Health behavior and hygiene practices among islamic boarding school students in Indonesia: A qualitative study

Abstract

BACKGROUND:

Islamic boarding schools in Indonesia are essential for religious and character education, yet health behavior and hygiene practices (HBHP) among students remain limited, leading to preventable illnesses. This study aimed to explore HBHP in boarding schools, identify supporting and inhibiting factors, and examine the role of community health centers (CHCs) in promoting student health.

MATERIALS AND METHODS:

A qualitative design with thematic analysis was applied. Nineteen informants were purposively selected, including students, teachers, administrators, caretakers, CHC health promotion officers, and a health department representative. Data were collected through in-depth interviews and participatory observation and then analyzed using Braun and Clarke’s framework with NVivo 12 Plus.

RESULTS:

Five themes emerged: (1) daily hygiene constraints and common health disorders such as skin, digestive, and respiratory problems; (2) psychosocial and academic impacts of illness, including homesickness, reduced concentration, and disrupted religious activities; (3) factors shaping health behavior, including institutional rules, role models, peer influence, and personal habits; (4) the interface between CHCs and boarding schools through counseling, screening, and health programs, constrained by limited resources; and (5) strategies to overcome barriers, such as schedule adjustments, simplified access, and interprogram collaboration.

CONCLUSION:

The findings highlight that student health in boarding schools is influenced by individual routines, institutional policies, and health system support. Strengthening school rules, teacher role modeling, and consistent CHC involvement are critical to improving HBHP. This study contributes qualitative evidence for culturally grounded health promotion models in Indonesian boarding schools.

Background

Islamic boarding schools in Indonesia are essential for religious and character education; however, they frequently lack adequate focus on Health Behavior and Hygiene Practices (HBHP).[1] Sanitation and health behavior are significant health concerns, subject to the influence of environmental factors and students’ lifestyles.[2,3] Health behaviors and hygiene practices in these environments must be addressed, as they can influence students’ overall health and well-being.[1] Factors including knowledge, attitudes, and current health program policies can affect students’ health behaviors.[4,5] Educational institutions with substantial populations encounter distinct challenges in promoting healthy behaviors, influenced by interventions from community health centers (CHC) and internal policies.[6]

To prevent illness and enhance quality of life, students should practice good personal hygiene, maintain a clean environment, and adopt healthy lifestyle patterns.[2,7] Habits such as hand washing with soap, regular baths, keeping restrooms and rooms clean, and eating a healthy, balanced diet are all part of HBHP.[8] It has been demonstrated that health education, including counseling on menstrual hygiene and healthy eating practices, successfully raises students’ awareness of and attitudes toward healthy behaviors.[6] Environmental considerations are also important; a high degree of environmental consciousness, for example, through adopting eco-friendly programs, can encourage the development of healthy habits.[9,10] Therefore, integrating social support, policies, and education that can encourage students to adopt healthy lifestyles influences the implementation of HBHP.[11]

Health Behavior and Hygiene Practices (HBHP) are not widely implemented in these educational settings, which is the main problem in this study. This leads to several health problems, including respiratory, digestive, and skin infections.[12,13] Numerous students’ health may suffer due to inconsistent personal hygiene practices, such as washing their hands with soap and keeping their surroundings clean.[8,14] Students’ awareness of the value of a healthy diet and good personal hygiene, which should enhance their quality of life, has decreased due to the lack of health education.[1,15] Furthermore, the congested setting and scarcity of medical resources exacerbate pre-existing health issues and may postpone adopting healthy habits.[7] Smoking and sharing personal belongings also raise the risk of disease transmission.[16,17]

Numerous researchers have examined health behavior and hygiene practices among students in educational institutions using quantitative approaches. However, fewer studies have applied qualitative methods to explore this issue in depth, particularly with regard to the role of community health centers (CHCs) in health development and the ways institutional policies support hygienic and health-promoting behaviors. To address this gap, the present study developed the conceptual framework presented in Figure 1, which was informed by both a literature review and preliminary field exploration.

Figure 1.

