [23, 24], peer relationship [12, 25,
Data collection
26], and experience [27–29].
Each school had to have at least one class of students to
Based on previous findings, this study proposed a the-
ensure a sufficient sample size. Although students fully
oretical framework (Fig. 1) to describe the factors that
understood the questionnaire content, they refused to
impacted children’s toilet behavior in school.
participate in the survey for other reasons. The survey
The theoretical framework was used to guide some de-
selected third-grade and sixth-grade students from each
signs in this study. For example, it guided the designing
school. The questionnaire developed in this study was
of the questionnaire (e.g., designing practical issues
used to investigate the students’ toilet behavior. After
around the influencing factors), guided data analysis
obtaining consent from participants, the one-on-one
[e.g., analysis of survey data by structural equation mod-
interview method was used to help students understand
eling (SEM)], and helped in the interpretation of results
the questions correctly and avoid inauthentic answers.
(e.g., to verify research hypotheses based on the theoret-
This study employed trained professionals in environ-
ical framework).
mental health and health education fields to help con-
duct the survey. At the same time, the questionnaire was
Questionnaire development
not handed over to students and teachers in advance.
Although the quality of hygiene facilities affected stu-
This survey was conducted in June 2019. The collected
dents’ toilet behavior [3], the subjective experience of
data were entered using Excel (version 2010) by two per-
using the toilet would also influence students’ toilet be-
sons parallelly to avoid mistakes. Subsequently, the data
havior [22]. This study focused more on the impact of
were logically reviewed before carrying out the analysis.
sanitation of school toilets on students’ toilet behavior.
Based on the theoretical framework, previous findings
[10, 14, 30] were also referred. A questionnaire, includ- Analysis
ing five factors, was developed: toilet facilities (number Demographic characteristics of students and survey data
of toilets, distance from classroom to toilets, and so presentation
forth), cleanliness (floor, defecation pit, and so forth), This study used the number and proportion to describe
hygiene practices (washing hand behavior, awareness of the demographic characteristics of the sample popula-
using a toilet, and so forth), peer relationship (number tion and the frequency of urination and defecation. Be-
of friends, relationship with friends, and so forth), and sides, the study also used the number and proportion to
experience (meeting people who scare you). The ques- describe the result of each item of the questionnaire.
tionnaire included 33 perceptual items in total (Add- Students of different ages and sexes might have differ-
itional files). The answer to each item was designed to ences in their choices of using toilets in the school.
be five degrees from most optimal to least optimal, refer- However, this study focused on analyzing the impact of
ring to the designs of Likert scale questions. Moreover, students’ experience on their toilet behavior. Therefore,
the self-reported frequency of voiding and defecating a correlation analysis was performed between the toilet
was also included. The study protocols and experience of students and the frequency of toilet use.

Fig. 1 A theoretical framework of students going to a school toilet. H1–H5 represent the hypothesis that each common factor had a direct and
significant impact on students going to a school toilet
Shao et al. BMC Public Health (2021) 21:32 Page 4 of 11

Exploratory factor analysis some indicators of model fit to assess the model fit. The
The data might be missing on a few items in the ques- indicators of model fit included normed fit index, com-
tionnaire due to the use of the one-to-one survey parative fit index (CFI), and root mean square error of
method. On the contrary, the analysis method using approximation (RMSEA) [34].
SEM needed the data to be complete. Therefore, the an- Additionally, the Akaike Information Criterion (AIC)
swer to each item in the questionnaire was assigned 1–5 was also used to assess the model [35]. However, no
points from the most optimal to least optimal, and the overall test of model fit was available for such a model,
missing value was filled using the mean substitution in which case it was recommended to prefer the model
method. with the smallest AIC value [35].
A principal component analysis (PCA) was carried out
using SAS (version 9.4) on the survey data. The maximal
Path analysis with variables
rotation of variance was used to preserve the factors
The validity of the questionnaire was tested by EFA and
whose root eigenvalue was more significant than 1. An
CFA. Based on the result, path analysis with variables
exploratory factor analysis (EFA) was carried out using
[33] was used to analyze the effect of hypothetical fac-
all the items. The Kaiser–Meyer–Olkin (KMO) value
tors on school toilet behaviors of students. Indexes such
and the Bartlett spherical test value of the questionnaire
as χ2 value, CFI, AIC, and others [34, 35] were also used
data were calculated; the preliminary analysis showed
to guide the model correction. The progress of the ana-
the data were suitable for factor analysis [31]. Items with
lysis is shown in Fig. 2.
a factor load of less than 0.4 [31, 32] was rejected, and
the standard for the cumulative variance contribution
rate was higher than 0.5 [31]. Based on the result of the Results
factor load, the items of the questionnaire were Sample description
screened. Table 1 presents the distribution of demographic charac-
teristics of students and the frequency of students void-
Confirmatory factor analysis ing and defecating. A total of 761 students were given
This study used confirmatory factor analysis (CFA) to the questionnaire, which included 50% each of boys and
test the latent variables proposed using the theoretical girls mostly in the age range of 9–14 years. The recovery
framework. All SEM analyses were performed with rate was 100%. The data indicated that more than 90%
Amos, version 7.0, using maximum likelihood estimation of students used the school toilet to urinate at a fre-
with standard errors and parameter coefficients of the quency of 3–6 per day. Nearly half of the students occa-
SEM. A P value < 0.05 (two-sided) was the level of statis- sionally defecated in the school toilet. More than 16% of
tical significance [33]. This study used the χ2 test and students never used the school toilet for defecating.

