Content uploaded by Amensisa Hailu Tesfaye
Author content
All content in this area was uploaded by Amensisa Hailu Tesfaye on May 02, 2024
Content may be subject to copyright.
Handwashing Practices among Public Primary School Students in
East Dembiya District, Ethiopia
Garedew Tadege Engdaw,
1*
Desalegn Alemu,
2
Mekuriaw Alemayehu,
1
and Amensisa Hailu Tesfaye
1
1
Department of Environmental and Occupational Health and Safety, Institute of Public Health, College of Medicine and Health Sciences,
University of Gondar, Ethiopia;
2
East Belesa Woreda Health Department Offices, Northwest, Ethiopia
Abstract. Poor water sanitation and hygiene is a public health problem in developing and underdeveloped countries,
including Ethiopia, and remains an important public health issue among primary school students. Students have been
repeatedly exposed to various communicable diseases associated with water sanitation and hygiene. The objective of
this study was to assess predictors of handwashing practice among second-cycle public primary school students
in East Dembiya District, northwestern Ethiopia, 2022. A cross-sectional study was conducted among 752second-
cycle primary school students. Data were gathered through face-to-face interviews using a structured interviewer-
administered questionnaire and observational checklists adopted and modified from different sources of literature. The
data were checked further by visualizing and computing rates with the SPSS version 26 statistical software. Multivariable
logistic regression was used to identify predictors. The prevalence of washing practices among second-cycle primary
school students was 57.6% (95% CI 53.90–61.10). Residency (urban) (adjusted odds ratio [aOR] 52.17, 95% CI:
1.30–2.87), access to media (aOR 51.66, 95% CI: 1.11–2.49), hygiene and sanitation club membership (aOR 51.88,
95% CI: 1.26–2.80), good knowledge about handwashing (aOR 53.93, 95% CI: 2.34–6.60), and a positive attitude
toward handwashing (aOR 53.63, 95% CI: 2.01–5.584) were predictors of handwashing practice among second-cycle
primary school students. This study showed that handwashing practice among primary school students was low. Avail-
ing handwashing facilities, better media access, formation of a hygiene and sanitation club in the school, celebration of
“Handwashing Day”with students, and leading behavior change communication are all important for improving students’
handwashing practice.
INTRODUCTION
One of the easiest, least expensive, and most efficient
ways to prevent the transmission of infection through feces,
bodily fluids, and inanimate objects is to cleanse one’s
hands properly.
1
Children and adolescents should wash
their hands frequently because they are the age group most
likely to contract a disease from dirty hands.
2
Additionally,
there is an elevated chance for the transmission of infectious
diseases because of the conditions of nearby children in
classrooms.
2
Within the grounds of primary schools, diar-
rhea and acute respiratory infections are frequently spread.
Crowded environments and the absence of knowledge
about taking care of themselves are conducive to the spread
of microorganisms.
3
Children are immediately exposed to
microorganisms when they touch contaminated hands, with
inmate objects acting as the disease-transmission medium.
4
Primary school students have been repeatedly exposed
to various communicable diseases associated with water,
sanitation, and hygiene (WASH). Scabies, conjunctivitis, dys-
entery, giardiasis, and other bacterial, viral, protozoan, and
helminthic diseases and infections were among the most
common.
5,6
Poor WASH is a public health problem in devel-
oping and underdeveloped countries, including Ethiopia,
and remains an important public health issue among primary
school students.
7
Poor handwashing habits are a major
issue in emerging nations, where they contribute to numer-
ous illnesses and even fatalities. Poor WASH is thought to
be the root cause of 88% of diarrheal diseases. More than
250,000 children die of WASH-related illnesses each year in
Ethiopia, where inadequate WASH is linked to 60% of
pathogens that cause diarrhea and other illnesses.
7
As a
result, in Ethiopia, they are regarded as significant contribu-
tors to disease, mortality, and impairment.
7,8
In children
aged 0 to 14 years, infections account for half of all hospital
visits and 12% of all admissions.
9
Among these, respiratory
infections and infectious intestinal disease are responsible
for 48% and 29% of children’s visits to the health care facil-
ity, respectively.
10,11
In underdeveloped nations, 80% of
diseases are caused by poor household and personal sani-
tation, and approximately 2.2 million people die each year,
most of whom are children.
12
A systematic review indicated
that handwashing lowered the risk of respiratory infection,
with risk reductions ranging from 6% to 44% (pooled value
24%, 95% CI 6–40%).
13
Poor handwashing practice in schools were discovered to
have a detrimental effect on attendance and health.
14,15
In
Ethiopian primary schools, students in Yirgalem Town,
16
Damote Woide District,
17
Mareko District,
7
and Arbaminch
Town
18
had good handwashing habits more often than the
national average, at 39.1%, 28.10%, 23.3%, and 22.23%,
respectively. In general, the prevalence of good handwash-
ing practices among students in Ethiopian schools was low,
ranging from 13.3% to 39.1%.
19
The main causes of water-related diseases are inadequate
water supply, poor sanitation behavior, and poor handwashing
practice, which can lead to decreased educational perfor-
mance and an increased possibility of dropout; this, in turn,
prevents children from gaining the various economic and
health benefits associated with educational achievement.
6,20
According to a recent study, instructional initiatives to
encourage handwashing in educational environments seek
to improve compliance.
21
However, developing nations
22,23
have called attention to the lack of carefully performed stud-
ies to assess the efficacy of handwashing interventions in
preventing the spread of respiratory and gastrointestinal
infections.
* Address correspondence to Garedew Tadege Engdaw, Department
of Environmental and Occupational Health and Safety, Institute of
Public Health, College of Medicine and Health Sciences, University
of Gondar, 196 Ethiopia. E-mail: garedewtadi27@gmail.com
826
Am. J. Trop. Med. Hyg., 110(4), 2024,pp. 826–834
doi:10.4269/ajtmh.23-0201
Copyright © 2024 American Society of Tropical Medicine and Hygiene
The ideas of Lawrence Green aim in examining human behav-
ior from a health perspective by causing it to occur through
health promotion initiatives. According to Green, predisposing
factors, which are those that come from an individual’sknowl-
edge, attitudes, beliefs, values, and norms; supportive factors,
which include health facilities, access to health and WASH facili-
ties, health and health-related rules, and skills related to health;
and reinforcement factors, which include health professionals
and teachers, community and school leaders, or influential indi-
viduals of decision-making are what cause or shape behavior.
