Hygiene Behavior and Its In uencing Factors among Primary School Children in Delanta District, North East Ethiopia


 Background: Poor hygiene behaviours create a serious public health threat to school children. One of the major problems faced by school children are infections. The primary causes of infections are associated with poor water supply, poor sanitation and poor hygiene behaviors which can lead to decreased academic performance and increased likelihood of dropout; this, in turn, prevents children from attaining the numerous economic and health benefits associated with educational attainment. Thus, the study aims to assess hygiene behaviors and influencing factors among primary school children in Delanta District, North East Ethiopia, 2020.Methods: An institution based cross-sectional study was conducted among 407 primary school students of Delanta District, from February 1to29, 2020. The participants were selected using systematic random sampling technique. Data were collected using pre-tested interviewer administered structured questionnaire. Descriptive statistics using frequency, proportion, summary measures were done. Binary and multivariate logistic regressions were also done to identify independent variables associated with hygiene behaviors among primary school children. P value less than 0.05 and adjusted odds ratio with 95% confidence interval non-inclusive of one was considered as statistically significant. Results: A total of 407 respondents were included with a response rate of 100%. The prevalence of positive hygiene behavior was 59.7 %( 95% CI 54.6%, 64.1%). Out of the total respondents 205 (50.4%) had knowledge on water handling practices whereas 236 (58%) of the respondents had knowledge on latrine utilization but 258 (63.4%) of respondents did not know the proper hand washing practices. In the multivariable logistic regressions analysis, taking training on hygiene and sanitation (AOR 2.2; 95% CI 1.3, 3.6), having awareness on hand washing practices (AOR: 1.92, 95% CI (5.5, 15.7) and having knowledgeable on latrine utilization (AOR: 1.96, 95% CI 1.02, 2.67) demonstrated a statistically significant association with the hygiene behavior. Conclusion: The overall findings revealed that the students had adequate knowledge on water handling and latrine utilization but poor knowledge on hand washing practices and a greater number of school children did not aware on water handling and hand washing practices. Therefore, focused strategies should be designed on promoting knowledge of school children on toilet use and hand washing practices.

questionnaire. Descriptive statistics using frequency, proportion, summary measures were done. Binary and multivariate logistic regressions were also done to identify independent variables associated with hygiene behaviors among primary school children. P value less than 0.05 and adjusted odds ratio with 95% con dence interval non-inclusive of one was considered as statistically signi cant.
Results: A total of 407 respondents were included with a response rate of 100%. The prevalence of positive hygiene behavior was 59.7 %( 95% CI 54.6%, 64.1%). Out of the total respondents 205 (50.4%) had knowledge on water handling practices whereas 236 (58%) of the respondents had knowledge on latrine utilization but 258 (63.4%) of respondents did not know the proper hand washing practices. In the multivariable logistic regressions analysis, taking training on hygiene and sanitation (AOR 2.2; 95% CI 1.3, 3.6), having awareness on hand washing practices (AOR: 1.92, 95% CI (5.5, 15.7) and having knowledgeable on latrine utilization (AOR: 1.96, 95% CI 1.02, 2.67) demonstrated a statistically signi cant association with the hygiene behavior.
Conclusion: The overall ndings revealed that the students had adequate knowledge on water handling and latrine utilization but poor knowledge on hand washing practices and a greater number of school children did not aware on water handling and hand washing practices. Therefore, focused strategies should be designed on promoting knowledge of school children on toilet use and hand washing practices.