Fig. 2 Data collection and analysis progress in the study

Shao et al. BMC Public Health (2021) 21:32 Page 5 of 11

Table 1 Demographic characteristics of students and frequency other factors. Thus, the hygiene practice was dropped
of voiding and defecating in school toiletsa (n = 761) from the final model (Table 3).
Characteristics No. of participants interviewed Proportion, % Finally, four factors from the theoretical framework
Sex were retained, and their cumulative variance contribu-
Boys 382 50.20 tion rate was 59.54%, which exceeded the standard of
50% [31]. Reliability testing of 18 items found that Cron-
Girls 379 49.80
bach’s alpha value was 0.763, indicating that the ques-
Age, year
tionnaire had the right internal consistency [37].
≤9 104 13.70 Cronbach’s alpha values of four items in the model were
10 171 22.53 0.755, 0.883, 0.761, and 0.700, which explained that each
11 106 13.97 item had good credibility [38]. The reliability was also
12 160 21.08 tested using the average of variance extracted. The
values were 0.623, 0.461, 0.472, and 0.437, close to or
13 107 14.10
reaching the reference value of 0.5, implying that each
≥14 111 14.62
variable could be interpreted using the matching latent
Grade variable [39]. The normalized factor loading value was
Third grade 380 49.93 0.46–0.79; 16 items exceeded 0.5 (Table 3). H0 indicated
Sixth grade 381 50.07 that the questionnaire had a better structure [31, 32].
Frequency of voiding
CFA progress with research data
3–4 times per day 401 52.83
This study used EFA to screen out the relevant variables.
5–6 times per day 295 38.87
The SEM method in the CFA helped verify the assump-
1–2 times per day 39 5.14 tions. These assumptions included whether these vari-
≤1 time per day 17 2.24 ables were independent of one another, whether these
Never 7 0.92 variables could correctly reflect the content of hypothet-
Frequency of defecation ical factors, and whether any common influence existed
between the factors. At the same time, the SEM method
Sometimes 366 48.16
also helped verify the validity of the questionnaire. In
Always 267 35.13
the SEM method, the chi-square value helped under-
Never 127 16.71 stand whether the model adapting to the data was
a
Numbers might not sum to a total because of missing data accepted.
The results of the EFA progress showed a compara-
Table 2 presents the number and proportion of each tively slightly better model fit without hygiene practice.
choice for each item in the toileting-related question- Fitting data to the final model (Fig. 3) using weighted
naire. Choice a to choice e represented five degrees from least squares estimation yielded a significant χ2 test of
most optimal to least optimal. model fit [χ2 =291.614 (128 df), P < 0.000]. It was a sig-
nal for model rejection, which was expected because of
CFA progress the enormous sample size [33, 40].
Questionnaire test and EFA progress In the SEM method, the model adaptation index
Before the EFA, this study found that a few items had helped judge the degree of fit of the model and choose
missing data, and the percentage was less than 1%. The the model with the best fit. The model adaptation index
PCA method was used to analyze the 33 items. The included RMSEA, the adjusted goodness-of-fit statistic
KMO value of the survey data was 0.848, and the Bart- (AGFI), the goodness-of-fit index (GFI), the Tucker–
lett sphere test rejected the H0 hypothesis (P < 0.0001). Lewis coefficient (TLI), and the critical N (CN). The
Therefore, the survey data were suitable for factor ana- smaller the RMSEA value, the larger the AGFI, GFI, and
lysis [36]. Sixteen items were excluded because the fac- TLI values, the better the model fitted. The CN value
tor loading was less than 0.4. Eighteen items were finally varied depending on the size of the sample [33, 40].
retained. Further, the KMO value was 0.856, and the In the final fitted model, the model adaptation index
Bartlett sphere test rejected the H0 hypothesis (P < was RMSEA of 0.041 (90% confidence interval: 0.035–
0.0001). 0.047), which was lower than the reference value of 0.08
Because of low factor loading (not reaching 0.4), no [33]. The AGFI was 0.945, the GFI was 0.959, and the
valid model could be fitted when the hygiene practice TLI was 0.963, which were all higher than the reference
was included in the model. This was probably because of value of 0.900. CN was 435, which was higher than 200
the potential collinearity between hygiene practice and [33]. These model fit indicators showed a good model
Shao et al. BMC Public Health (2021) 21:32 Page 6 of 11

