Original article: Handwashing practices among caregivers of children

Abstract

Introduction: Hand washing has been proven to reduce the risk of acquiring infection; this is why every 15th October is being set aside as Global Hand washing Day, which aims at improving global awareness on the importance of hand washing. Materials and Methods: The study was cross‑sectional, parents/caregivers were
consecutively recruited over 8 months, and pretested questionnaire was administered by the researchers and trained assistants. Results: There were 102 (32%) males and 217 (68%) females with a male‑to‑female ratio of 1:2.1. A total of 279 (87.5%) respondents reported that they were aware of the moments of hand hygiene. Their relations (38.3%) were the most common source of information on
hand hygiene. However, soap and water (72.4%) were the predominant items used for handwashing. Furthermore, 317 (99.1%) respondents were incorrect on the steps of hand washing technique. All respondents (100%) reported washing their hands after using the restroom. However, their educational and social status had no
significant relationship with their ability to mention the steps in hand washing and the critical moments in hand hygiene, respectively, (educational status: ‡Fisher’s exact = 0.440; P = 1.00, and $Fisher’s exact = 3.308; P = 0.282, respectively) and (social class: ‡‡Fisher’s exact = 0.756; P = 1.00 and $$Fisher’s exact = 1.232; P = 1.00, respectively). However, there were statistically significant relation with adhering to the principles of handwashing (educational status: †χ2 = 7.835; df = 2; P = 0.019) and (social class: ††χ2 = 7.952; df = 2; P = 0.019), respectively. Conclusion: Majority of the respondents wash their hands especially after soiling with dirt; and water and soap were mostly used; however, the technique of hand washing was poorly understood by caregivers and this was shown to be less influenced by their educational or social status.

Full text

233
© 2019 Medical Journal of Dr. D.Y. Patil Vidyapeeth | Published by Wolters Kluwer - Medknow
 Handwashing has been proven to reduce the risk of acquiring
infection; this is why every 15th October is being set aside as Global Handwashing
Day, which aims at improving global awareness on the importance of handwashing.
   The study was cross‑sectional, parents/caregivers were
consecutively recruited over 8 months, and pretested questionnaire was administered
by the researchers and trained assistants.  There were 102 (32%)
males and 217 (68%) females with a male‑to‑female ratio of 1:2.1. A total of
279 (87.5%) respondents reported that they were aware of the moments of hand
hygiene. Their relations (38.3%) were the most common source of information on
hand hygiene. However, soap and water (72.4%) were the predominant items used
for handwashing. Furthermore, 317 (99.1%) respondents were incorrect on the
steps of handwashing technique. All respondents (100%) reported washing their
hands after using the restroom. However, their educational and social status had no
signicant relationship with their ability to mention the steps in handwashing and
the critical moments in hand hygiene, respectively, (educational status: ‡Fisher’s
exact = 0.440; P = 1.00, and $Fisher’s exact = 3.308; P = 0.282, respectively)
and (social class: ‡‡Fisher’s exact = 0.756; P = 1.00 and $$Fisher’s exact = 1.232;
P = 1.00, respectively). However, there were statistically signicant relation
with adhering to the principles of handwashing (educational status: †χ2 = 7.835;
df = 2; P = 0.019) and (social class: ††χ2 = 7.952; df = 2; P = 0.019), respectively.
Majority of the respondents wash their hands especially after soiling
with dirt; and water and soap were mostly used; however, the technique of
handwashing was poorly understood by caregivers and this was shown to be less
inuenced by their educational or social status.
 Caregivers, critical moments in hand hygiene, hand hygiene,
handwashing

Ibrahim Aliyu, Abdulsalam Mohammed, Bashir Mariat Zubayr1, Godpower Chinedu Michael2, Bukar Alhaji Grema2,
Umar Isah Umar, Mahmud Jahun Gambo, Halima Umar Ibrahim3
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DOI:
10.4103/mjdrdypu.mjdrdypu_159_18
Address for correspondence: Dr. Ibrahim Aliyu,
Department of Paediatrics, Aminu Kano Teaching Hospital,
Kano, Nigeria.
E‑mail: ibrahimaliyu2006@yahoo.com
Hand hygiene has minimized the number of child deaths
from diarrhea by almost half; and from pneumonia by
one‑quarter.
Critical moments in hand hygiene for caregivers are:
after using a bathroom, after changing a diaper, before
feeding a child, before eating and before preparing food,
Original Article