Background
Poor hygiene means children are regularly ill and miss school, adults are not able to work to support their families, patients are at risk in healthcare environments, and people's dignity is compromised.
Forty percent of the world school-age children have faced worm infections. The primary causes of infection are associated with poor water supply, poor sanitation and poor hygiene behaviors which can lead to decreased academic performance and increased likelihood of dropout; this, in turn, prevents children from attaining the numerous economic and health bene ts associated with educational attainment. And approximately 5,000 children die daily from water, sanitation and hygiene related diseases (Rahman et al., 2019).
In least-developed countries, only 57% of schools had adequate drinking water facilities and 53% had adequate hygiene practices. In sub-Saharan Africa, diarrhea is the second most common cause for school children mortality which is prevented by effective and appropriate hand washing practice (Vally et al., no date;Global Handwashing Partnership, 2018).
In fact, as a result of unsafe water quality, sanitation and poor hygiene behaviors occurs that 842000 deaths annually and mostly in low income countries accounts 361000 deaths of under ve years of age children ('Study undertaken by : Technical support and guidance : Data collection and entry : Data analysis and report writing ':, 2019).
Studies have shown that the lack of adequate latrine facilities in primary schools can lead to high absenteeism and academic low performance in school children. Poor, inadequate, unhealthy latrine conditions, children are at risk for poor health, and they are unwillingness to be in school (Lopamudra Ganguly and and Satpati, 2019).
Millions of children are stunted and/or suffer from chronic illness due to lack of WASH. Half of all childhood malnutrition can be traced to WASH-related causes (Wagner and Pramling, 2019).
Each year, children lose 443 million school days because of water related illnesses, of which 272 million are lost due to diarrhea alone. More than 40 percent of diarrhea cases in school children result from transmission in schools rather than homes (Peter Barrett, Alberto Treves, Tigran Shmis, 2017).
Taking intervention measures on water, sanitation and hygiene behaviours at school level improves health of school students. Practicing safe water supply, proper hand washing and latrine utilization in schools could also prevent diarrhea and gastrointestinal diseases.
In Ethiopia, 60% of schools lack access to water and majority of the schools have traditional pit latrines which do not meet the minimum latrine standard. Moreover, the ratio of students to toilets is on average a higher than national standards. Teachers and students who are unable to wash their hands, or access clean and safe toilet facilities are exposed to health risks (Federal Democratic Republic of Ethiopia Ministry of Education, 2017).
In Ethiopia, access to WASH has not resulted in higher education attainments. A signi cant number of students drop out of school; such that only 47% of students complete grade eight. This alludes to the importance of WASH facilities to enhance students experience in schools and improve their learning environment ( Study participants, sample size determination and Sampling procedure All primary school children living in Delanta district were source population. The Sample size was calculated based on the rst speci c objective was determined by using a formula for estimating a single population proportion by assuming a con dence level of 95%, marginal error of 5%, and a 61.7% proportion of positive hygiene behavior among primary school children (Mulubrhan.Asefa(MSc), 2013).Sample size for rst objective was calculated using single population proportion formula and adding 10% non-response rate, the nal sample size was 407. Out of 37 primary schools found in the district, 10 primary schools were included in the study. The sample sizes were distributed to each School proportional to the average number of students. By assuming homogeneity between classes and grades, the participants were selected by using a systematic sampling technique after identifying an initial starting respondent by using a random method.

Data collection instrument and procedure
A standardized structured interviewer administered questionnaire was used to collect data. The questionnaire was translated to Amharic and then pre-test was done in similar primary School in Delanta district which were not included in the study, prior to the actual data collection to assess the suitability of the questionnaire with regards to duration, language appropriateness, content, validity, and question comprehensibility. Data collection was carried out by 2 clinical nurses and 3 B.Sc. environmental health professionals recruited from the health center and the health o ce. They received two days training on interview and sampling techniques by the principal investigator before three days of the actual study being done.