Table 2 Number and proportion of each option from variables in the students’ behavior of using the questionnairea (n = 761)
Variable Proportion of each option from a variable
(n)
Option Option Option Option Option
a b c d e
Toilet facilities
Was the toilet far away 86.55 12.52 0.67 (5) 0.13 (1) 0.13 (1)
(650) (94)
Was the time enough to use the toilet at break 97.21 2.26 0.53 (4) 0 0
(731) (17)
Was the toilet usually crowded 71.35 24.27 3.58 0.80 (6) 0
(538) (183) (27)
Did you need to wait while using the toilet 75.50 21.85 1.19 (9) 1.19 (9) 0.26 (2)
(570) (165)
Were you late for class due to using the toilet at break 73.33 26.40 0.13 (1) 0 0.13 (1)
(550) (198)
Were you criticized by a teacher due to using the toilet 91.97 7.61 0 0 0.42 (3)
(653) (54)
Toilet hygiene
Was the toilet usually clean 53.39 21.12 18.73 6.64 0.13 (1)
(402) (159) (141) (50)
Was there usually any stool or urine on the toilet floor 66.05 24.67 3.45 5.31 0.53 (4)
(498) (186) (26) (40)
Was there usually any garbage (such as toilet paper) on the toilet floor 64.19 27.85 2.79 4.51 0.66 (5)
(484) (210) (21) (34)
Was there usually any dirty water stain on the toilet floor 56.90 32.49 3.32 6.63 0.66 (5)
(429) (245) (25) (50)
Was there usually any stool or urine in the defecation pit 32.85 36.97 9.71 18.62 1.86
(247) (278) (73) (140) (14)
Was there usually any garbage (such as toilet paper) in the defecation pit 44.15 28.72 9.97 16.36 0.8 (6)
(332) (216) (75) (123)
Was the toilet well ventilated and smell free 31.08 20.19 36.92 11.42 0.4 (3)
(234) (152) (278) (86)
Was the toilet usually dark 65.47 21.38 11.16 1.59 0.4 (3)
(493) (161) (84) (12)
Did you have the experience of slipping or falling in the toilet 87.27 11.67 0.66 (5) 0.27 (2) 0.13 (1)
(658) (88)
Had you ever accidentally stepped into the defecation pit in the toilet 98.80 1.06 (8) 0 0.13 (1) 0
(743)
Were there usually flies and maggots in the toilet 28.82 44.49 15.54 10.49 0
(217) (33) (117) (79)
Had you ever been bullied by other students in the toilet 91.60 2.80 0.2 7 (2) 5.33 0
(687) (21) (40)
Hygiene practice
Would you urinate or defecate on the toilet floor in case of an urgency 98.41 0.80 (6) 0.13 (1) 0.66 (5) 0
(742)
Would you endure waiting for the break if you wanted to use the toilet during class 34.00 34.26 12.75 18.59 0.4 (3)
(256) (258) (96) (140)
Would you litter your used toilet paper 98.01 0.80 (6) 0 1.20 (9) 0
(738)
Would you pay attention to the urine or feces at the designated location in the toilet 84.67 4.87 1.43 8.88 0.14 (1)
(591) (34) (10) (62)
Did the teacher teach you how to wash your hands after using the toilet 18.30 42.71 30.37 6.23 2.39
(138) (322) (229) (47) (18)
Do you wash hands every time after using the toilet 60.21 13.53 18.57 7.69 0
Shao et al. BMC Public Health (2021) 21:32 Page 7 of 11