Conceptual framework of factors influencing students’ health behavior and hygiene practices in boarding schools

Given the low level of Health Behavior and Hygiene Practices (HBHP), which directly impacts students’ physical health and well-being, this research is extremely urgent.[12] As sizable educational establishments, schools are essential in promoting healthy habits that can lower the incidence of infectious diseases and other health problems among pupils.[8] This study adds something new by qualitatively examining hygiene and health behavior within the distinctive organizational and cultural context of Indonesian Islamic boarding schools. It incorporates viewpoints from various stakeholders to guide the creation of a culturally grounded health-promotion model, in contrast to earlier research on general school populations. Thus, this study aimed to look at the hygiene and health behavior of students in Indonesian Islamic boarding schools, find factors that help and hinder them, and assess how community health centers can help create a healthier learning environment.

Materials and Methods

Study design and setting

This study uses thematic analysis in a qualitative approach. A qualitative approach was selected to obtain a comprehensive grasp of the elements influencing students’ healthy behavior and the difficulties encountered in putting these healthy behaviors into practice. According to Braun and Clarke (2021), this method enables the researcher to ascertain informants’ experiences, opinions, and perceptions concerning health and hygiene practices in Islamic boarding schools. The study was conducted between September and December 2024. The study sites included traditional and contemporary boarding schools in the Jember Regency, East Java, Indonesia.

Study participants and sampling

The study involved 19 informants: students, teachers or educators, administrators of the Islamic boarding schools, caretakers, and healthcare personnel from the CHC overseeing student health. Informants were purposively selected based on specific criteria. The criteria for students as participants were those who studied and resided in the boarding school for more than one year, while the criteria for teachers were those who taught full-time with more than one year of teaching experience. The criteria for administrators were those in charge of health-related matters at the school for more than 1 year. This study involved 19 informants, consisting of 10 men and nine women. The informants included six students, three teachers, three administrators, two caretakers, four health promotion officers from the CHC, and one informant from the health department of Jember Regency.

Data collection tool and technique

Data were collected through in-depth interviews and participatory observations. Interviews were conducted using an open-ended guide to elicit experiences, opinions, and issues related to health and hygiene behaviors. Observations were made regarding sanitation and hygiene practices performed by students in the boarding schools. The data were coded and analyzed using thematic analysis to identify key themes related to the factors influencing health behavior in these schools[18]

Ethical consideration

This study received approval from the ethics committee and adheres to research ethics standards. All participants were provided with clear information about the research objectives, the procedures to be followed, and their right to participate or withdraw from the study at any time without consequence. For participants younger than 17 years, parental or guardian consent was obtained. Confidentiality and anonymity of participants were strictly maintained throughout the research process. In addition, all informants were asked to provide written consent before conducting the interviews. The study received ethical approval from the Faculty of Dentistry, University of Jember’s health research ethics committee under approval number 2455/UN25.8/KEPK/DL/2024.

Statistical analysis method

All interview and observation data were transcribed verbatim in Bahasa Indonesia and, when required, translated into English for analytical purposes. Data were organized and coded using NVivo 12 Plus software. We used reflexive thematic analysis by Braun and Clarke’s six-phase framework: (1) familiarization with the data through repeated readings of transcripts, (2) generation of initial codes, (3) identification of potential themes, (4) review and refinement of themes, (5) definition and naming of themes, and (6) report production. Two researchers independently analyzed an initial collection of transcripts, compared and deliberated on differences, and subsequently modified the codebook. The residual transcripts were analyzed by a single researcher, accompanied by periodic peer debriefings and an external audit trail to maintain consistency. Triangulation was executed across various data sources (students, teachers, caretakers, administrators, and community health officials), and member checking was carried out with chosen participants to validate the reliability of the emerging themes. All analytical judgments were recorded to improve the openness and reliability of the results. Triangulation techniques were used to ensure the reliability and validity of the research, which involved comparing data from different sources (students, caretakers, healthcare workers, and boarding school administrators). In addition, member validation was conducted to ensure data credibility by seeking feedback from key informants on the preliminary findings and data interpretation. All procedures followed research ethics principles[19]

Results

After analyzing the interview data, 124 codes were generated, which were then grouped into 21 categories and clustered into five overarching themes. These themes reflected the complexity of health behavior and hygiene practices in boarding schools, covering everyday challenges to institutional responses. The first theme describes students’ daily hygiene constraints and common health disorders.

