Hand Washing Practice Before Covid-19 Pandemic and Associated Factors Among Primary School Children at Hawassa City Sidama Ethiopia

Objectives the aim of this study was to assess hand washing practice before covid-19 pandemic and associated factors among primary school children, Hawassa City, Sidama, Ethiopia Method An institution-based cross-sectional study was conducted at primary schools children in Hawassa city, Sidama Ethiopia from February to October 2019. A total of 739 students were selected using multistage sampling techniques. Information about socio demography and associated factors was collected by structured questionnaire. Result In this study, about 399 (54%) of the students wash their hands at critical times. Availability of hand washing material, availability soap/ash, availability water and pear inuence (AOR =1.75, 95% CI=1.22, 2.23), (AOR = 3.23, 95% CI =2.02, 5.15), (AOR = 1.76, 95% CI=1.07, 2.89),(AOR=0.32 95% CI=0.101,0.98) had higher odds of washing practice respectively. The magnitude of hand washing practice was low in this study before covid -19 pandemic. In this regard, Poor access to hand washing facilities need to strengthen as intervention efforts. Further, health education promotion for hand washing practice could be done in school by Hawassa city administration Education and better facilities need to avail by the


Introduction
Human hands are the chief vehicles for transmitting infections. Gastrointestinal or diarrhea and respiratory diseases are among the major causes of infectious disease in children with poor hand washing practice. Also it contributes for high rates of school absenteeism in developing countries including Ethiopia [1]. In many countries a high prevalence of water, Hygiene and sanitation related diseases causing morbidity and mortality for many people and children in particular [2] Hand washing practice is considered when children wash their hands using proper technique at critical times (before eating, after toilet,) with detergents like soap, ash etc) [3]. Hand washing with soap is a simple and effective measure to prevent transmission of gastrointestinal and other respiratory infection in school-age children [2,4] Unimproved hygiene, inadequate sanitation, and insu cient and unsafe drinking water account for 19% of child mortality worldwide [5,6].Sixty two percent of all deaths in Africa and 31% of all deaths in Southeast Asia are caused by infection related to poor hand washing practice [7]. In developing countries 80% of disease burden are related to poor hygiene and sanitation practice. Ethiopia one of the least developing countries whose sanitation coverage is less than 40% and access to unsafe water supply is on average more than 50 % [8]. Among 7-14 years of age, 34% didn't wash their hands after using toilet and 78% wash their hands only with water before eating [9].A base line study conducted in some districts of SNNPR showed, water facility and sanitation facility were 47% and 42 % respectively [10].
Globally nearly one third of world population doesn't have access to sanitation facilities and some are unable to practice basic hygiene. Inadequate and unsafe water, poor sanitation, and unsafe hygiene practice are the main cause of diarrhea, which results in at least 1.7 million children's death annually worldwide. [11,]. There are known factors associated with poor hand washing practice accessibility to safe water is account 50%, no access to hand washing facility, toilet facility, poor knowledge, attitude and practice at school and home compound are the main factors which lead to children's to have poor hand washing practice [3].
Poor hand washing practice is the common cause of diarrhea and pneumonia in developing countries.
Improved sanitation facilities contribute to 36% reduction in risk of diarrhea, while hand washing with soap reduces the risk of diarrhea by 48% [11]. Hand washing with soap before eating and after using the toilet could save more lives than any single vaccine or medical intervention [12].
WHO report in 2020 indicated 2 in 5 schools around the world lacked basic hand washing facilities prior to COVID-19 pandemic. [13]. Ethiopia Ministry of Education indicates only 20.8% of the primary schools have hand washing facilities. Of this, 88.9% of them have functional and 11.1% of the schools remained to have non-functional facilities. Nearly one third (29%) of the hand washing facilities were accompanied with soap or another substitute [14]. Therefore, this study provides important information about the practice of hand washing before covid-19 and the possible factors associated in Hawassa, Ethiopia.

Study area, design and Period
A cross sectional study design was conducted at public and private schools which are found in Hawassa city. Hawassa is the capital city of Sidama regional state, Southern Ethiopia. The study was conducted from-February 2019 to October 2019.