Data Quality management and analysis
The questionnaire was adapted from pervious literatures (Mulubrhan.Asefa(MSc), 2013).The questionnaire was translated in to Amharic version then back to English to check for the consistency. The data collectors and supervisors were trained for two days on interview and sampling techniques and common understanding was reached on the questionnaire. The instrument was Pre-tested on 5% of the sample from school with the population having similar socio-demographic characteristics that were not included in the study. During the actual data collection, data was collected by trained health professional.
The supervisors along with the principal investigator were checked for completeness of collected questionnaire on daily basis during the data collection period.
Data was entered into Epi data version 4.6.2 Software and was exported to SPSS version 24 for further analysis. Descriptive statistics was done using frequency, proportion, summary measures. Binary logistic regression model was used to identify statistically signi cant associated factors with hygiene behaviour.
First bi-variable analysis was made for each independent variable to outcome variable. Those variables with P-value less than 0.3 were imported to nal model (multivariable analysis). In multivariable logistic regression analysis, variables with P-value less than 0.05 and 95% CI didn't cross one was considered as statistically signi cant variables. The tness of the model was checked by Hosmer and Lemeshow goodness of t test

Ethical considerations
The ethical issues of this study was reviewed and approved by ethical review committee of College of Medicine and Health Sciences, Wollo University. Permission letter was obtained from South Wollo Zonal Health Department and the respective districts and schools .verbal informed consent was sought from all respondents' and teachers before the start of each interview. The right of the study participants to refuse participation or withdraw from the study at any time was respected.

Results
Socio-demographic characteristics of the respondents A total of 407 respondents were participated in the study with a response rate of 100%. The majority (60.2%) of respondents were a male while162 (39.8%) of the participants were female students. The mean age of the children was 14.9 years (±0.52 SD). Most (58.5%) and (82.3%) of the respondents were in 15-19 age group and from rural residence.100 (25.6%) of them miss the class in the past two weeks prior to data collection. 44 (44%) of the students who missed the class in the past two weeks due to diarrhea.   Discussion poor sanitation, shortage of water, low water quality and improper hygiene behaviors are the major causes of risk for health of school children who spent long hours at school compound. This study ndings discussed based on the objectives outlined in the introduction and their in uence on hygiene behavior among primary schools children.
In this study, 59.7% of school children had positive hygiene behavior which is consistent with the study done in Angolela, Ethiopia, 52.3% of the participants practiced positive hygiene behaviour (Vivas et al., 2010).The study also consistent with the study conducted among school children in Tigray region, Ethiopia 61.7% of the participants had practiced positive hygiene behavior (Mulubrhan.Asefa(MSc), 2013).This study is consistent with a study done in Kenya, the respondents reported that high knowledge, proper hygiene behavior and their institutions had appropriate WASH facilities were signi cantly less likely to report WASH related illness (Waruingi, 2015).
Knowledge make signi cant contribution to practicing positive hygiene behavior on latrines utilization 58% and hand washing practices 36.6% by the students. This nding is relatively comparable with a study done in 2016 in Oromia, Ethiopia 59% of the participants had good knowledge on hygiene behavior (Endashaw Fentaye, 2016) and a study done in Tigray Region, Ethiopia showed that there is signi cant difference on knowledge of latrine utilization 91.1% of the study participants did not know proper latrine but 71% of respondents had knowledge on hand washing practices in Tigray Region. This discrepancy might be large sample size(n=528) in Tigray study (Mulubrhan. Getting water from protected sources in primary schools is a protective factor from poor hygiene behavior among primary school students. This study revealed that almost half of the schools (50%) access water from protected sources and students who have got water from protected sources 72.3% of them more likely to practice positive hygiene behaviour than others. This nding is different the nding from a study conducted in Ginchi, Oromia, Ethiopia 96% of schools were not getting adequate water supply. This is might be mainly associated with budget difference and low awareness on the importance of the facilities (Endashaw Fentaye, 2016).
Training on water, sanitation and hygiene activities demonstrated positive in uence on the hygiene behavior of school children. This study revealed that 49.6% participants were trained on hygiene sanitation, and 64.4% of them had positive hygiene behaviors. The study nding was consistent with the study done in Tigray region 60.3% in which students who were trained on hygiene sanitation practiced positive hygiene behavior counterparts (Mulubrhan.Asefa(MSc), 2013).
This study found out that the presence of hygiene sanitation club was signi cantly associated with practicing positive hygiene behaviour among school children.
Primary school clubs (WASH) in the district promote proper utilization latrine, water handling and hand washing practices. Similarly, Schools clubs (WASH) in Malawi, promote the importance of clean water, good hygiene and improved sanitation. Club members create their own songs, dramas and games to communicate safe water and hygiene messages within their schools and communities (Water, Children and WHO, 2010). A study done in Tanzania shows that top three activities conducted by school WASH clubs were latrine cleaning, promotion of hygiene behaviour and practices through art, drama and/or poetry either in the schools 63% or in the community 40% (Antwi-agyei et al., 2017).