24
Little information is available about the factors that influence
schoolchildren’s handwashing practices from previous studies
conducted in Ethiopia, particularly in the study area.
This study provides insight into personal, social, and insti-
tutional factors that influence handwashing practice. Infor-
mation obtained from this study will help local planners and
policymakers. Therefore, the aim of this study was to assess
handwashing practices and the associated factors among
second-cycle primary school students.
MATERIALS AND METHODS
Study area and period. Accordingtothe2021East
Dembiya district culture and tourism office report, the district
has a total population of 271,053, of whom 138,110 are male.
Of these 23,354 (8.62%) are urban residents.
25,26
The district
has 58 primary schools, 16 of which are full-cycle from grades
1 to 8. According to the 2021 academic year register and class
attendance, a total of 23,680 (13,080 male and 10,600 female)
students were attending their primary schools.
25
The district
also had one primary hospital (an institution that was built and
is staffed and equipped for the diagnosis of disease and for
the treatment of medical and surgical patients and sick and
injured people, as well as their housing during this process).
The modern hospital also often serves as a center for investi-
gation, research, and teaching, contains five health centers
(higher level health service centers), and 11 health posts (basic
healthcare facilities). This study was conducted from May 10
to June 20, 2022 (Supplemental Information).
Study design and population. A cross-sectional study
was conducted at the level of the school using a quantitative
method with a group of randomly chosen students who were
enrolled in second-cycle elementary schools at the time of data
collection. Students in grades 5, 6, 7, and 8 at East Dembiya
district’sfirst cycle secondary school made up the study group
in 2022. Students who took nighttime courses and those with
learning disabilities were not included. Students who attend
evening courses in Ethiopia have different social traits from
those who do so during they day. They were left out of this study
to prevent the results from being over- or underestimated.
Sample size determination, sampling technique, and
procedure. The required sample size was determined for
the first objective and the factors using a single population
proportion assumption. The sample size for the first objec-
tive was calculated using percentages of handwashing prac-
tice, margin of error, confidence interval, design effect, and
nonresponse rate, which were predicted to be, correspond-
ingly, 37.0%,
27
5%, 95%, 1.5, and 5%. Although the sample
size for the second objective was calculated using the dou-
ble population proportion formula using Open-Epi version
3.01 software. The largest sample size for the associated
factors was 466; adding the nonresponse rate of 10% and
multiplying by the design effect of 1.5, the final sample size
for the associated factors was 769. To achieve the overall
stated objectives, a sample size was chosen for the associ-
ated factors of handwashing practice (Table 1).
From a total of 16 primary schools in the district, five were
selected at random. The students were selected from five
primary schools using a multistage sampling method. The
stratification was made into grades 5 through 8. The grades
were then stratified into sections. According to the number
of students in each school and section, the calculated sam-
ple size was proportionally allocated to them. From the
student list for each grade, student frames have been devel-
oped in cooperation with the teachers.
Operational definitions.
Good handwashing practice. Students who scored $67%
on the overall handwashing practice–related questions from
the observational checklist were considered to have a “good
handwashing practice,”whereas those whose total score
was ,67% were classified as having “poor handwash-
ing practice.”
7
Good knowledge on handwashing. Students who scored
$67% on the overall handwashing knowledge-related ques-
tions were considered to have “good knowledge,”whereas
those with a score ,67% were considered to have
“poor knowledge.”
7
Positive attitude toward handwashing. Students who
scored $67% on the overall handwashing attitude-related
questions were considered to have a “good attitude,”whereas
thosewithascore,67% were considered to have a “poor
attitude,”
7,29
Handwashing facility. A handwashing facility was any
setup of a container with water and soap in the school or
household compound for handwashing purpose.
29
Data collection tool and quality management. Structured
interviewer-administered questionnaires containing closed-
and open-ended questions were prepared. One environmen-
tal health professional supervisor with a bachelor’s degree
and five experienced bachelor’s-level nurses were selected
for the data collection process, and they received the
required training (regarding questioning techniques, ethical
issues, how to select respondents and fill out the question-
naire, and how to receive feedback on their interviewing
skills). The questionnaires were given codes during the data
collection process so that inconsistencies could be
TABLE 1
Sample size determination for the associated factors of handwashing practice, 2022.
Factors associated with HWP HWP Exposed, n(%) HWP Nonexposed, n(%) cOR (95% CI) Sample Size Reference
Knowledge on handwashing 106 (71) 220 (58.2) 1.78 466
28
Attitude on handwashing 223 (71.7) 103 (47.5) 2.81 144
28
Knowledge on water handling 236 (69) 90 (49) 2.33 208
28
cOR 5crude oddsratio; HWP 5handwashing practice.
PREDICTORS OF HAND WASHING PRACTICE 827
corrected right away. The data collectors, supervisor, and
primary investigator reviewed the completed questionnaires
every day for completeness and consistency. The collected
data were entered by a degree holder health informatics
professional (data encoder) using the Epi-data version 4.6
software. Using the statistical program SPSS version 26, the
data were further cleansed by visualizing and computing fre-
quencies. In accordance with the initial statistics, corrections
were made. The questionnaire included questions about the
students’understanding of and attitudes toward handwash-
ing, as well as questions pertaining to handwashing practice.
It also included sociodemographic data about the primary
school students and their parents.
Data collection methods, instruments, and procedure.
Data were collected from 752second-cycle primary school
students. Data was gathered by face-to-face interviews
using a structured interviewer-administered questionnaire
and observational check lists adopted and modified from dif-
ferent literatures.
30–32
The questionnaire includes sociode-
mographic variables and individual factors (eight questions),
knowledge (12 questions), attitude (10 questions), and hand-
washing practice (eight questions), residence of the stu-
dents, maternal and paternal educational status, occupation
of the mother and father, and critical times of handwashing
and its importance. The observation checklist included a list
of important handwashing elements during data collection.
An observational checklist had been used to evaluate the
handwashing practice of students. To evaluate the hand-
washing practice of students, eight closed-ended questions
with the options “yes”or “no”and questions with another
alternative were used. Handwashing practice had been
assessed using two criteria: handwashing with soap and
water after using toilets and handwashing with soap and
water before meals. Each factor is measured on a 5-point
frequency scale, with 1 5always and 5 5never. The five-
frequency table was dichotomized. Students who answered
1(always)to2(very often) were categorized as washers
(scale 1), and those who answered 3 (often)to5(never) were
classified as nonwashers (scale 0). The dichotomized items
have been added up to produce an aggregate index point.