Theme 1. Everyday hygiene constraints and common health disorders

According to an analysis of the students’ narratives, they commonly dealt with recurring health issues, particularly skin conditions like boils, scabies, and itching. Fever was mentioned as a common occurrence among students, and digestive complaints such as vomiting, diarrhea, and stomachaches were also frequently reported. The various health problems that exist in the boarding school setting were further demonstrated by respiratory problems like cough, flu, and dyspnea, as well as reproductive health issues among female students.

The students’ testimonies demonstrated the close relationship between the illnesses they experienced and their daily activities. The lack of soap, irregular handwashing, and infrequent bathing were frequently highlighted as contributing factors. The risk of cross-infection was increased even more when personal items like towels, toiletries, and prayer clothes were shared. Another important factor was dietary habits: many students regularly skipped breakfast or balanced meals in favor of instant noodles, spicy snacks, and soft drinks. Another layer of health risk was added when it was discovered that smoking was a common habit among male students.

These concerns were vividly expressed in the voices of participants. One student explained, “Sometimes we share towels or clothes because there are not enough” (S3). Another noted, “Bad habits usually include not washing hands before meals, not using soap… Even when they know about their stomach problems, they still eat spicy food and skip breakfast” (S11). From a health officer’s perspective, gender-specific issues also surfaced: “For female students, they usually experience itching, vaginal discharge… in the genital area” (D11).

Taken together, these accounts illustrate how limited facilities, unhygienic routines, and unhealthy consumption patterns intersect to create a heavy burden of preventable illness among boarding school students.

Theme 2. Psychosocial and academic impacts of health disorders

Students’ health issues had serious psychological and academic repercussions in addition to having an impact on their physical health. When sick, many students expressed feeling homesick, depressed, and uncomfortable, which occasionally resulted in a desire to go back home. Some students felt they were a burden to their peers, which made it harder for them to maintain social interactions, which added to their psychological burdens.

Students’ performance and daily routines were also disturbed by illness. According to several informants, health issues made it difficult for them to focus in class, attend classes, or engage in religious activities like prayer. Sleep disturbances were also frequently reported in the boarding school setting, reducing students’ ability to participate in their academic and spiritual lives.

These concerns were reflected in students’ voices. One student shared, “When I am sick, I often feel homesick and want to go home and be visited by my parents” (S11). Another explained, “When my body is hot, I feel less comfortable staying in the boarding school” (S6). A participant added, “I just want to get better quickly because when I am sick, I feel sorry for burdening others, sometimes I feel sad” (S5). The link between illness and educational disruption was noted: “When I feel unwell, it disrupts my prayer because I feel weak and dizzy, and during exams, when I am sick, I cannot study properly” (S3).

Taken together, these narratives demonstrate how health disorders extend beyond physical discomfort, affecting students’ emotional well-being, academic achievement, and ability to fulfill religious obligations.

Theme 3. Factors shaping health behavior and indicators of well-being

Individual, social, and institutional factors impacted students’ hygiene and health-related behavior. Students’ daily routines were significantly shaped by the boarding school’s rules and the presence of teachers and caregivers who served as role models. While some students acknowledged that habits from their homes, especially those from rural areas, continued to affect their behavior, others stated that disciplinary actions encouraged them to adhere to health-related regulations. Another factor was peer pressure, as students frequently emulated the actions of their peers, whether positively or negatively.

In addition to outside influences, informants highlighted several well-being indicators. Regular eating habits, personal hygiene, and clean living quarters were frequently cited indicators of a healthy student. Additionally emphasized were neatness, discipline, and the capacity to care for oneself and one’s surroundings. In the context of boarding schools, regular exercise and physical activity were viewed as additional markers of good health.