Strength and limitation of the study
Strength: It has never been done similar studies in the study area before. So it can serve as a resource for those who want to work on this next study. Because the study was conducted on school children who are change agents, changing hygiene behaviors of school children, can also help to change diseases burden from students' family and their community at large.
Limitation: The short coming of this study was its cross-sectional nature of the study, which is unable to correctly demonstrate the way of relationship or association. Due to nancial limitation, the study could not cover private schools. As a result, the nding is not generalized to all schools in the study area.

Conclusion And Recommendation
It is an emerged evidence from this study that the school students who had adequate knowledge or awareness on latrine utilization and hand washing practices were likelihood to practice the positive hygiene behaviors.
Knowledge and awareness on latrine utilization and hand washing practices are in uencing factors for practicing positive hygiene behaviours among primary school children.
According to the study ndings, among motivational factors trained on water, sanitation and hygiene (WASH) activities was signi cant indicator for practicing positive hygiene behaviors.
Obtaining water from protected sources and presence of hand washing facilities near to toilets were the most enabling factors that had signi cant in uence for practicing positive hygiene behavior.
From observation ndings, latrines within the school compound were poor in quality, lack cleanliness, not sex segregated, unable to ensure privacy and the hand washing facilities were not functional. Hand washing after defecation and using soap during washing their hands were under reported practices.
Unavailability of soap was the reasons for not using soap during washing hands.

Recommendation
Operational recommendation The ministry of education should develop a school curriculum with guidelines for hygiene practices. Such a curriculum, if well implemented, may result into improved hygiene behaviours which will lead to a reduction on diarrhea morbidity, respiratory infections and decrease WASH related illness dropout rates.
School directors should direct efforts towards promote knowledge or awareness of school children on latrine utilization and hand washing practices, strengthening school WASH clubs, Organizing and coordinating WASH trainings for students and teachers. They should also review availability of water from protected sources provided in the schools with an aim of improving them so that students can use the water to drink and clean their toilets after use as a sign of their proper use.
Public primary school principals in the schools under study should regard hand washing facilities with water will also be located in these toilets, then the students will be in a position to wash their hands after visiting the toilets.
School management should try and improve on privacy, type and number of toilets in their schools but give more emphasis to the number of the toilets. This will ensure that all the students access the toilets without struggle.
In addition, parents should also be included in the activities, and correct information regarding use of sanitation facilities. It is important that schools, households and communities work more closely together to change hygiene behaviour of school children. Furthermore, I am grateful to Delanta district education o ce, primary school directors and teachers for their support during data collection and giving necessary information for this thesis work.
Availability of data and materials: All data generated or analyzed during this study are included in this article. The data that support the ndings of this study are also available from the corresponding author upon reasonable request.
Ethics approval and consent to participate: Ethical clearance was obtained from the Ethical Review Committee of Wollo University Research Ethics Review Committee reviewed the ethical acceptability of the research. Those study participants who were selected to participate were informed about the purpose of the study, the importance of their participation, and their ability to withdraw at any time. Written consent was obtained prior to data collection.

Consent for publication:
Not applicable.
Competing interests: The authors declare that they have no competing interests  A diagram has shown the sampling procedures of primary schools and school children in Delanta district, North East Ethiopia.