The act of handwashing has been integrated
into our daily activities and children are often
taught early on its importance. Handwashing has
been proven to reduce the risk of acquiring infection,
this is why every 15th October is being set aside as
Global Handwashing Day; the main objective of
this day is aimed at improving the global awareness
of the importance of handwashing.[1‑6] The steps
in handwashing may appear simple, but it is quite
technical; therefore, caregivers need to be taught on
the proper procedure.[7‑12]
Department of Paediatrics,
Aminu Kano Teaching
Hospital, Bayero
University, 1Department of
Pediatrics, Institute of Human
Virology, 2Department of
Family Medicine, Aminu
Kano Teaching Hospital,
Kano, 3Department of
Paediatrics, Federal Medical
Centre, Birnin Kudu, Nigeria
This is an open access journal, and arcles are distributed under the terms of the
Creave Commons Aribuon‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as
appropriate credit is given and the new creaons are licensed under the idencal
terms.
For reprints contact: reprints@medknow.com
How to cite this article: Aliyu I, Mohammed A, Zubayr BM, Michael GC,
Grema BA, Umar UI, et al. Handwashing practices among caregivers of
children. Med J DY Patil Vidyapeeth 2019;12:233-8.
 19‑09‑2018
 18‑02‑2019

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234 Medical Journal of Dr. D.Y. Patil Vidyapeeth ¦ Volume 12 ¦ Issue 3 ¦ May-June 2019
Aliyu, et al.: Handwashing practices
or handling of raw meat, sh, or poultry; or any other
situation leading to potential contamination; the basic
principle of hand hygiene recommend by the World
Health Organization is the use of water/soap when the
hands are visibly dirty/soiled, otherwise, use of hand
rubs/sanitizers is encouraged.[13‑18]
Nigerians have a poor reading culture,[19] most of these
vital information on hand hygiene are often readily
displayed in the form of write‑ups and cartoons placed at
strategic locations, but how often are they read? In view
of the importance of handwashing, we carried out a study
determining the handwashing practices among caregivers
of children seen in Aminu Kano Teaching Hospital, Kano.

The study was crosssectional, it included parents/guardians
of children attending the Pediatric Outpatient Clinic of
Aminu Kano Teaching Hospital. This was conducted
between March 2016 and November 2016. Caregivers
that declined consent to this study were excluded. Using
a prevalence of 70.6%, as reported by Aigbiremolen
et al.,[20] the calculated minimum sample size was 162;
however, this was expanded to 324; which will improve
the validity of the results. Individuals were recruited from
the Pediatric Outpatient Clinic, they were selected through
a purposive sampling method. Pretested questionnaires
were administered by the researchers and trained research
assistants (this was translated to the local language and
validated to ensure internal consistency with a Cronbach’s
Alpha value of 0.7). The questionnaire contained relevant
information such as knowledge of Global Handwashing
Day, knowledge of 5‑moments of hand hygiene, technique
of handwashing, and personal hand hygiene practices.
The social class of the respondents was determined using
the format suggested by Oyedeji.[21]
Ethical approval was obtained from the Ethics
Committee of Aminu Kano Teaching Hospital, Kano
and informed consent was also obtained from the
participating individuals.
Data analysis
The data generated from the questionnaires were entered
and analyzed using the statistical software, Statistical
Package Social Sciences version 16.0 (SPSS Inc.,
Chicago, Illinois, USA). Data were presented as tables and
summarized as frequencies and percentages. Chi‑square and
Fisher’s exact tests for categorical variables were deplored,
and P < 0.05 was considered as statistically signicant.

