Predictors of hand hygiene behaviours among primary and secondary school children in a rural district setting in Zimbabwe: a cross-sectional epidemiologic study

Hand hygiene is one of the most effective and efficient ways of controlling faecal–oral diseases. However, little is known about the predictors of hand hygiene behaviours among school children. A predesigned checklist guide was used to observe hygiene behaviours of 460 pupils from four rural schools in Shamva South district, Zimbabwe. A pretested questionnaire was administered to obtain demographic data of the observed school children. Membership of a Water, Sanitation and Hygiene (WASH) club, age, gender and the level of education were associated with hand hygiene practices (p< 0.05). The findings indicated that investing in hand hygiene behaviour change processes among school children using the promotion, formation, resuscitation and empowerment of WASH clubs in schools is important in disease prevention among communities in developing countries.

In addition, school children act as agents of behaviour change in their families and communities by spreading information learnt at school (Khatoon et al. ). The school also provides rich opportunities to intervene early and correct undesirable health habits of children before they become well established (Wills et al. ). Therefore, the objectives of the present study were to (a) identify positive and negative hand hygiene practices, (b) ascertain the determinants for the use of desirable hand hygiene practices and (c) suggest interventions for promoting hand hygiene among school children.

Study design and determination of sample size
A descriptive cross-sectional epidemiologic study was carried out at four rural schools (two primary and two secondary), between February and May 2019 in Shamva South district, Zimbabwe. This district has 18 primary and 11 secondary schools, with a total of 16,854 school children enrolled (Parliament Research Department of Zimbabwe ). Of these schools, the authors accessed and obtained permission to carry out the study in 11 schools. Other schools could not be reached due to logistical challenges.
Four schools (36.4%) were purposively selected from the 11 accessed schools, on the basis that they had basic WASH services during the study period (WHO/UNICEF ). Basic school WASH services meant the provision of (a) handwashing facilities that have soap and water avail- The pupils were recruited through the school administration and their teachers. In total 460 pupils participated in this study, of whom 37% (170) were in grades 6 and 7 (primary level of education) and 63% (290) in forms 3 and 4 (secondary level education). In Zimbabwe, forms 3 and 4 refer to the third and fourth years of secondary education, respectively.
To be eligible, pupils had to be at a level of education above grade 5. The rationale behind this criterion was that school WASH clubs (a key issue assessed in this study) were dominated by senior pupils (grades 6 and 7 in primary schools and forms 3 and 4 in secondary schools). The four studied schools had a total of 23 classes that were eligible for participation in this study. Fourteen of these classes comprised pupils in grades 6 and 7, and the remaining 9 classes comprised pupils in forms 3 and 4. In each of these 23 eligible classes, the objectives and procedures of the study were explained and the pupils were invited to voluntarily participate. Prior to data collection, consent was obtained from the parents and guardians of the pupils.
The study protocol and instruments were ethically reviewed and approved by the institutional review board of the authors' university and the school authorities in the four studied schools.

Questionnaire and observation
A structured age-appropriate questionnaire was administered in English to school children between the ages of 11 and 17 years (mean ± SD: 14.61 ± 1.8 years), in a face-toface 5-10-min interview. Four expert teachers in primary and secondary education reviewed the questionnaire to determine and improve its appropriateness to the age of the school children.

Measurement of study variables
The questionnaire and observation guide were developed based on the stated study objectives and contained hygiene-related issues assessed in previous studies (Hoque

).
In line with the objectives of the current study, binary logistic regression analyses were conducted to determine OR of factors that may influence the hand hygiene behaviour (dependent variables). The hand hygiene behaviours were handwashing with soap and water (no ¼ 0, yes ¼ 1), hygienic hand drying (no ¼ 0, yes ¼ 1) and clean fingernails (no ¼ 0, yes ¼ 1). Hygienic hand drying referred to the use of methods that posed less risk of transmission of microbiological hand contaminants from one child to another. Such methods included shaking and waving hands (commonly referred to as the shaking dry method), use of disposable paper towels and air drier. On the other hand, unhygienic hand drying entailed shared drying cloths and rubbing hands on the uniform. There were nine independent factors: hygiene education in the last 6 months (0 ¼ not received,

RESULTS
Characteristics and hand hygiene practices of school children Table 1 shows the relationship between socio-demographic characteristics and hand hygiene behaviours of 460 pupils selected from four rural schools in Shamva South district, Zimbabwe. There were no differences in handwashing practice (use of soap and water) based on the gender, age and educational level of the pupils (p > 0.05). In addition, no differences were found in the cleanliness of fingernails based on the demographic factors (p > 0.05). Hygienic hand drying was practised more by males, older children (>14 years) at secondary school (p < 0.05). Having clean teeth (brushed) and combed hair was significantly associated with use of soap and water for handwashing purposes (p < 0.05). A substantial proportion of pupils with dirty teeth and uncombed hair did not use soap and water for handwashing purposes. Being a member of the school WASH club was significantly associated with use of soap and water for handwashing and use of a hygienic hand drying method (p < 0.05). Pupils who had received hygiene education from health workers in the last 6 months showed good hand hygiene behaviours than those who did not. Out of a total of 460 pupils, 39.6% (182) did not wash their hands with soap and water. About 35% (159) of them did not dry hands using approved methods and 9% (42) had dirty fingernails.

Predictors of hand hygiene behaviours
This study investigated the predictors of three hand hygiene behaviours: handwashing with soap and water, hygienic hand drying and keeping of fingernails clean.
The association of each type of hand hygiene behaviour with the investigated independent risk factors is presented in Table 2.

Handwashing with soap and water
The strongest associations were observed between being a member of a school WASH club and the use of soap and water for handwashing (

Multinomial logistic regression analyses
Results of the multinomial logistic regression analyses are shown in Table 3. Membership to a WASH club was found to be a significant predictor for the use of soap and water for handwashing (OR ¼ 5.08, 95% CI [3.24-7.98], p ¼ 0.001) and for the use of a hygienic hand drying method

Limitations of the study
This study's findings should be interpreted in the context of some limitations. The study was cross-sectional in design and the studied schools and sample of school children were not randomly selected. The study population

CONCLUSION AND REMARKS FOR FURTHER STUDIES
Our findings showed that there is a lack of hand hygiene practices among school children who did not belong to a