Both students and staff expressed these views. One informant explained, “For my friends to get used to healthy living, I think it is the boarding school rules and the teachers. The rules usually have penalties, and students follow the teachers because they see them as role models” (D11). Another noted, “I think knowledge is also a factor; most of the students come from rural areas, so perhaps their habits from home carry over to the boarding school, and when they see their friends not maintaining personal hygiene, they tend to follow suit” (D15). Students also shared their perspectives: “A healthy student is someone who does not have bad breath, is neat, clean, and has a clean room” (S3), while another added, “In my opinion, a healthy student is someone who can take care of themselves, for example, by keeping things clean. Students who do this can be considered healthy” (P13).

These accounts show that students’ health behavior is shaped by the interplay of structural regulations, role models, peer influence, and personal habits. At the same time, well-being is judged not only by the absence of illness but also by cleanliness, discipline, and the ability to maintain a healthy lifestyle.

Theme 4. Boarding school–CHC interface: roles, programs, and challenges

The results showed a close relationship between community health centers (CHCs) and boarding schools, which is crucial for intervention, education, and monitoring. According to health officers, CHCs performed health surveys, offered counseling, and performed screenings for conditions such as hemoglobin levels, weight, dental health, and vision. In addition, they arranged health education programs for students and distributed posters and pamphlets. Since these activities were incorporated into the CHCs’ official performance indicators and yearly evaluation programs, they were deemed necessary.

Organized programs and policies supported these activities. The Ministry of Health’s school health regulation, the Jember Regency Healthy Boarding School program, and the regional program “Healthy Boarding School Initiative, Collaboration, and Innovation” were among the initiatives the informants discussed. According to these frameworks, CHCs had to assign schools to categories, with category three being the minimum goal. At least one boarding school was under the jurisdiction of each CHC, guaranteeing consistent health promotion.

Nevertheless, several difficulties were noted. CHCs’ capacity to carry out programs successfully was frequently hampered by a lack of funding, staff, and the challenge of getting caregiver consent. Informants also mentioned that the sustainability of peer health ambassadors was hampered by the lack of standardized training modules and students’ demanding schedules. The voices of participants reflected these dynamics. One health officer explained, “The role of CHC is primarily in monitoring and evaluation. We first assess the health issues in the boarding school, then we monitor and intervene through counseling, socialization, and health screenings” (D15). Another officer added, “The health program for students in the boarding school must be conducted because it is part of our performance assessment. We conduct a survey every year using this form” (D1). However, difficulties were highlighted: “Besides a lack of staff, another challenge is when we work with students, and when they graduate, the regeneration stops. We have to start over from scratch” (D10).

These findings suggest that CHCs play a crucial role in supporting student health. However, their efforts are constrained by systemic challenges that require adaptation and innovation within the boarding school environment.

Theme 5. Overcoming barriers and moving forward

Both health officers and boarding school employees discussed workable ways to get past the operational and structural obstacles that community health centers (CHCs) faced when implementing health programs. One popular strategy was rescheduling counseling sessions to avoid scheduling conflicts with students. Health education, for instance, was frequently scheduled after Friday prayers or when students were more available and at ease.

Simplifying the permissions process was another tactic. Instead of repeatedly contacting official channels, CHC staff turned to reliable intermediaries who were already acquainted with the management of the boarding school. This made entry easier and decreased opposition to health promotion initiatives.

It was also stressed that various health programs should work together. CHCs frequently combined their work with school health units, mental health programs, environmental health projects, and nutrition services. This method gave students a more thorough health education while making the most available resources. Informants described these solutions clearly. One health officer stated, “To overcome these barriers, we usually schedule counseling after Friday prayers, if the boarding school has no activities at that time” (D10). Another added, “We also face permission challenges, so we go through a single entry point, someone already familiar with the boarding school” (D1). A further perspective highlighted inter-program collaboration: “We collaborate with nutrition and environmental health teams to provide counseling together” (D15).