Five of the questionnaires were excluded from analysis
because of incomplete response, therefore, 319 were
analyzed. There were 102 (32%) males and 217 (68%)
females with a male‑to‑female ratio of 1:2.1.
Three hundred and fourteen (98.4%) respondents
believed that handwashing could reduce the risk of
infection, while only ve (1.6%) did not share similar
view. Furthermore, 287 (90%) reported that they
were aware of the proper handwashing technique and
32 (10%) were not aware of it.
Two hundred and seventy‑nine (87.5%) respondents
reported that they were aware of the critical moments
hand hygiene while only 40 (12.5%) were not
aware; however, 279 (99.3%) could not list the
critical moments in hand hygiene correctly, however,
two (0.7%) respondents could not remember the exact
periods.
Relations (38.3%) of the respondents were the most
common sources of information on hand hygiene,
followed by the mass media (19.6%), while information
from friends (8.7%) was the least; however, majority of
the respondents (55.2%) were not aware of the Global
Handwashing Day; furthermore, 51.7% of those who
were aware of the Global Handwashing Day could state
the date correctly while 30.8% had forgotten the date.
Soap and water (72.4%) were the predominant items
used for handwashing, while clean cloth (2.2%) was the
least used [Table 1].
One hundred and ninety‑four (60.9%) respondents had
seen posters on handwashing while 125 (39.1%) had not
seen any. Seventy‑one (36.6%) respondents had seen
only one poster, 84 (43.3%) had seen 2–5 posters, while
39 (20.1%) had seen >5 posters; however. One hundred
and sixty‑eight (86.6%) respondents had read those
posters while 26 (13.4%) never bothered to read them.
Among those that read the posters, 164 (97.6%) believed
that they understood the messages on the posters, while
only four (2.4%) did not understand the information on
the posters [Table 1].
One hundred and sixty‑one (50.5%) of the respondents
had personal hand rubs, while 158 (49.5%) did not have
any. However, 289 (90.6%) were willing to use hand rubs
if offered, while 30 (9.4%) of them did not like hand
rubs. Majority (50%) of those who did not like hand
rubs had no prior information on its usage [Table 2].
Three hundred and sixteen (99.1%) respondents could not
mention the steps on handwashing technique correctly,
while three (0.9%) respondents had forgotten the steps
on handwashing. However, 248 (77.7%) respondents
reported adhering to the principle of hand hygiene
always, while 71 (22.3%) do not always adhere to hand
hygiene principles; however, most (95%) wash their
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Medical Journal of Dr. D.Y. Patil Vidyapeeth ¦ Volume 12 ¦ Issue 3 ¦ May-June 2019
Aliyu, et al.: Handwashing practices
hands after handling pampers/soiled clothes [Table 3],
but all respondents (100%) reported washing their hands
after using the restroom.
Among those who could not mention the steps in
handwashing majority reported seeing posters on
handwashing technique; however, this observation was
not statistically signicant (‡Fisher’s exact = 0.044;
P = 1.00) but those who reported adhering to the
principles of handwashing, majority reported seeing
posters on handwashing and this observation was
statistically signicant (†χ2 = 25.123, df = 1, P = 0.00);
however, listing the critical moments of hand hygiene
had no statistically signicant relationship with seeing
posters on handwashing ($Fisher’s exact = 0.203;
P = 1.00), [Table 4].
Signicant proportion of the respondents who reported
adhering to the principles of hand hygiene had heard of
the handwashing day (121, 48.8%); this observation was
statistically signicant (‡χ2 = 7.075, df = 1, P = 0.010).
However, majority of those who were incorrect in listing
the critical moments in hand hygiene were not aware of
the Global Handwashing Day [Table 5].
Majority of the respondents had secondary school
education; however, there was no statistically signicant
relation between their educational status and the ability
to correctly mention the steps in handwashing (‡Fisher’s
exact = 0.440, P = 1.00); also comparing their educational
status with the ability to list the critical moments in
hand hygiene was not statistically signicant ($Fisher’s
exact = 3.308; P = 0.282), but there was a statistically
signicant relation from comparing their educational
status with adherence to the principle of hand
hygiene (†χ2 = 7.835; df = 2; P = 0.019), [Table 6].

handwashing among the respondents

Source of information
Relations 110 (38.3)
Friends 25 (8.7)
School 44 (15.3)
Hospital 52 (18.1)
Mass media 56 (19.6)
Total 287 (100)
Heard of Global Handwashing Day?
Yes 143 (44.8)
No 176 (55.2)
Total 319 (100.0)
Date of Global Handwashing Day?
Correct 74 (51.7)
Incorrect 25 (17.5)
Do not know 44 (30.8)
Total 143 (100.0)
Handwashing items
Water only 25 (7.8)
Water and soap 231 (72.4)
Clean cloth 7 (2.2)
Multiple items 56 (17.6)
Total 319 (100.0)
Location of posters
Home 13 (6.7)
Hospital 120 (61.5)
School 44 (22.6)
Mass media 6 (3.1)
Multiple sources 11 (6.2)
Total 194 (100.0)