Table 2 Number and proportion of each option from variables in the students’ behavior of using the questionnairea (n = 761)
(Continued)
Variable Proportion of each option from a variable
(n)
Option Option Option Option Option
a b c d e
(454) (102) (140) (58)
Peer relationship
How many close friends did you usually have 74.73 9.84 7.71 7.18 0.53 (4)
(562) (74) (58) (54)
Did you often go to the toilet alone 21.70 43.28 25.83 9.19 0
(163) (325) (194) (69)
Did you usually go to the toilet with close friends 147.3 44.43 33.95 7.29 0
(108) (335) (256) (55)
Would you accompany your close friends to the toilet whenever you did not want to go 26.43 28.42 31.87 13.15 0.13 (1)
(199) (214) (240) (99)
Would you wait for your close friends to return to the classroom whenever you met him or her 36.29 27.81 28.48 7.42 0
in the toilet (274) (210) (215) (56)
Experience
How did you usually deal with the situation of meeting a classmate having a bad relationship 85.66 6.91 1.46 1.86 4.12
with you when going to the toilet (645) (52) (11) (14) (31)
How did you usually deal with the situation of meeting a classmate who liked to bully other 81.56 7.29 3.45 2.25 5.44
students when going to the toilet (615) (55) (26) (17) (41)
How did you usually deal with the situation of meeting a classmate who liked to make fun on 84.69 7.99 2.4 (18) 1.46 3.46
your going to the toilet (636) (60) (11) (26)
How did you usually deal with the situation of meeting a teacher when going to the toilet 93.77 2.91 1.72 0.66 (5) 0.93 (7)
(708) (22) (13)
a
Numbers might not sum to a total because of missing data

fit. According to the SEM model, all factor loadings were 1–3 points, respectively. Finally, the toilet frequency was
more significant than 0.5, except one (peer relationship represented by the scores from voiding and defection
pointed to X15), which showed that the questionnaire frequency.
had the right validity. In the SEM model, cleanliness and The final model had a comparatively slightly better
toilet facilities had a strong correlation (R2 value was model fit (Fig. 4). The model adaptation index was χ2
0.48). value of 5.380 (3 df), P = 0.146, RMSEA of 0.032 (90%
confidence interval: 0.000–0.076), AGFI of 0.986, GFI of
Path analysis with research data 0.997, TLI of 0.967, and CN of 1590, which showed that
Some hypotheses were verified using the CFA and SEM. the model was within acceptable limits.
These hypotheses included the independence between The result of the path analysis showed that the fre-
the variables, whether the variables reflected the hypo- quency of students using school toilets was affected by
thetical factors, the interaction between the hypothetical the cleanliness of the toilets, which supported the H2 hy-
factors, and the validity of the questionnaire. However, pothesis in the theoretical framework. A certain degree
the impact of hypothetical factors on students’ use of of correlation existed between cleanliness and toilet fa-
school toilets needed further data analysis. Thus, the cilities, which was consistent with the findings of the
SEM method in the path analysis was used to analyze PCA.
the effect of factors on toilet frequency.
The sum of the scores obtained from the variables,
which reflected the same common convergence accord- Discussion
ing to the SEM, represented the factors. The frequency The purpose of this study was to test some determina-
of voiding and defecating was used as a dependent vari- tions imposed by scholars ([12, 16, 21, 26], and so forth)
able. The voiding frequency was divided into five levels: and having an impact on students using school toilets.
never, ≤1 per day, 1–2 per day, 3–4 per day, and 5–6 This study was one of several initial quantitative studies
per day. The defecation frequency was divided into three to characterize determinations on toilets based on sub-
levels: always, sometimes, and never. The frequencies, jective feelings. Moreover, it provided valuable insights
according to the answer, were assigned 1–5 points and into how to improve students’ toilet use.
Shao et al. BMC Public Health (2021) 21:32 Page 8 of 11