Students who answered 1 (always)to2(very often) for both
factors were assigned to the appropriate handwashing group.
Twelve questions were used to assess students’knowl-
edge regarding handwashing practice. The questions mostly
involve students’personal cleanliness, the transmission of
hygiene-related diseases, waste segregation, the proper use
of latrines, and contaminated materials. Each successful
answer received 1 point, and incorrect responses or unsolved
questions received 0 points. The answers to these questions
were then summed together to obtain a knowledge score
ranging from 0 to 12.
Ten questions were used to assess student’s attitude
toward handwashing. The 5-point Likert scale measure was
used for assessing attitudes toward handwashing based on
factors relating to beliefs about handwashing with soap
(e.g., washing hands just with water and soap is as good
as washing hands with water only). Likert scale responses
(1 5strongly disagree,25disagree,35neutral,45agree,
and 5 5strongly agree). The score for attitude varied from
1 to 50. The scale was dichotomized, with 1 5firmly dis-
agreeing and 5 5strongly agreeing. The cumulative score
was created by adding up the dichotomized items. Students
who answered 1 (strongly disagree)to3(neutral) for all ques-
tions were classified as having a negative attitude toward
handwashing practice, whereas those who scored 4 (agree)
and 5 (strongly agree) for all criteria were classified as having
a positive attitude toward handwashing practice.
Reinforcing factors were assessed using four important
referents (parents, friends, teachers, and health profes-
sionals) based on a 5-point frequency scale (1 5always to
55never). The 5-point frequency scale was dichotomized,
whereby those who scored 1 (always)or2(very often) were
classified as perceiving high pressure from important refer-
ents (score 0), and those who scored 3 (often) to 5 (never)
were classified as perceiving less pressure from important
referents (score 1).
Predisposing factors were measured as a composite
score for those students who answered yes to at least eight
of 11 questions asking about such things as “human feces
and urine contain germs”;“clean objects are not free from
germs”; and “germs can be acquired when desks, doors,
books, and animals are touched.”Failure to handwash,
transmitting infectious disease, and washing your hands
with soap are important before feeding or eating.
Furthermore, enabling factors were assessed as a com-
posite score for those students who answered seven of
10 questions requesting information about the presence and
place of handwashing stations, the presence of a water sup-
ply within the washing installation, the presence of soap for
handwashing, the ratio of toilets to male and female stu-
dents, the presence of only water for handwashing at home,
and the school handwashing facility.
Data quality assurance. The questionnaire was trans-
lated from English into the district’s local language (Amharic)
and then back to English to check for consistency. Data
quality was ensured throughout the collection, coding, entry,
and analysis processes. The data collectors and the supervi-
sor were trained. A pretest was performed before collecting
data to ensure the instrument’s validity. During the collection
of the data, one bachelor’s-level nurse supervisor and six
experienced nurse data collectors were hired, and sufficient
instruction and follow-up were provided. During the data col-
lection, the questionnaires were coded so that errors could
be addressed as soon as possible. The data collectors,
supervisor, and primary investigator reviewed the completed
questionnaires daily for completeness and consistency. The
data were cleansed further by visualizing and computing
rates with the SPSS version 26 statistical software (IBM Cor-
poration, Armonk, NY). Corrections were made according to
the original data. The supervisor, along with the principal
investigator, checked for the completeness of the collected
questionnaires daily during the data collection period.
Data management, processing, and analysis. The col-
lected data had been checked for completeness and consis-
tency before being entered into Epi-Data version 4.6. For
further analysis, it was transferred to SPSS version 26.0
software. In multivariable logistic regression analysis, factors
that were statistically significant in univariable analysis, bio-
logically plausible variables, and those pertinent to the
study’s primary objectives were included. The results were
presented in the form of charts and written content, with
descriptive statistics such as mean, standard deviation,
and proportion used to characterize the study population
in relation to the key variables. Internal consistency
ENGDAW AND OTHERS828
(reliability) for the independent variable (Cronbach’s alpha
values) was acceptable for both adopted and modified ques-
tions. Cronbach’s alpha scores for handwashing knowledge
and attitude were 0.87 and 0.77, respectively. Although we
calculated the reliability of the dependent variable, the hand-
washing practice of the students, we found an adequate
value (Cronbach’s alpha 50.91). The independent variables
associated with handwashing practice were investigated
using multivariable logistic regression analysis. The degree
of association between the independent factors and the
dependent variable was determined using an odds ratio (OR)
with a 95% CI. In the bivariable logistic regression analysis,
the final regression model included all variables with a
P-value ,0.25. In multivariable logistic regression analysis,
variables with P-value ,0.05 were used to identify a statisti-
cally significant association. The Hosmer–Lemeshow test
was used to assess the final model’s quality of fit. The out-
come explains a good fit(P50.93).
33
Ethical consideration. Ethical clearance was obtained
from the University of Gondar College of Medicine and
Health Sciences Institute of Public Health Ethical Review
Committee on April 14, 2022 (ref. no. IPH/2119/2022). A
support letter was obtained from the Department of Environ-
mental and Occupational Health and Safety, school adminis-
trators, and the East Dembiya District Education Office.
Volunteers were properly informed about the study’s goals,
procedures, benefits, and risks, as well as their right to dis-
continue or decline participation through an information
sheet. Finally, participants’parents or guardians signed a
written informed consent form. Parents who agreed that
they would allow their children to engage in this study signed
an informed consent form. The participants who acknowl-
edged their engagement in the study were then requested to
complete an informed consent document. All actions were
conducted in accordance with the 2019 Revised Declaration
of Helsinki and the Ethical Criteria for the Use of Human
Subjects in Research.
34
RESULTS
Sociodemographic characteristics of students. A total
of 752 students participated, with a response rate of 97.8%.
Four hundred thirty-four (57.7%) of the students were female,
and 163 (21.6%) were urban dwellers. One hundred seventy-
four (23.1%), 219 (29.1%), 122 (16.2%), and 238 (31.6%) were
from grades 5, 6, 7, and 8, respectively. The mean age of the
students was 14. 54 61.74years, which ranges from 12 to
20 years (Table 2).