These accounts demonstrate that despite financial limitations, human resource shortages, and structural restrictions, CHCs and boarding schools actively adapted to ensure that health promotion activities could continue. By creatively adjusting schedules, building trust through intermediaries, and fostering inter-program collaboration, they could sustain their commitment to improving student health in the boarding school setting.

Discussion

This study used thematic analysis to investigate boarding school students’ hygiene and health behaviors. Five key themes emerged: (1) the limitations of daily hygiene and prevalent health conditions; (2) the psychological and educational effects of health issues; (3) the elements influencing health behavior and well-being indicators; (4) the relationship between community health centers (CHCs) and boarding schools in assisting with health initiatives; and (5) methods to get past obstacles and continue. These results thoroughly explain how the interaction of personal behaviors, institutional policies, and health system assistance influences student health experiences. The following discussion examines each theme in light of the available data and its implications for practice and policy.

The first theme emphasizes the common health conditions and daily hygiene limitations that students face. The results show that avoidable health issues such as skin infections, digestive disorders, respiratory ailments, and reproductive health issues are common among students. These findings emphasize the adverse effects of poor dietary practices, dangerous behaviors such as smoking, and inadequate sanitary facilities. Prior research on teenagers living in institutional or boarding settings has shown similar trends, with overcrowding and inadequate sanitary facilities contributing to a higher incidence of respiratory infections and scabies.[20,21,22] Furthermore, students’ anemia and gastrointestinal issues have been linked to irregular eating patterns and the consumption of low-nutrient foods.[12,23] According to our findings, the most important ways to lower the disease burden in this setting are through health education and establishing supportive infrastructure that addresses handwashing with soap, basic hygiene practices, and access to balanced meals.

The second theme demonstrates how boarding school students’ health issues go beyond physical symptoms and significantly impact their academic performance and psychosocial well-being. When ill, many students reported feeling depressed, homesick, and uncomfortable, which occasionally resulted in social disengagement and a sense of burdening others. As a reflection of the wide-ranging effects of ill health on their spiritual and developmental lives, illness also interfered with their ability to focus in class, take part in exams, and pray. Studies of teenagers in residential or resource-constrained environments have shown similar trends, with physical illness being strongly associated with emotional distress and lower academic achievement.[24] These results emphasize the value of integrated health promotion strategies focusing on disease prevention and offering psychosocial support through peer engagement, counseling, and teacher-health professional collaboration.

The third theme emphasizes how a complex interplay of institutional regulations, role models, peer pressure, and personal knowledge shapes students’ health behavior and hygiene practices. Peer imitation frequently reinforced either positive or negative behaviors, while boarding school rules and the presence of teachers or caregivers as authority figures were found to have a significant impact on students’ willingness to adopt healthier practices.[4,11] These results are consistent with behavioral theories like the Theory of Planned Behavior, which highlights how perceived control and subjective norms influence health-related behavior.[25,26] Indicators of well-being that students and staff have described include neatness, cleanliness, consistent eating habits, and the capacity to take care of oneself and the environment. These traits reflect personal accountability and the larger cultural emphasis on order and discipline in the boarding school. These findings imply that effective health promotion must incorporate peer-based interventions, role modeling, and structural enforcement to strengthen students’ sustainable, healthy behaviors.

The fourth theme highlights how crucial community health centers are to addressing student health in boarding schools through program implementation, counseling, and monitoring. As part of their performance indicators, health officers clarified that their duties include conducting yearly surveys, offering health education, and assisting with screenings.[11,27] National and regional health policies support these initiatives, such as the Healthy Boarding School Initiative in East Java and the Ministry of Health’s regulation on school health. However, several obstacles were noted, such as a lack of funding, a staffing shortage, and trouble getting caregivers’ consent. Similar restrictions have been noted in other research on school health programs, where systemic barriers frequently diminish the efficacy of interventions.[19,28] Notwithstanding these obstacles, CHC programs’ strategic role in incorporating preventive and promotional services into the boarding school setting is highlighted by their alignment with health policy benchmarks.