Table 3 Results of factor analysis of students going to school toiletss

Variable Cleanliness Peer Experience Toilet
relationship facilities
Was the toilet usually crowded (X1) 0.351 − 0.051 0.018 0.631
Did you need to wait while using the toilet (X2) 0.182 −0.119 0.035 0.579
Was the toilet usually clean (X3) 0.748 0.001 0.047 0.204
Was there usually any stool or urine on the toilet floor (X4) 0.750 −0.011 0.072 0.152
Was there usually any garbage (such as toilet paper) on the toilet floor (X5) 0.738 −0.001 0.023 0.098
Was there usually any dirty water stain on the toilet floor (X6) 0.636 0.054 −0.010 0.135
Was there usually any stool or urine in the defecation pit (X7) 0.757 −0.089 0.007 0.013
Was there usually any garbage (such as toilet paper) in the defecation pit (X8) 0.757 −0.095 −0.030 0.058
Was the toilet usually dark (X9) 0.497 −0.110 0.241 0.051
Were there usually flies and maggots in the toilet (X10) 0.687 −0.063 0.096 0.139
Did you wash hands every time after using the toilet (X11) 0.460 −0.120 0.016 0.233
Did you often go to the toilet alone (X12) –-0.017 0.677 −0.071 −0.174
Did you usually go to the toilet with close friends (X13) 0.002 0.786 −0.083 −0.102
Would you accompany your close friends to the toilet whenever you did not want to go (X14) −0.092 0.662 −0.061 −0.022
Would you wait for your close friends to return to the classroom whenever you met him or −0.071 0.558 −0.051 0.044
her in the toilet (X15)
How did you usually deal with the situation of meeting a classmate having a bad relationship 0.065 −0.037 0.634 −0.023
with you when going to the toilet (X16)
How did you usually deal with the situation of meeting a classmate who likes to bully other 0.030 −0.091 0.635 0.007
students when going to the toilet (X17)
How did you usually deal with the situation of meeting a teacher when going to the toilet 0.040 −0.074 0.574 0.064
(X18)
Root eigenvalue 5.252 2.469 1.759 1.237
Variance contribution rate (%) 29.178 13.714 9.773 6.872
a
Bold data indicated that the factor loading was higher than 0.4

Fig. 3 Final SEM and parameter values for the CFA progress. One-way arrows indicate a significant association, and two-way arrows indicate a
significant correlation. Numbers over arrows indicated a standardized regression coefficient, and numbers over observed variables (rectangles)
indicated explained variance (R2). P < 0.001 and P value close to 0.05 were indicated by *** and **, respectively. The e indicates the residual in SEM
Shao et al. BMC Public Health (2021) 21:32 Page 9 of 11

Fig. 4 Final SEM and parameter values for path analysis. One-way arrows indicated a significant association and two-way arrows indicated a
significant correlation. Numbers over arrows indicated a standardized regression coefficient, and numbers over observed variables (rectangles)
indicated explained variance (R2). A P value < 0.001 and a P value close to 0.05 were indicated by *** and **, respectively. The e indicates the
residual in SEM

The data supported the casual relationship H2 (Fig. 4). toilets were usually located close to their study building.
Cleanliness was the primary consideration for students’ Despite queues sometimes, students were not late for
toilet use on campus, which was consistent with previ- classes; hence, crowding had no visible impact on their
ous findings on the positive effects of cleanliness and toilet behaviors. However, the adequacy of toilet facilities
students using school toilets [22]. A meaningful and sta- did not have a direct and significant impact on students
tistically significant association was found between toilet going to school toilets in the study. Enough toilets were
cleanliness and toilet use for both boys and girls [19, required because they were vital in the establishment of
20]. Additionally, providing a clean toilet could signifi- healthy voiding habits, prevention of elimination syn-
cantly reduce the possibility of children being exposed dromes, and correction of established dysfunctional
to pathogens [21]. However, toilets lacked measures to voiding [10].
deal with feces and urine and handwashing in rural areas The experience of teasing and bullying might be a de-
in Guangdong and Chongqing, China [41, 42]. terrent to toilet use [12, 25, 26], but it was not reported
Figure 3 shows that the visual experience of the overall as a problem in the study. Figure 4 shows the path coef-
cleanliness of the toilet had the most significant impact ficient of experience pointing to toilet frequency was
on students’ toilet use (the path coefficient of 0.81). The 0.07. Even if the value was statistically significant, the
washing facilities and convenient handwashing had the value was too low. Thus, whether unfriendly experience
least impact on toilet use (the path coefficient of 0.52). influenced students using toilets because of students not
Poor toilet conditions, including the presence of feces, reporting bullying needed further investigation. This
urine, blood, vomit, flies, maggots, and smell, led to poor finding was consistent with previous findings [44]. Many
visual and olfactory experience that prevented students students did not disclose bullying they experienced or
from using school toilets [12]. Moreover, children who witnessed because of a sense of helplessness, concerns
attended primary schools with better-maintained toilets over inappropriate adult action, self-reliance, shame, and
were less likely to be absent in a cross-sectional study in others. Peer relationships were not affected by toilet use
Kenya [43]. in the study, but a negative correlation between peer re-
In the final adjusted model, the adequacy of toilet fa- lationships and experience was consistent with previous
cilities was not an impact factor for students’ toilet use. findings. For example, the girls said they were “scared”
The crowding did not prevent students from using to go to the toilet alone because it was situated away
school toilets when they had physiological needs. Even if from the primary school buildings, and they faced some
the toilet ratios did not reach a relatively sufficient problems including lack of privacy, bullying, facing male
standard, the primary reference standard was the Code teachers, and so forth. Thus, they preferred to go to the
for design of school [15]. Moreover, this finding was dif- toilets in pairs [27]. Having good peer relationships
ferent from previous findings; for example, students could help children avoid these risks when using school
were likely not to use toilets when queues were present, toilets.
particularly during planned breaks [10]. Students had This study had several limitations. A pre-survey was
enough break time if they needed to use a toilet, and needed to test the reliability and validity of the
Shao et al. BMC Public Health (2021) 21:32 Page 10 of 11