The majority of secondary school students, 610 (81.2%)
and 609 (81%), were aware that human feces contain germs
that can cause disease and that germs can be acquired
when desks, doors, books, and animals are touched. How-
ever, the majority 552 (73.5%) of them knew water was only
enough for handwashing. Second-cycle primary school stu-
dents have good knowledge about handwashing practices,
and 532 (70.7%) had a positive attitude about handwashing
practices (Table 3).
The radio informs the majority of 499 (66.3%) second-
cycle primary school students about handwashing. Teachers
put pressure on 409 (54.3%) of the students who partici-
pated to wash their hands. All schools claimed to celebrate
Handwashing Day, but among the participating children,
only 26% of the students had celebrated it (Table 4).
There were 35 toilets in the inspected classroom. The
latrine-to-student ratios were 1:89 and 1:74 for male and
female students, respectively. Of these restrooms, 24 (68.6%)
had a handwashing station outside the latrine chambers. At
the time of inspection, the majority of the second-cycle pri-
mary school latrines had water without soap or other saniti-
zers. In terms of sanitation facilities, only three schools met
the requirements for a medium-hygiene facility, but none met
the criteria for a best-standard facility (Table 5).
Handwashing practice and predictors among second-
cycle primary school students. In this study, the preva-
lence of washing practices among second-cycle primary
students was 57.6% (95% CI 53.90–61.10). A bivariable
and multivariable logistic regression analysis was con-
ducted to determine the factors associated with handwash-
ing practice. On bivariable analysis, residence, access to
media, hygiene and sanitation club membership, knowledge
on handwashing, training, the presence of a handwashing
facility, and attitude toward handwashing were found to be
significantly associated, with a P-value ,0.25 and were can-
didates for multivariable logistic regression.
In multivariable logistic regression analysis, residency (adjusted
OR [aOR] 52.17, 95% CI: 1.30–2.87), access to media
(aOR 51.66, 95% CI: 1.11–2.49), hygiene and sanitation
club membership (aOR 51.88, 95% CI: 1.26–2.80),
TABLE 2
The distribution of sociodemographic characteristics of the
second-cycle primary school students (N5752)
Sociodemographic Characteristics n%
Sex
Male 318 42.3
Female 434 57.7
Age
11–14 335 44.5
.14 417 55.5
Students’grade
5 206 27.4
6 204 27.1
7 162 21.5
8 180 24
Residence
Urban 163 21.6
Rural 589 78.4
Maternal educational status
Unable to read 310 41.2
Read and write 266 35.4
Primary school 138 18.4
Secondary school 22 2.9
College and above 16 2.1
Fathers’educational status
Unable to read 317 42.2
Read and write 236 31.4
Primary school 122 16.2
Secondary school 37 4.9
College and above 40 5.3
Maternal occupational status
Housewife 530 70.5
Merchant 136 18
Government employee 28 3.7
Shopkeepers 58 7.7
Fathers’occupational status
Farmer 457 60.8
Merchant 210 27.9
Government employee 62 8.2
Daily laborers 23 3
PREDICTORS OF HAND WASHING PRACTICE 829
knowledge (aOR 53.93, 95% CI: 2.34–6.60), and attitude
toward handwashing (aOR 53.63, 95% CI: 2.01–5.584)
became significant predictors for handwashing practice among
second-cycle primary school students (Table 6).
DISCUSSION
Good handwashing practice in primary school is essential
for the prevention of WASH-related diseases, and it is a
priority issue to protect the health of the community. School-
children are particularly vulnerable to neglecting basic per-
sonal hygiene. This study was designed to assess handwashing
practice among second-cycle primary school students. The
overall good handwashing practices were found to be 57.6%
in this study. This finding is consistent with a previous study
conducted in northern Ethiopia.
8
However, the findings of this
study were lower than those of Nigeria
35
and Chitungwiza,
Zimbabwe.
36
Although the finding is higher than the
studies conducted in eastern Ethiopia;
27
Mareko,
7
Damot,
37
Arbaminch,
18
Ethiopia; rural India
38
; and Indonesia.
39
The
difference in study setting (town), only grade 7 students
attending school, age difference (ranked from 10–17 years),
adaptation of the Predisposing, Reinforcing, and Enabling
Constructs in Ecological Diagnosis and Evaluation and Policy,
Regulatory and Organizational Constructs and Education and
Environmental Development (PRECEDE–PROCEED) model
of behavior determinants, and the mixed method approach
were used; the difference in sample size calculation (Dobson’s
formula was used for the sample size) in Zimbabwe were the
reasons for this discrepancy. Although there is variation in the
kinds of institutions included in the study in Nigeria (private
and public), only descriptive studies were used, and the stu-
dents included in the study varied in age from 6 to 14years.
Other possible reasons could be differences in sociodemo-
graphic characteristics, knowledge and attitude toward
handwashing, availability of handwashing facilities, sample
size, tool used for assessing handwashing practice, and the
techniques of assessment. Existing handwashing promotion
programs in different settings can lead to different levels of
practice as well.
In the current study, residency was directly associated
with the handwashing practices of second-cycle primary
students from the district. Students who were urban dwellers
were twice as likely to practice proper handwashing as
rural students (aOR 52.17, 95% CI 1.30–2.87). This is con-
sistent with a study conducted in Ethiopia
40
; Damot Woide,
Ethiopia
37
; London
41
; eastern Ethiopia
27
; and Colombia.
30
However, it is in contrast to a study from Mareko,
7
Damot,
37
and Arbaminch, Ethiopia.