Reason for disliking hand-rub 
Skin reaction 6 (20)
Cost 6 (20)
Burden of carrying 3 (10)
Not aware of hand rub 15 (50)
Total 30 (100)


Wash before touching your child?
Yes 232 (72.7)
No 87 (27.3)
Total 319 (100)
Wash after handling pampers/soiled clothes
Yes 303 (95)
No 16 (5)
Total 319 (100)
Wash before feeding child
Yes 271 (85)
No 48 (15)
Total 319 (100)

‡
Seen posters? Incorrect  Total
Yes 192 2 194
No 124 1 125
Total 316 3 319
Adherence to hand hygiene†
Seen posters? Yes No Total
Yes 169 25 194
No 79 46 125
Total 248 3 319
List moments in hand hygiene$
Seen posters? Incorrect  Total
Yes 182 1 183
No 97 1 98
Total 279 2 281
‡Fisher’s exact=0.044, P=1.00; †χ2=25.123, df=1, P=0.00; $Fisher’s
exact=0.203; P=1.0
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236 Medical Journal of Dr. D.Y. Patil Vidyapeeth ¦ Volume 12 ¦ Issue 3 ¦ May-June 2019
Aliyu, et al.: Handwashing practices
Similarly, majority of the respondents were of the
middle class; however, there was no statistically
signicant relation between their social class
and the ability to correctly mention the steps in
handwashing (‡‡Fisher’s exact = 0.756; P = 1.00);
also it had no statistically signicant relationship with
the ability to correctly list the critical moments in hand
hygiene ($$Fisher’s exact = 1.232; P = 1.00), but it
had a statistically signicant relation with adherence
to the principle of hand hygiene (††χ2 = 7.952; df = 2;
P = 0.019), [Table 6].

There were more females than males reported in this
study; this observation is not surprising because most
mothers in most resource‑limited settings are either
self‑employed or “stay at home mothers,”[22] therefore,
they have more time to themselves, furthermore,
mothers are more caring and will be eager to take their
sick children to hospital for treatment.[23‑25]
Majority of the respondents (98.4%) believed in the
importance of handwashing in disease prevention,
this observation was similar to that reported
by Asekun‑Olarinmoye et al., (93%)[26] but our
gure was higher than that reported by Aigbiremolen
et al. (70%)[20] and Datta et al., (84%).[27] Similarly,
90% of our respondents reported been aware of the
proper technique of handwashing; this observation
was similar to previous reports.[25‑27] Furthermore, most
of the respondents (87%) in this study were aware of
the critical moments in hand moment; this pattern was
similar to that reported by Datta et al.,[27] but higher
than the 56% reported by Aigbiremolen et al.[20]
However, most respondents got information on hand
hygiene from relations; this highlights strong family
ties which is prevalent in most developing society,
this may be signicantly inuenced by our culture,
religion, and beliefs;[28] therefore, health authorities and
nongovernmental agencies need to do more in public
enlightenment because some of these practices may be
harmful, furthermore, they need to explore on the benets
of integrating some of these practices with the goal of
increasing community acceptance of health policies.
About 44.8% of the respondents had heard of the Global
Handwashing Day; this nding was similar to the 46%
reported among university medical students,[29] but
slightly lower than the 64.4% reported by Mohammed
et al.[30] among health professionals. Furthermore, most
of our respondents (51.7%) could correctly state the
date earmarked for celebrating Global Handwashing,

hand hygiene practices
Adherence to hand hygiene‡


Yes No Total
Yes 121 22 143
No 127 49 176
Total 248 71 319
Listing critical moments in hand hygiene†


Incorrect  Total
Yes 132 2 134
No 147 0 147
Total 279 2 281
‡χ2=7.075, df=1, P=0.010; †Fisher’s exact=2.210; P=0.227