questionnaire. Although the sample was big, using an informed consent of the participants from their parents and guardians was
untested questionnaire directly might have missed some not obtained. However, the written informed consent of the principal of the
surveyed school was obtained. The survey plan, questionnaire, participants’
details. Because of the limited funds and the shortage of informed consent, informed consent from school leaders instead of
staff to carry out on-site work, this study selected 2 re- informed consent from parents were all reviewed and approved by the
gions and 30 schools with a high degree of coordination Ethics Committee of National Center for Rural Water Supply Technical
Guidance, Chinese Center for Disease Control and Prevention.
to promote the on-site work. Therefore, this study inev-
itably had a selection bias. Another limitation was the Consent for publication
use of self-reported data and the potential for recall er- Not applicable.
rors; students might provide socially desirable answers.
Competing interests
Finally, using a structured questionnaire and SEM might The authors declare no competing interests.
be a new trial for assessing hygiene behaviors and others.
Testing the influence of multiple possible factors rather Author details
1
National Center for Rural Water Supply Technical Guidance, Chinese Center
than the use of single variables could be more intuitive for Disease Control and Prevention, 13 Government Street, Changping
and convincing. Nevertheless, evidence to prove these District, Beijing, China. 2Chongqing Center for Disease Control and
findings was not sufficient, and hence more longitudinal Prevention, 8 Changjiang Second Road, Yuzhong District, Chongqing, China.
designs were needed to support them. Received: 25 November 2019 Accepted: 20 December 2020