18
This may be due to the high
degree of acceptance of national handwashing initiatives
(handwashing day) by urban secondary cycle primary school
students, and additional interventions by health extension
workers may boost students’frequency and compliance
with handwashing practice in urban compared with rural res-
idencies. Urban education may expose students to various
health-extension packages through a variety of behavioral
change and communication approaches. Services such as
WASH and utilities present a challenge in rural areas, with
many residents struggling to access the services they need
at an affordable rate. Even water, a basic necessity for
human life, may not be provided or treated by a utility
TABLE 3
Predisposing factors for second cycle primary school student’s
handwashing practice in East Dembiya District, 2022
Characteristics n%
Human’s feces contain germs Yes 610 81.2
No 142 18.8
All clean objects are not free from germs Yes 181 24
No 571 76
Human urine contains germs Yes 533 71
No 219 29
Germs can be acquired when desks,
door, books, and animals are touched
Yes 609 81
No 143 19
Poor handwashing causes disease Yes 541 72
No 211 28
Water is enough for handwashing Yes 552 73.5
No 200 26.5
Handwashing with soap is necessary
after coughing or sneezing
Yes 578 76.9
No 174 23.1
Failure to wash hands transmits
infectious disease
Yes 447 59.5
No 305 40.5
If you wash your hands really well with
water, you don’t need to use soap
Yes 601 79.9
No 151 20.1
You only need to wash your hands with
soap if they look dirty or smell bad
Yes 624 83
No 128 17
Washing your hands with soap is
important before feeding or eating
Yes 610 81.2
No 142 18.8
Knowledge Good 542 72
Poor 210 28
Attitude Positive 532 70.7
TABLE 4
Reinforcing factors for second-cycle primary school student’s
handwashing practice in East Dembiya District, 2022
Reinforcing Factors n%
Sources of information about handwashing
Television 90 11.9
Radio 499 66.3
Leaflets 9 1.1
Newspaper 154 20.7
Handwashing practice referents
Parents 191 25.3
Teachers 409 54.3
Health professionals 91 12.3
Friends 61 8.1
Pressure from parents
High 191 25.3
Low 561 74.7
Pressure from friends
High 61 8.1
Low 691 91.9
Pressure from teachers
High 409 54.3
Low 343 45.7
Pressure from health professionals
High 91 12.3
Low 661 87.7
Important referent pressure
High pressurized 409 54.3
Less pressurized 343 45.7
The presence of a hygiene and sanitation
club in the school
Yes 446 59.4
No 306 40.6
The school celebrates Handwashing Day
Yes 200 26
No 552 74
If yes, have you ever participated?
Yes 200 26
No 552 74
ENGDAW AND OTHERS830
company in rural areas; this leaves students to rely on well
water, which can be unsafe to use for personal cleanliness
and drinking without some kind of softener or filter. However,
low levels of hand hygiene practices in rural regions may
also be explained by a lack of knowledge and skills about crit-
ical handwashing times and the proper handwashing tech-
nique. Additionally, because of their family’s hard labor, poor
educational status, and outdoor activities, rural students and
their households may not have access to handwashing facili-
ties or the time to perform effective handwashing because
they perceive it to be time-consuming. Additionally, due to its
price, soap is not always accessible in rural areas.
42,43
Students who had access to media were 1.7 times more
likely to have good handwashing practice compared with
their counterparts (aOR 51.66, 95% CI: 1.11–2.49). This is
supported by the study in northern Ethiopia.
8
However, it is
in contrast to the studies in Bogota, Colombia
30
; Damot
Woide
37
; India
44
; Ghana
45
; Arbaminch
18
; London
41
; and
Mareko District, Ethiopia.
7
The variations could be due to
differences in geographic area, parents’educational and
occupational status, and living standards. Media (films, per-
formances, dramas, and plays) are familiar to students and
help gain and maintain their attention to and interest in the
theories and concepts under discussion. Students can see
the theories and concepts in action. In more than a figurative
sense, theories and concepts leap from the screen, and stu-
dents can hone their analytical skills by analyzing media using
the theories and concepts that they are studying. Another
possible reason may be that media play a considerable role in
establishing and improving behavioral changes among socie-
ties, and particularly in students’behaviors. Radio broadcasts
provide real-time information for rural areas, and some that
broadcast 24 hours a day can provide the most recent
updates to listeners about health and health-related issues
(handwashing). Radio has the ability to reach across borders
andcanbecomeavaluablesourceofinformationwherereli-
able health-related information and news are scarce.
Membership in the school hygiene and sanitation club was
directly associated with handwashing practices in the current
study. The odds of performing good handwashing practices
among second-cycle primary students who were members of
the school hygiene and sanitation club were twice as likely to
have good handwashing practices (aOR 51.88, 95% CI:
1.26–2.80). This study is consistent with studies conducted in
eastern Ethiopia,
27
northern Ethiopia,
8
and India.
44
However,
this is not comparable to the studies in Mareko,
7
Damot
Woide,
37
Colombia,
30
Ghana,
45
Arbaminch,
18
Nigeria,
35
TABLE 5
Enabling factors for second cycle primary school student’s
handwashing practice in East Dembiya District, 2022
Characteristics n%
Presence of handwashing station
Present 24 68.6
Absent 11 31.4
Location of handwashing station
Outside latrine room 24 100
Presence of water supply within washing
installation
Yes 24 100
Presence of soap for handwashing
No 24 100
Ratio of toilet to male students
Below standard 5 100
Ratio of toilet to female students
Below standard 5 100
Presence only of water for handwashing
at home
Yes 177 23.5
No 575 76.5
Presence of soap and water for
handwashing at home
Yes 163 21.6
No 589 78.4
School handwashing facility
Medium 3 33.33
Low 5 66.67
TABLE 6
Factors associated with handwashing practice among second cycle primary school students in East Dembiya District, (N5752)
Characteristics
Handwashing practice
cOR (95% CI) aOR (95% CI)Good Poor
Residency
Urban 121 42 3.22 (1.45–5.06)* 2.17 (1.30–2.87)
‡
Rural 278 311 1 1
Access to media
Yes 221 101 2.25 (1.66–3.04)* 1.66 (1.11–2.49)*
No 212 218 1 1
Hygiene and sanitation club membership
Yes 255 128 2.13 (1.59–2.87)
†
1.88 (1.26–2.80)
†
No 178 191 1 1
Knowledge
Good 376 166 6.08 (4.26–8.66)
‡
3.93 (2.34–6.60)
‡
Poor 57 153 1 1
Training
Yes 240 109 2.39 (1.77–3.23)
†
1.14 (0.76,1.72)
No 193 210 1 1
Presence of handwashing facility
Yes 117 60 3.60 (2.52–5.13)* 1.08 (0.62,1.86)
No 202 373 1 1
Attitude toward handwashing
Positive 376 156 6.89 (4.83–9.827)
†
3.63 (2.01–5.584)
†
Negative 57 163 1 1
aOR 5adjustedodds ratio; cOR 5crudeodds ratio. 1 5reference gro up.