Sample size determination
The sample size was determined using single population proportion formula. The sample size was calculated based on the following assumptions: The expected proportion of hand washing with soap after toile by primary school students which will be 14.8 % based on the study conducted among primary school students in northern Ethiopia [3]. (p=14.8%),Con dence Interval of 95% and margin of error 3%.The nally total sample size was determined to be 739.

Sampling technique
A multistage random sampling technique was used. All primary school (45 schools) in Hawassa city were strati ed in to public and private in the rst stage. Then 5 from public and 7 from private were selected by randomly sampling technique in the second stage. In third stage, the sample size is divided based on the proportion of the total number of students in each school. All sections are clustered (Grouped) in each school and clusters are selected using simple random sampling method in fourth place. Then In the last stage study subjects were selected using systematic sampling method. (see Additional gure 1).

Data collection process
A pre-tested structured questionnaire, face to face interviewer administered, was used to collect data from study participants. Data was collected by well trained health professionals and daily evaluated by Supervisors.

Data analysis
The data was coded, entry, cleaning and editing then analysis was done using EPI-Info version 2002 and SPSS version 20 statistical packages. Tables and gures were used to describe variables. The association between dependent and independent variables were determined by using odds ratio with a 95% con dence interval, P-value is less than 0.05will be considered statistically signi cant. Potential confounders were controlled with logistic regression model (multi-variat analysis).

Ethical Consideration
Ethical approval was obtained from the institutional review board of Hawassa University College of Medicine and health sciences. Permission to conduct the study was also obtained from Hawassa city Education O ces and the schools. All participants were informed about the purpose and importance of the study and they were provided written consent.

Socio-demographic characteristics
A total of 739 respondents were interviewed with response rate of 100%.Among those ve hundred forty one (73%) were from government school and one hundred ninety eight (27%) were from private school. Three hundred seventy eight (51.2%) were female and the remaining were males. Out of total respondents two hundred thirty two (31.4%), and ve hundred seven (68.6%) were between age group of 6-11 and 12 + years respectively.
Water supply situation at school and home Among 12 primary schools observed, all of them have (100%) water facilities in which pipe water is the main source. Six hundred forty seven (87.6%) of respondents reported that water is available at their home. The main source of water includes, six hundred twenty (95.8%) pipe water. Regarding, the frequency of water availability at home, three hundred forty (52.6%) respondents reported that water is always available, three hundred four (47.0%) indicated water is sometimes available and others responded water is not available at all.
School latrine, hand washing stand, water and soap/ash related factors at school near to toilet.
Observed school latrine, hand washing stand, water and soap/ash related factors at school. Concerning learning about personal hygiene and sanitation as one subject in the class, six hundred eighty one (92.2%) helps to remember and wash hands, six hundred forty two (86.9%) helps to know the use of hand washing practice, ve hundred eighty one (78.6%) helps to teach our family. They also assessed for proper hand washing steps by using yes/no questions: those who said yes six hundred thirteen (82.9%) and out of this who showed the step is sixty two (9.9%) correctly.
Factors that determine hand washing practice Logistic regression analysis was used to identify the variables which in uence good hand washing practice and to control the effect of confounding variable on hand washing practice. To determine the factors associated with hand washing practice bivariate and multivariate analysis, PV<0.05 and 95%CI were used. Availability of hand washing material, availability of soap/ash, availability of water and pear in uence found to have association with good hand washing practice (