Conclusions
References
Cleanliness was the primary consideration for students’
1. Fujiwara-Pichler E, Maddocks A, Barnes PM. Standards in school toilets: do
toilet use on campus; the visual experience of the overall extra resources make a difference? J Public Health. 2006;28(3):294–5.
cleanliness of the toilet had the most significant impact 2. Scott B, Curtis V, Rabie T, Garbrah-Aidoo N. Planning: Health in our hands,
but not in our heads: understanding hygiene motivation in Ghana. Health
when students used the toilet. This study was one of sev-
Policy Plan. 2007;22(4):225–33.
eral initial quantitative studies to characterize determi- 3. Freeman MC, Greene LE, Dreibelbis R, Saboori S, Muga R, Brumback B,
nations on toilets based on students’ subjective feelings, Rheingans RJTM, Health I. Assessing the impact of a school-based water
treatment, hygiene and sanitation programme on pupil absence in Nyanza
thus providing some reference for future research.
Province, Kenya: a cluster-randomized trial. Trop Med Int Health. 2012;17(3):
380–91.
Supplementary Information 4. Organization WH: The world health report 2002: reducing risks, promoting
The online version contains supplementary material available at https://doi. healthy life: World Health Organization; 2002.
org/10.1186/s12889-020-10099-4. 5. Bowen A, Ma H, Ou J, Billhimer W, Long T, Mintz E, Hoekstra RM, SJ\ L.
Hygiene: A cluster-randomized controlled trial evaluating the effect of a
handwashing-promotion program in Chinese primary schools. Am J Trop
Additional file 1. Questionnaire. Med Hygiene. 2007;76(6):1166–73.
6. Von Gontard A, Niemczyk J, Wagner C, Equit MJ. Psychiatry a: Voiding
Abbreviations postponement in children—a systematic review. Eur Child Adolesc
EFA: Exploratory factor analysis; CFA: Confirmatory factor analysis; Psychiatry. 2016;25(8):809–20.
PCA: Principal component analysis; KMO: Kaiser–Meyer–Olkin; SEM: Structural 7. Mattsson S, Gladh G, Lindström SJ. Relative filling of the bladder at daytime
equation modeling; CFI: Comparative fit index; RMSEA: Root mean square voids in healthy school children. J Urol. 2003;170(4):1343–6.
error of approximation; AIC: Akaike Information Criterion; AGFI: Adjusted 8. Kajiwara M, Inoue K, Usui A, Kurihara M, Usui TJ. The micturition habits and
goodness-of-fit statistic; GFI: Goodness-of-fit index; TLI: Tucker–Lewis prevalence of daytime urinary incontinence in Japanese primary school
coefficient; CN: Critical N children. J Urol. 2004;171(1):403–7.
9. Lundblad B, Hellström AL. Perceptions of school toilets as a cause for
irregular toilet habits among schoolchildren aged 6 to 16 years. J Sch
Acknowledgments
Health. 2005;75(4):125–8.
The authors are thankful to all individuals involved in the survey of children’s
10. Upadhyay V, Mathai J, Reed PW. Primary school children: Access to toilets.
behavior of going to school toilets in a rural primary school in China.
Acta Paediatr. 2008;97(11):1546–9.
11. Freeman M, Clasen T, Dreibelbis R, Saboori S, Greene L, Brumback B, Muga
Authors’ contributions R, RJE R. Infection: The impact of a school-based water supply and
Q.Z. designed the study; T.S. conducted the data analysis, made all tables treatment, hygiene, and sanitation programme on pupil diarrhoea: a cluster-
and all figures, participated in the writing, revision; all authors participated in randomized trial. Epidemiol Infect. 2014;142(2):340–51.
the final review of the manuscript. All authors have read and approved the 12. Caruso BA, Dreibelbis R, Ogutu EA, Rheingans RJ. Sanitation, development
manuscript. Hf: if you build it will they come?Factors influencing rural primary pupils'
urination and defecation practices at school in western Kenya. J Water
Funding Sanitation Hygiene Dev. 2014;4(4):642–53.
Not applicable. 13. Charan J, Biswas TJ. How to calculate sample size for different study designs
in medical research? Ind J Psychol Med. 2013;35(2):121.
Availability of data and materials 14. Barnes P, Maddocks A. Standards in school toilets–a questionnaire survey. J
The datasets used and analyzed during the current study is not expected to Pub Health. 2002;24(2):85–7.
be shared. If someone wants to obtain the raw data of this study, a 15. Ministry of Housing and Urban-Rural Development of the People’s Republic
reasonable request can be sent to the first author by E-mail. of China (MOHURD): Code for design of school GB 2011. Beijing: China
Construction Industry Press, 2010.
Ethics approval and consent to participate 16. Sommer M. Where the education system and women's bodies collide: the
Written informed consent was informed and obtained from all participants social and health impact of girls' experiences of menstruation and
before inclusion in the study. Due to the tight investigation time, the written schooling in Tanzania. J Adolesc. 2010;33(4):521–9.
Shao et al. BMC Public Health (2021) 21:32 Page 11 of 11