Significantat *P,0.01;
†
P,0.02;
‡
P,0.001.
PREDICTORS OF HAND WASHING PRACTICE 831
Zimbabwe,
36
and the Amhara region.
46
This may be because
students in the WASH club got useful training and more fre-
quent exposure to the material through the club to improve
hygiene practices in general and handwashing practices in
particular as members of the club. The School Health Club
promotes and maintains behavioral change with regard to
good hygiene practices and the appropriate use and mainte-
nance of sanitation facilities in schools. Another possible rea-
son could be differences in sociodemographic characteris-
tics, students’knowledge and attitude toward handwashing,
the availability of handwashing facilities in the school and
home, the difference in sample size, the tool used to assess
handwashing practice, and the assessment techniques. The
other variation could be due to difference in study popula-
tions and settings between Nigeria and Zimbabwe.
In the present study, knowledge was significantly associ-
ated with the handwashing practices of second-cycle pri-
mary school students. Students who had good knowledge
of handwashing were 4 times more likely to have good hand-
washing practices compared with their counterparts (aOR 5
3.93, 95% CI: 2.34–6.60). This is in line with previous studies
in Mereb-Leke District, northern Ethiopia
8
; southern India
31
,
Chitungwiza, Zimbabwe
36
; Sodo-Zuria District, southern
Ethiopia
47
; and Nigeria.
35
However, in other studies, knowl-
edge was not associated with hand hygiene practice in east-
ern Ethiopia
27
; Indonesia
39
; Nigeria
35
; Arbaminch
18
; Bogota,
Colombia
30
; and India.
44
The variations may be due to differ-
ence in parents’educational and occupational status, health
care promotion services, living standards, and access to
media. Although knowledge plays a determinant role in
hygiene practices in general and handwashing practices in
particular,
31
surface-level knowledge does not lead to desirable
behavioral change that elicits better practice.
48
Another varia-
tion might be attributed to differences in awareness creation,
scale of classification, and the number of enrolled subjects.
49
Attitude was directly associated with the handwashing
practice of second-cycle primary students in the current
study. Students who had a positive attitude toward hand-
washing were 3.6 times more likely to have good handwash-
ing practice compared with their counterparts (aOR 53.63,
95% CI (2.01–5.584). This is supported by the studies con-
ducted in Hosanna town,
50
Colombia,
30
southern Ethiopia,
47
Indonesia,
39
nine African countries,
51
and Arbaminch.
18
How-
ever, the attitude was not associated with handwashing
practice in southern India,
31
northern Ethiopia,
8
Indonesia,
39
Nigeria,
35
Chitungwiza,
36
and eastern Ethiopia.
27
The varia-
tions may be due to the differences in the sociodemographic
status of the students, their parents’educational status, and
their access to media and study areas. There may be differ-
ences in sociodemographic characteristics, hygiene prac-
tices, and health-related characteristics. Although those with
a positive attitude are thought to have good knowledge,
which is the underpinning of skill or practice.
43
Access to handwashing facilities (a reliable water supply,
affordable soap or an alcohol-based rub, a sink or similar
receptacle that can be safely emptied, and information on
effective handwashing techniques) was an essential tool in
preventing and mitigating communicable disease through
handwashing.
52
In this study, the presence of handwashing
facility was not associated with the washing practices of
second-cycle primary school students. This result is sup-
ported by Arbaminch,
18
Nigeria,
35
Indonesia
39
but is in
contrast to a study conducted in eastern Ethiopia.
27
This
may be attributed to variations in the sociodemographic
characteristics of the study population, sample size, study
area, and settings. Another possible reason may be that the
presence of necessary facilities for handwashing may help
students practice handwashing easily.
All the factors that make it possible (or easier) for indivi-
duals or populations to change their behavior or their envi-
ronment (resources, conditions of living, societal supports,
and skills that facilitate a behavior’s occurrence, antece-
dents to behavior that provide the rationale or motivation for
the behavior, and factors after a behavior that provide con-
tinuing reward or incentive for the persistence or repetition
of the behavior need to be present simultaneously to make
handwashing practice possible and sustained.
CONCLUSION
This study showed that handwashing practice among
second-cycle primary students was low. The level of prac-
tice was determined by residency, knowledge of handwash-
ing, attitude toward handwashing, membership in the school
hygiene and sanitation club, and access to media. Availing
handwashing facilities, better media access, formation of a
hygiene and sanitation club in the school, celebration of Hand-
washing Day with students, and leading behavior change com-
munication are all important for improving the handwashing
practice of second-cycle primary school students.
Limitations. Because of the nature of its cross-sectional
design, this study may not show a cause-and-effect relation-
ship. Furthermore, because the findings were based on the
research subjects’self-reported responses, there could be
respondent and social desirability bias (i.e., overreporting of
appropriate handwashing practice). Thus, the findings of this
study may not be applicable to students in other cultural set-
tings. Furthermore, because of financial limitations, the study
could not include private schools. As a result, the findings
cannot be generalized to all schools in the study area.
Received April 3, 2023. Accepted for publication December 4, 2023.
Published online March 12, 2024.
Note: Supplemental material appears at www.ajtmh.org.
Acknowledgments: We thank the data collectors, supervisors, schools,
and students who participated in the study and the local health authori-
ties for their cooperation. The American Society of Tropical Medicine
and Hygiene (ASTMH) assisted with publication expenses.
Authors’contributions: The study was conceptualized and designed
by G. T. Engdaw and D. Alemu. The data collection tool was modified
by G. T. Engdaw and D. Alemu. G. T. Engdaw was in charge of the
statistical analysis and interpretation of the findings, as well as writ-
ing the original draft of the manuscript. G. T. Engdaw and A. H Tes-
faye edited the manuscript. The final version of this work was read
and approved by all authors.
Data availability: All the data supporting our results is shown in the
manuscript. The datasets used and/or analyzed in the current study
are available from the corresponding author upon legitimate request.
Authors’addresses: Garedew Tadege Engdaw, Mekuriaw Ale-
mayehu, and Amensisa Hailu Tesfaye, Department of Environmental
and Occupational Health and Safety, Institute of Public Health, Col-
lege of Medicine and Health Sciences, University of Gondar, Ethio-
pia, E-mails: garedewtadi27@gmail.com, mekuriaw04@gmail.com,
and amensisahailu@gmail.com. Desalegn Alemu, East Belesa
Woreda Health Department Offices, Northwest, Ethiopia, E-mail:
desalegnalemu4444@gmail.com.