Discussion
In this study we assessed the magnitude of hand washing practice and factors affecting hand washing practice. Of the students interviewed, 80.9% reported wash their hands at critical times. Of these 51.1% students were washing their hands using soap/ash after defecation and 57.1%were washing their hands using soap/ash before meal. This nding is consistent with the nding from Northern Vietnam which reported that 60% students of wash hands before meal [15,16].Self reported frequency of hand washing with soap/ash at after toilet and before meal is higher than study conducted in rural northern Ethiopia. According to this study, hand washing using soap before meal was 36.2% and after defecation 14.8% [3].This difference may be due to access to sanitation facility is higher in urban setting than rural Ethiopia [17,18].
The self-reported frequency of hand washing before meals among school children in this study has similarity with the frequencies reported studies from northern Ethiopia. According to this study, hand washing before meal 99.7% [3]. Studies in other countries for example, in Erbil city on primary schools children regarding personal hygiene shows similar nding which is 98.8% hand washing hands before meals [19].
This study also found that the observed hand washing stand near to toile at school is more than ninety percent but the functionality (water availability) is very low, and the report at home reveals that the functionality of hand washing stand is around sixty nine percent. This shows functional hand washing stand is more available at home than school. Observational check list also reveals that none of the school has soap/ash near to toilet for hand washing but student report showed that availability of soap/ash near to toilet at home is more than seventy four percent. And hand washing with soap/ash after toilet at school and hand washing with soap/ash at home were also different 52.5% (N=120) and 72.3 (272) respectively.
Then, this encourages children's to practice hand washing more at home than school. This difference may be because of urban health extension workers working using their effort at home but not at school and schools may not give attention to this hygiene practice and inadequate supervision of the concerned body on school hygiene practice.
Study conducted in Ghana showed about 60% of the schools had hand washing points. But, Only 30% of the schools have clean running water. To promote hand washing, hand washing-facilities must be easily accessible and available at all times with the right materials and place necessary to make the process a successful [20,16].
This study also showed that why students did not wash their hands after toilet in the availability of water and soap/ash, the most frequent reason were failure to remember. The reason they given were almost similar with the study conducted at Colombia and Indonesia which is (78.2%), (81.8%) respectively [21,22]. This study indicated higher percentage than Colombia's study, this may be because of high social value in our country, during break time and students may prefer to play with their claque. Placing visual aids and other signs at school near to the hand washing facilities at visible site may encourage students to remember and wash their hands; schools should be more concerned about this and display appropriate reminders [20,22].
The most important source information about hand washing practice and hygiene were parents (77.2%) followed by school environment 56.0%. This nding also almost consistent with the study conducted in Indonesia, the main sources of information about hygiene and hand washing were parents (88.5%), followed by school (66.7%) [5, 15, 22 and 23].Based on this study, therefore, teachers should be more involved in promoting proper hand washing at schools, since they are close to and interact with students' learning activities there.
This study also showed that those students who have access to hand washing material (hand washing stand, plastic container) more likely to practice hand washing than those who don't have. This study also revealed that school children are who accessed soap/ash and water are more likely to wash their hands at critical times than those who don't have soap/ash and water access. And this shows that Soap/ash and water has signi cant association with hand washing practice. Studs conducted in other countries on primary school on determining factors that associated with hand washing practice also consistent with this study for instance, study conducted in Indonesia which is availability of clean water (Adj OR = 4.24, 95% CI = 1.92-9.35) and soap (Adj OR = 5.55, 95% CI = 2.36-13.08) at hand washing stands were found to be signi cant predictors of proper hand washing [21].Study conducted in Indonesia reveals that, when clean water was available at hand washing stands, the respondents were four times more likely to wash their hands properly. Similarly, when soap was available at hand washing stands, the respondents were about six times more likely to wash their hands properly [16].
Studies conducted in different countries also showed that availability of hand washing materials (Soap/ash, plastic container, Basin, sink, standing pipe water, water and towel) are the most important factors that affects the practice of hand washing [20,21,22].
Regarding pear in uence on hand washing practice, those school children's who were in uenced by pear less likely to practice hand washing than those who had not in uenced by their pears. In other studies for instance, study conducted in Vietnam and London reveals that pear in uence have great impact in improving hand washing practice [24,15].But in this study, those students in uenced by pears less likely to practice hand washing than those do not in uenced, this may be because of those in uential students may not have adequate knowledge on hand washing practice or they may be negatively practicing hand washing.

Conclusion
The present study found that the prevalence of good hand washing practice was low among the primary school children. The study also revealed Poor access to hand washing facilities such as clean water, soap/ash and hand washing stand near to toilet. Furthermore, teachers are poorly involved on proper hand washing practice to teach and supervise school children. Thus, Poor access to hand washing facilities need to strengthen as intervention efforts. Further, health education promotion for hand washing practice could be done in school by Hawassa city administration Education o ce and better facilities need to avail by the stakeholders.

Declarations
Ethics approval and consent to participate Ethical approval was obtained from the institutional review board of Hawassa University College of Medicine and health sciences. Permission to conduct the study was also obtained from Hawassa city Education O ces and the schools. All participants were informed about the purpose and importance of the study and they were provided written consent.