17. Antwi-Agyei P, Mwakitalima A, Seleman A, Tenu F, Kuiwite T, Kiberiti S, 44. DeLara EW. Why adolescents don't disclose incidents of bullying and
Roma E. Sanitation, Development Hf: Water, sanitation and hygiene (WASH) harassment. J Sch Violence. 2012;11(4):288–305.
in schools: results from a process evaluation of the National Sanitation
Campaign in Tanzania. J Water Sanitation Hygiene Dev. 2017;7(1):140–50.
18. UNICEF, United Nations Children's Fund NY: Water, sanitation and hygiene Publisher’s Note
(WASH) in schools. 2012. Springer Nature remains neutral with regard to jurisdictional claims in
19. Njuguna V, Karanja B, Thuranira M, Shordt K, Snel M, Cairncross S, Biran A, published maps and institutional affiliations.
Schmidt W-PJU, Water II, Centre S. The sustainability and impact of school
sanitation, water and hygiene education in Kenya; 2008.
20. Mathew K, Zachariah S, Shordt K, Snel M, Cairncross S, Biran A, Schmidt W-P.
The sustainability and impact of school sanitation, water and hygiene
education in southern India; 2009. p. 275–92.
21. Freeman MC, Clasen T, Brooker SJ, Akoko DO, Rheingans RJ. Hygiene: The
impact of a school-based hygiene, water quality and sanitation intervention
on soil-transmitted helminth reinfection: a cluster-randomized trial. Am J
Trop Med Hygiene. 2013;89(5):875–83.
22. Garn JV, Caruso BA, Drews-Botsch CD, Kramer MR, Brumback BA, Rheingans
RD, Freeman MC. Health p: Factors associated with pupil toilet use in
Kenyan primary schools. Int J Environ Res Pub Health. 2014;11(9):9694–711.
23. Vivas A, Gelaye B, Aboset N, Kumie A, Berhane Y. Williams MAJJopm,
hygiene: knowledge, attitudes, and practices (KAP) of hygiene among
school children in Angolela, Ethiopia. J Prev Med Hygiene. 2010;51(2):73.
24. Joshi A, Amadi C. Health p: Impact of water, sanitation, and hygiene
interventions on improving health outcomes among school children; 2013.
p. 2013.
25. Vernon S, Lundblad B, Hellstrom AJ. Health, development: Children's
experiences of school toilets present a risk to their physical and
psychological health. Child Care Health Dev. 2003;29(1):47–53.
26. Norling M, Stenzelius K, Ekman N, Wennick A. High school students’
experiences in school toilets or restrooms. J Sch Nurs. 2016;32(3):164–71.
27. Abrahams N, Mathews S, Ramela P. Health i: Intersections of ‘sanitation,
sexual coercion and girls’ safety in schools. Trop Med Int Health. 2006;11(5):
751–6.
28. Cowie H, Oztug O. Pupils’ perceptions of safety at school. Pastoral Care
Educ. 2008;26(2):59–67.
29. Kendrick K, Jutengren G, Stattin H. The protective role of supportive friends
against bullying perpetration and victimization. J Adolesc. 2012;35(4):1069–
80.
30. Hoarau B, Vercherin P, Bois CJSP. School toilets. Sante Publique. 2014;26(4):
421–31.
31. Williams B, Onsman A, Brown T. Exploratory factor analysis: A five-step guide
for novices. Aust J Paramed. 2010;8(3):1-13.
32. Kline P. An easy guide to factor analysis: Routledge; 2014.
33. Minglong W. Structural Equation Modeling - Amos Operation and
Application[M]. 2009;7:39–59.
34. Kline RB. Principles and practice of structural equation modeling: Guilford
publications; 2015.
35. Byrne BM. Structural equation modeling with Mplus: basic concepts,
applications, and programming: routledge; 2013.
36. Taherdoost H, Sahibuddin S, Jalaliyoon N, Mathematics p: Exploratory factor
analysis; concepts and theory. Adv Appl Pure Math. 2014;27:375-82.
37. Tavakol M, Dennick RJMT. Post-examination analysis of objective tests. Med
Teacher. 2011;33(6):447–58.
38. Lu S, Zhang J, Zhang H, Zhang J-H, Ke LJ. A study on the relationship
between tourism destination image, tourist satisfaction and behavioral
intentions: A case study of Guilin Seven Star Park. Hum Geogr. 2011;26(4):
121–6.
39. Farrell AM. Insufficient discriminant validity: A comment on Bove, Pervan,
Beatty, and Shiu (2009). J Bus Res. 2010;63(3):324–7.
40. Hooper D, Coughlan J, Mullen MR. Structural equation modelling:
Guidelines for determining model fit. Elec J Bus Res Methods. 2008;6(1):53–
60.
41. S-p NIE, Shen S-J, Mai Z-H. Status of toilet hygiene and sanitation facility in
rural schools in Guangdong. Chin J Sch Health. 2012;6:30.
42. Zhao Y-N, Zhou C-B, Li Y. Rural school toilet sanitation in Chongqing during
2015–2017. Chin J Sch Health. 2019;40(01):122–4.
43. Dreibelbis R, Greene LE, Freeman MC, Saboori S, Chase RP, Rheingans RJ.
Water, sanitation, and primary school attendance: A multi-level assessment
of determinants of household-reported absence in Kenya. Int J Educ Dev.
2013;33(5):457–65.