ENGDAW AND OTHERS832
REFERENCES
1. Khoury MJ et al., 2009. The scientific foundation for personal
genomics: recommendations from a National Institutes of
Health–Centers for Disease Control and Prevention multidisci-
plinary workshop. Genet Med 11: 559–567.
2. Ryan MA, Christian RS, Wohlrabe J, 2001. Handwashing and
respiratory illness among young adults in military training. Am
J Prev Med 21: 79–83.
3. Vessey JA, Sherwood JJ, Warner D, Clark D, 2007. Comparing
hand washing to hand sanitizers in reducing elementary
school students’absenteeism. Pediatric Nurs 33: 368–372.
4. Richards CL, Iademarco MF, Atkinson D, Pinner RW, Yoon P,
Mac Kenzie WR, Lee B, Qualters JR, Frieden TR, 2017.
Advances in public health surveillance and information dis-
semination at the Centers for Disease Control and Prevention.
Public Health Rep 132: 403–410.
5. Okyay P, Ertug S, Gultekin B, Onen O, Beser E, 2004. Intestinal
parasites prevalence and related factors in school children, a
western city sample—Turkey. BMC Public Health 4: 1–6.
6. Andrasfay T, Wu Q, Lee H, Crimmins EM, 2022. Adherence to
social-distancing and personal hygiene behavior guidelines
and risk of COVID-19 diagnosis: evidence from the Under-
standing America Study. Am J Public Health 112: 169–178.
7. Shehmolo M, Gari T, Jember Tesfaye D, Boti N, Oumer B, 2021.
Magnitude and factors associated with hygiene practice among
primary school children in Mareko district, southern Ethiopia: a
cross-sectional study. J Multidiscip Healthc 14: 311–320.
8. Assefa M, Kumie A, 2014. Assessment of factors influencing
hygiene behaviour among school children in Mereb-Leke Dis-
trict, northern Ethiopia: a cross-sectional study. Am J Public
Health 14: 1000.
9. Health Protection Agency, 2005. Health Protection in the 21st
Century—Understanding the Burden of Disease; Preparing
for the Future. London, United Kingdom: Health Protection
Agency. Available at: https://assets.publishing.service.gov.uk/
government/uploads/system/uploads/attachment_data/file/
294762/06-761-infectious-diseases-futures.pdf. Accessed
February 15, 2024.
10. Mathers CD, 2020. History of global burden of disease assess-
ment at the World Health Organization. Arch Public Health 78:
1–13.
11. Murray CJ, Lopez AD, Mathers CD, Stein C, 2001. The Global
Burden of Disease 2000 Project: Aims, Methods and Data
Sources. Geneva: World health organization.
12. Scott B, Curtis V, Rabie T, Garbrah-Aidoo N, 2007. Health in our
hands, but not in our heads: understanding hygiene motiva-
tion in Ghana. Health Policy Plan 22: 225–233.
13. Rabie T, Curtis V, 2006. Handwashing and risk of respiratory
infections: a quantitative systematic review. Trop Med Int
Health 11: 258–267.
14. Trinies V, Garn JV, Chang HH, Freeman MC, 2016. The impact
of a school-based water, sanitation, and hygiene program on
absenteeism, diarrhea, and respiratory infection: a matched–
control trial in Mali. Am J Trop Med Hyg 94: 1418–1425.
15. Saba D, Ercan A, S¸enkaya I, Gebitekin C, Hayati
€
O, 2001. K€
unt
arkus aorta yaralanmasıiki olgu sunumu [Blunt injury of the
aortic arch: report of two cases]. Turkish J Thorac Cardiovasc
Surg 7:201–203.
16. Eshetu D, Kifle T, Hirigo AT, 2020. Knowledge, attitudes, and
practices of hand washing among Aderash primary schoolchil-
dren in Yirgalem Town, southern Ethiopia. JMultidiscip
Healthc 13: 759–768.
17. Admasie A, Guluma A, Feleke FW, 2022. Handwashing practices
and its predictors among primary school children in Damote
Woide District, south Ethiopia. An institution based cross-
sectional study. EnvironHealthInsights16:11786302221086795.
18. Besha B et al., 2016. Assessment of hand washing practice and
its associated factors among first cycle primary school chil-
dren in Arba Minch Town, Ethiopia, 2015. Epidemiology (Sun-
nyvale) 6: 1–10.
19. Melaku A, Addis TJ, 2023. Handwashing practices and associ-
ated factors among school children in Kirkos and Akaki Kality
sub-cities, Addis Ababa, Ethiopia. Environ Health Insights 17:
11786302231156299.
20. Delea MG, Snyder JS, Belew M, Caruso BA, Garn JV, Sclar GD,
Woreta M, Zewudie K, Gebremariam A, Freeman MC, 2019.
Design of a parallel cluster-randomized trial assessing the
impact of a demand-side sanitation and hygiene intervention
on sustained behavior change and mental well-being in rural
and peri-urban Amhara, Ethiopia: Andilaye study protocol.
BMC Public Health 19: 801.
21. Baxter A, Cleary V, 2002. Hand hygiene in local primary school
children—an infection control and health promotion initiative.
Br J Infect Control 3: 14–17.
22. Rabie T, Curtis VJ, 2006. Handwashing and risk of respiratory
infections: a quantitative systematic review. Trop Med Int
Health 11: 258–267.
23. Kumar S, Loughnan L, Luyendijk R, Hernandez O, Weinger M,
Arnold F, Ram PK, 2017. Handwashing in 51 countries: analy-
sis of proxy measures of handwashing behavior in multiple
indicator cluster surveys and demographic and health surveys,
2010–2013. Am J Trop Med Hyg 97: 447–459.
24. Notoatmodjo S, 2012. Promosi kesehatan dan perilaku kesehatan.
Jakarta: Rineka Cipta. https://doi.org/10.1017/CBO978110741
5324.004
25. Tarekegn M, Tekie H, Dugassa S, Wolde-Hawariat Y, 2021.
Malaria prevalence and associated risk factors in Dembiya
district, north-western Ethiopia. Malar J 20: 1–11.
