The purpose of this study was to comprehensively appraise and synthesize studies on hand hygiene practices among primary and secondary school students in sub-Saharan Africa (SSA). This is a thorough review of scientific papers published between 2015 and 2023 from primary databases such as the Web of Science, Science Direct, PubMed, and Google Scholar. The review criteria were met by 26 out of 63 studies assessed for legibility. The review demonstrated that students in SSA had moderate and good hand washing practices in terms of regular hand washing, cleaning hands after defecation, and before and after eating. Furthermore, the review pinpoints hand washing practices as influenced by factors such as knowledge, hand washing facilities and materials, influences from parents and teachers or others, personal and social factors, media, gender, age, and other factors such as location, attitudes, and school modernity. Furthermore, the reviewed studies highlighted recommendations for improving hand hygiene practices, such as enhancing hand hygiene and environmental health education, mobilizing resources for hand washing, creating and implementing health policy, and conducting further studies. This review provides data for policymakers on how to improve student hand hygiene and adds to existing knowledge on hand hygiene practices.

  • This study presents evidence from the existing literature on school students’ hand hygiene practices in sub-Saharan Africa (SSA).

  • The review covered papers published in SSA from 2015 to 2023.

  • The hand hygiene practices of students were shown to be moderate and good.

  • The hand hygiene practices are subject to several factors including knowledge.

  • The findings encourage further efforts to promote hand hygiene at the school and home levels.

Water, sanitation, and hygiene (WASH) services are essential for achieving good health and the Sustainable Development Goals (SDGs). Clean water and sanitation are among the SDGs that emphasize the importance of universal, adequate, and equitable access to safe and affordable WASH for all, as well as the elimination of open defecation, particularly for women, girls, and people living in vulnerable areas. While the World Health Organization (WHO) recommends that every country should prioritize hand hygiene in policy and practice, access to facilities for practicing hand hygiene and support for the behaviors needed are lacking in many settings (UNICEF 2021b), and most efforts have been directed toward improving water supply and sanitation (Bishoge 2021).

Because hygiene refers to situations and behaviors that are primarily concerned with conserving health and preventing disease (Kumwenda 2019), the supply of affordable hygiene equipment and hygiene education has the potential to alleviate suffering and loss of life. Hand, food, personal, menstrual, home, and surface hygiene as well as institutional hygiene are aspects of hygiene. Hand cleaning, bathing daily, and washing clothes all assist in preventing the spread of dangerous bacteria in the body and hence maintaining good health (Burton et al. 2011). While hand hygiene is one of the most critical parts of hygiene, it is estimated that 2.3 billion individuals lack access to clean water and soap at home (UNICEF 2021a). Six hundred and seventy million people have no access to hand washing facilities. Hand hygiene facilities are lacking in many health care facilities, schools, and public places. For example, approximately 818 million children do not have access to basic hand washing facilities in their schools (WHO/UNICEF 2020).

Hand hygiene has attracted much attention and has been identified as a critical component in reducing the risk of transmission of the coronavirus (COVID-19) pandemic in all countries (WHO 2020b). In the fight against emerging, re-emerging, and infectious diseases, hand hygiene has emerged as a critical long-term public policy and practice concern. Hand hygiene is viewed as a very cost-effective (truly a ‘no-regrets’) investment that provides large health advantages at a cheap cost. As a result, hand hygiene should be regarded as an important daily practice that contributes to both health and economic resiliency. Despite efforts by the government and other stakeholders to improve WASH, access to hand hygiene services remains stubbornly low in developing countries. This jeopardizes the achievement of the SDGs in 2030 when approximately 1.9 billion people will still be unable to wash their hands at home or school (UNICEF &WHO 2021). Poor hygiene is responsible for almost 80% of infectious illnesses in underdeveloped countries. Hand hygiene is a social and environmental determinant that is critical for health improvement. Despite all efforts to improve them, health systems in sub-Saharan Africa (SSA) remain deplorable (Azevedo 2017; Oleribe et al. 2019; Amu et al. 2022). Inadequate human and financial resources, as well as poor leadership, are among the obstacles to improved health systems (Oleribe et al. 2019).

Hand washing regularly with water and soap or an alcohol-based rub is a simple and convenient (Mbakaya et al. 2017; Omari et al. 2022; Wolf et al. 2023) public health intervention that is highly cost-effective. It is critical for communities and schools worldwide to protect against a variety of infectious diseases, such as diarrhea (Solomon et al. 2021; UNICEF 2023; UN-Water 2023). However, it is not as successful as certain other interventions in lowering diseases (Wolf et al. 2023), such as immunization, covering coughs and sneezes, cleaning surfaces regularly, and preparing food safely (Ministry of Health NZ 2022). Furthermore, maintaining hand washing behaviors is difficult due to reasons such as limited water availability, lack of time, poor modeling of WASH infrastructures, and unattractive hand washing facilities (Chittleborough et al. 2012; Ezezika et al. 2023); therefore, the intervention is likely to be less cost-effective in the long run (Luby et al. 2009; Vindigni et al. 2011; Gould et al. 2017; Inauen et al. 2020). Increased hand washing practices in schools are a foundational improvement for the entire community. This is because schools are among the most essential sites to promote health education and activities (Pulimeno et al. 2020). It is planned that schools should be outfitted with hand hygiene facilities to promote students' hand hygiene practices.