on hand hygiene practices
‡
Educational status Incorrect  Total
At least primary 99 1 100
Secondary 191 2 193
Tertiary 26 0 26
Total 316 3 319
Adherence to hand hygiene†
Educational status Yes No Total
At least primary 71 29 100
Secondary 152 41 193
Tertiary 25 1 26
Total 248 71 319
Listing moments in hand hygiene$
Educational status Incorrect  Total
At least primary 95 2 97
Secondary 160 0 160
Tertiary 24 0 24
Total 279 2 281
‡‡
Social class Incorrect  Total
I 13 0 13
II 276 3 279
III 27 0 27
Total 316 3 319
Adherence to hand hygiene††
Social class Yes No Total
I 12 1 13
II 210 69 279
III 26 1 27
Total 248 71 319
Listing the moments in hand hygiene$$
Social class Incorrect  Total
I 12 0 12
II 242 2 244
III 25 0 25
Total 279 2 281
‡Fisher’s exact=0.440, P=1.00; †χ2=7.835; df=2; P=0.019; $Fisher’s
exact=3.308; P=0.282; ‡‡Fisher’s exact=0.756; P=1.00; ††χ2=7.952;
df=2; P=0.019; $$Fisher’s exact=1.232; P=1.00
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Aliyu, et al.: Handwashing practices
surprisingly, this was higher than that reported
among health professionals (15%)[30] and medical
students (11.7%).[29] This nding is worrisome because
the professionals who are supposed to be stakeholders
and advocates should be more knowledgeable.
Majority of respondents in our study used soap and
water (72.4%) for handwashing; this is different
from the ndings of Datta et al.[27] and Aigbiremolen
et al.[20] who reported the use of water alone as the most
common handwashing agent. This disparity may be
attributable to the difference in the population studied;
ours were predominantly of the middle class, with better
educational and socioeconomic status when compared to
theirs, which was a community‑based study with higher
respondents of lower socioeconomic class.
Although 60.9% of the respondents had seen posters
on handwashing technique, 86.6% of them reported to
have read them and 97.6% of them believed to have
understood the information contained. Furthermore,
77.7% reported adhering to the principles of hand
hygiene; however, 99.1% could not correctly mention
the steps of handwashing and none of the respondents
could rightly list the critical moments in hand hygiene.
This showed that there was knowledge gap among the
respondents. Unlike the report by Biran et al.[31] which
showed the effectiveness of intervention measures such
as use of lms, animation, and physical demonstration
in improving knowledge and acceptance of handwashing
practices. Galiani et al.[32] in their project in Peru
reported the inefciency of mass media‑based approach
alone in improving the acceptance and practice of
proper hand hygiene. They therefore, advocated the
inclusion of community level‑based approach. Although
more of those that had seen posters on hand hygiene
reported, they could mention the steps in handwashing,
adhere to proper handwashing technique and also
listing the critical moments in hand hygiene, but these
were not statistically signicant except adherence to
handwashing. There is the tendency of individuals to
casually read those posters without really comprehending
the information contained; therefore, a multipronged
approach as demonstrated by Biran et al.[31] and Galiani
et al.[32] should be a better option.
About 72.7%, 95%, and 85% of the respondents reported
washing their hands before handling their children, after
handling soiled clothes/pampers, and before feeding
their children, respectively, these ndings were higher
than that reported by Datta et al.[27] However, all the
respondents reported washing their hands after handling
feces; this observation was higher than the 79.6%
reported by Aigbiremolen et al.[20] and 84.9% reported by
Ekanem and Johnson.[33] The reason for this difference
was not completely clear; however, ethnic and religious
differences might had inuenced this nding. Our
society is Muslim predominant; they give high premium
to personal cleanliness, especially after defecation with
the use of at least clean water for purication.
Majority of the respondents in our study were of
the middle and upper class; and most had at least
primary education. However, this had no signicant
inuence on their ability to correctly mention the steps
of handwashing and also to correctly list the critical
moments in hand hygiene. However, their ability to
adhere to the principles of hand hygiene had signicant
relationship with their social class and educational status;
this observation was similar to that of Aigbiremolen
et al.,[20] Steiner‑Asiedu et al.,[34] and Vivas et al.[35]

Caregivers in our study were aware of the importance
and benets of handwashing; however, their relations
were the most common source of information on hand
hygiene; therefore, health care professionals need to do
more in the area of education and advocacy. Although
the use of posters is of relevance in health‑related
information dissemination, it may be of limited value
if it is not properly utilized. Finally, the educational
status and social class had more inuence on their
adherence to the principles of hand hygiene, but it had
no signicant inuence on the ability of respondents to
correctly mention the steps in handwashing or the ability
to correctly list the critical moment in hand hygiene.
Financial support and sponsorship
Nil.
Conicts of interest
There are no conicts of interest.

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