The fifth theme demonstrates the tactics used by community health centers to get past obstacles in providing health promotion and education in boarding schools. In order to prevent scheduling conflicts with students, health officers reported rescheduling counseling sessions, working with other health programs like school health services, environmental health, and nutrition, and depending on reliable intermediaries to streamline permissions procedures.[29] These flexible strategies show an attempt to keep the program running despite structural limitations and a lack of funding. Similar results have been noted in other community-based health programs where maintaining health promotion in settings with limited resources required flexible scheduling, relationship-building, and intersectoral collaboration.[2,5] According to these tactics, enhancing school health programs’ resilience and ensuring that preventive and promotional services are successfully delivered to students depend heavily on creativity and teamwork.

The five themes thoroughly explain how individual habits, institutional policies, and health system assistance influence student health in boarding schools. The results build on earlier studies by demonstrating that health issues in boarding schools are closely related to academic achievement, spiritual practices, and psychosocial well-being in addition to being caused by poor diet and hygiene. This study also emphasizes the dual function of community health centers in addressing barriers in the context of boarding schools as both policy implementers and adaptive innovators. This research provides a deeper understanding of how institutional collaborations and contextual factors impact hygiene practices and health behavior, in contrast to previous studies that mainly described disease prevalence. In particular, it presents boarding schools as distinct settings where institutional discipline, cultural norms, and public health policy interact to influence the health outcomes of adolescents. This contribution highlights the study’s novelty.

It is important to recognize the various limitations of this study. First, because the experiences reported may reflect the unique context of the study sites, the qualitative design restricts the findings’ applicability to all boarding schools. Second, participants’ answers may contain recall bias or social desirability bias due to the use of self-reported data. Third, although the study used NVivo-supported thematic analysis, the small number of coders involved limited intercoder reliability. The study has some noteworthy strengths despite these drawbacks. Numerous stakeholders, including students, instructors, caregivers, administrators, community health officers, and health department representatives, contributed various viewpoints that enhanced the results. A thorough investigation of hygiene and health behavior was also made possible by applying systematic thematic analysis, yielding insights beyond descriptive narratives and adding to scholarly research and health policy discussions.

These findings should be expanded upon in future studies using mixed-method approaches incorporating quantitative information on disease prevalence, nutritional status, and psychosocial well-being with qualitative insights. In order to document how students’ health behaviors and results evolve, particularly in reaction to policy changes or health education initiatives, longitudinal studies would be beneficial. Comparative research between various kinds of boarding schools and geographical areas may also reveal best practices and contextual differences that could guide scalable health promotion models. Future research should examine how cutting-edge tactics like peer-led interventions, digital health education, and intersectoral partnerships can improve student health. These studies would offer more solid proof to help practitioners and policymakers create all-encompassing and long-lasting health programs for boarding school settings.

Conclusion

This study concludes that improving students’ health behavior and hygiene practices in boarding schools requires coordinated action between schools and community health centers. The findings reinforce existing health policy benchmarks, particularly the Ministry of Health Regulation No. 1/2013 on school health implementation and the Islamic Boarding School Health program, which highlight sanitation, preventive services, and health education in educational settings. Strengthening school rules, role-modeling by teachers and caretakers, and routine health surveillance can help boarding schools meet national school health standards while supporting progress toward the Sustainable Development Goals on adolescent health and well-being.

AI policy statement

Artificial Intelligence (AI) tools were partially used in the preparation of this manuscript. Specifically, AI-assisted language editing (ChatGPT and Grammarly) was used to improve grammar, clarity, and readability. No AI tools were used for data collection, data analysis, or generation of figures. The authors reviewed and verified all content to ensure accuracy and take full responsibility for the integrity and originality of the manuscript.

Abbreviations

HBHP: Health Behavior and Hygiene Practices; CHC: Community Health Center.

Author’s contributions

JJ, SM and VW: Study conception and design. JJ: Data collection. JJ: Drafting of the article. JJ: Critical revision of the article. JJ: Final manuscript.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.