26. Zamkov O, Avtonomov V, Doroshenko M, 2011. Ethiopia-Tana
and Beles Integrated Water Resources Development Project:
Procurement Plan. Washington, DC: World Bank Group.
27. Berhanu A, Mengistu DA, Temesgen LM, Mulat S,Dirirsa G, Alemu
FK, Mangasha AE, Gobena T, Geremew A, 2022. Hand washing
practice among public primary school children and associated
factors in Harar town, eastern Ethiopia: an institution-based
cross-sectional study. Front Public Health 10: 975507.
28. Assefa M, Kumie A, 2014. Assessment of factors influencing
hygiene behaviour among school children in Mereb-Leke Dis-
trict, Northern Ethiopia: a cross-sectional study. BMC Public
Health 14: 1–8.
29. Berhe AA, Aregay AD, Abreha AA, Aregay AB, Gebretsadik AW,
Negash DZ, Gebreegziabher EG, Demoz KG, Fenta KA, Mamo
NB, 2020. Knowledge, attitude, and practices on water, sanita-
tion, and hygiene among rural residents in Tigray Region, north-
ern Ethiopia. J Environ Public Health 2020: 5460168.
30. Lopez-Quintero C, Freeman P, Neumark Y, 2009. Hand washing
among school children in Bogota, Colombia. Am J Public
Health 99: 94–101.
31. Shrestha A, Mubashir BA, 2015. Improving hand washing
among school children: an educational intervention in south
India. Al Ameen J Med Sci 8: 81–85.
32. Dagne H, Bogale L, Borcha M, Tesfaye A, Dagnew B, 2019.
Hand washing practice at critical times and its associated fac-
tors among mothers of under five children in Debark town,
northwest Ethiopia, 2018. Ital J Pediatr 45: 120.
33. Hosmer DW, Lemesbow S, 1980. Goodness of fittestsforthe
multiple logistic regression model. Commun Stat Theory
Methods 9: 1043–1069.
34. Shrestha B, Dunn LJ, 2019. The Declaration of Helsinki on medi-
cal research involving human subjects: a review of seventh
revision. J Nepal Health Res Counc 17: 548–552.
35. Oyibo PJ, 2012. Basic personal hygiene: knowledge and prac-
tices among school children aged 6–14 years in Abraka, Delta
State, Nigeria. Cont J Trop Med 6: 5–11.
36. Dube B, January J, 2012. Factors leading to poor water sanita-
tion hygiene among primary school going children in Chitun-
gwiza. J Public Health Africa 31: e7.
37. Admasie A, Guluma A, Debebe A, 2020. Hand washing practice
and associated factors among primary school children in Damot
Woide Woreda of Wolaita Zone, south Ethiopia: a cross-sectional
study. Environ Health Insights 16: 1178630222 1086795.
38. Dobe M, Mandal RN, Jha A, 2013. Social determinants of good
hand-washing practice (GHP) among adolescents in a rural
Indian community. Fam Community Health 36: 172–177.
39. Nazliansyah N, Wichaikull S, Wetasin K, 2016. Factors affecting
hand washing practice among elementary schools students in
Indonesia. Belitung Nurs J 2: 58–64.
40. Kumie A, Ali A, 2005. An overview of environmental health status
in Ethiopia with particular emphasis to its organization,
PREDICTORS OF HAND WASHING PRACTICE 833
drinking water and sanitation: a literature survey. Ethiopian J
Health Dev 19: 89–103.
41. Baxter A, Cleary V, 2002. Hand hygiene in local primary school
children—an infection control and health promotion initiative.
J Infect Prev 3: 14–17.
42. Gizaw Z, Yalew AW, Bitew BD, Lee J, Bisesi M, 2022. Effects of
local handwashing agents on microbial contamination of the
hands in a rural setting in northwest Ethiopia: a cluster rando-
mised controlled trial. BMJ Open 12: e056411.
43. Moe CL, Rheingans RD, 2006. Global challenges in water, sani-
tation and health. J Water Health 4: 41–57.
44. Sarkar M, 2013. Personal hygiene among primary school children
living in a slum of Kolkata, India. J Prev Med Hyg 54: 153.
45. Scott B, Curtis V, Rabie T, Garbrah-Aidoo N, 2007. Health in our
hands, but not in our heads: understanding hygiene motiva-
tion in Ghana. Health Policy Plan 22: 225–233.
46. Yizengaw H, Ebrahi H, Wassihun Y, Bazie GW, 2022. Hygiene
behavior and its influencing factors among primary school
children in Delanta District, north east Ethiopia [preprint].
https://doi.org/10.21203/rs.3.rs-1337773/v1
47. Haile D, Wolde J, Yohannes DJSOM, 2022. Determinants of
practice of birth preparedness and complication readiness
among pregnant women in Sodo Zuria District, southern Ethi-
opia: content analysis using Poisson’s regression. Sage Open
Med 10: 20503121221079479.
48. Vivas AP, Gelaye B, Aboset N, Kumie A, Berhane Y, Williams
MA, 2010. Knowledge, attitudes and practices (KAP) of
hygiene among school children in Angolela, Ethiopia. JPrev
Med Hyg 51: 73–79.
49. Eshetu D, Kifle T, Hirigo AT, 2020. Knowledge, attitudes, and
practices of hand washing among Aderash primary schoolchil-
dren in Yirgalem Town, southern Ethiopia. JMultidiscip
Healthc 13: 759–768.
50. Buda AS, Mekengo DE, Lodebo TM, Sadore AA, Mekonnen B,
2018. Knowledge, attitude and practice on hand washing and
associated factors among public primary schools children in
Hosanna town. Southern Ethiopia. 10: 205–214.
51. Pengpid S, Peltzer K, 2011. Hygiene behaviour and associated
factors among in-school adolescents in nine African countries.
Int J Behav Med 18: 150–159.
52. Bartram J, Sims J, Chartier Y, 2009. Water, Sanitation and
Hygiene Standards for Schools in Low-Cost Settings.Geneva,
Switzerland: World Health Organization.
ENGDAW AND OTHERS834
CopyrightofAmericanJournalofTropicalMedicine&HygieneisthepropertyofAmerican
SocietyofTropicalMedicine&Hygieneanditscontentmaynotbecopiedoremailedto
multiplesitesorpostedtoalistservwithoutthecopyrightholder'sexpresswrittenpermission.
However,usersmayprint,download,oremailarticlesforindividualuse.