In SSA, more than one-third of children (295 million) out of a total of 818 million do not have access to basic hand washing facilities at school (WHO 2020a). There is a scarcity of water and other necessities, such as soap. This increases the risk of infectious, developing, and re-emerging diseases such as diarrheal illnesses and acute respiratory infections among schoolchildren. Hand washing with soap has been found to reduce school absences by up to 50% due to diarrhea, influenza, and conjunctivitis (WHO/UNICEF 2023). As a result, soap-free hand washing is an essential component of healthy schools.

The government and other stakeholders, such as the WHO and the United Nations Children's Fund (UNICEF), have made several efforts to enhance hand hygiene in schools throughout SSA. Education strategies have been implemented to raise awareness and understanding, change habits, and encourage pupils to practice good hand hygiene (Irehovbude & Okoye 2020; Younie et al. 2020). Furthermore, there has been an increase in the availability of hand hygiene products and facilities such as water and soap in schools to promote hand washing behaviors and practices (Kisaakye et al. 2021; Berhanu et al. 2022). Despite all efforts to improve school hygiene services, the practice of proper hand washing remains low in developing countries, notably in SSA (Irehovbude & Okoye 2020; Endalew et al. 2022; Tamene et al. 2023). Only 15% of the SSA population has access to soap and water for hand washing (Amegah 2020). It appears that these initiatives do not always result in a long-term improvement in pupils' hand hygiene behaviors and practices. Thus, the goal of this review is to evaluate hand washing practices and the factors that influence them among primary and secondary school children in the SSA region. It describes the overall state of hand hygiene among school pupils in SSA and makes recommendations for improvement.

Settings

The review relied on studies conducted at primary and secondary schools in SSA nations. The SSA region is a geographical area, which is located in the south of the Sahara Desert. It includes all countries that are wholly or partially located in the south of the Sahara, excluding all countries in North Africa and any countries that may be included in SSA but are owned by Arab governments (Bishoge et al. 2020). The SSA region is made up of 50 countries. The region is still dealing with major issues such as civil war and wars, refugees, famine caused by drought, the expansion of infectious illnesses such as HIV/AIDS, and a bad environmental health status, all of which impede development (Kharsany & Karim 2016; Wudil et al. 2022). Furthermore, schools in SSA have inadequate hand hygiene compared to schools in other developing and developed countries (Kisaakye et al. 2021; Endalew et al. 2022). More research and interventions are needed to enhance hand hygiene in SSA schools.

Review procedures

The process of the systematic review started with developing the research question (Tawfik et al. 2019) (see Figure 1). The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines for reviewing, analyzing, and reporting systematic reviews (Page et al. 2021), which cover all aspects of the manuscript, including the title, abstract, introduction, methods, results, discussion, and funding. The PRISMA seeks to assist writers in improving systematic review reporting by allowing readers to readily analyze the strengths and limitations of the review results (Sohrabi et al. 2021). This is a qualitative systematic review by which the results of pertinent studies were summarized but not statistically integrated (Majumder 2015).
Figure 1

The systematic review procedures.

Figure 1

The systematic review procedures.

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Data sources

From 23 July to 20 August 2023, relevant published studies were searched through electronic databases such as PubMed, Web of Science, Science Direct, Scopus, and Google Scholar. The following phrases were used in the search: ‘hand washing’, ‘hand hygiene’, ‘hand disinfection’, ‘practices’, ‘behavior’, ‘primary school children’, ‘elementary students’, ‘secondary school students’, ‘middle school students’, ‘high school students’, and ‘Africa’ and ‘sub-Saharan Africa’. Figure 2 depicts the search and selection of relevant studies used in this study.
Figure 2

Flow diagram of the process used to identify the legible studies for the systematic review.

Figure 2

Flow diagram of the process used to identify the legible studies for the systematic review.

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Selection criteria and search outcomes

The following criteria were used to choose relevant studies: (i) studies conducted between 2015 and 2023, (ii) studies with an analytical quantitative and qualitative research design (cross-sectional, interview, and observational studies), and (iii) studies published in English language. The review omitted studies with insufficient reported information, journals lacking full texts, unpublished studies, cohort and case studies, experimental investigations, procedures, and reviews. After removing duplicates, two independent reviewers utilized Mendeley Reference Software to scan references and remove duplicates to choose the relevant studies. Mendeley is a free research management platform that combines desktop apps and Internet features to assist scholars in organizing their study, collaborating with other academics online, and discovering the most recent research trends (Silva & Pedrosa 2017). The researchers screened the studies based on the titles and abstracts and then downloaded and reviewed the full-text publications with complete information and unambiguous titles that met the requirements. Conversation among the researchers was held to resolve inconsistencies in the outcomes of various publications, as suggested by Avenalia et al. (2023).

Based on the keywords provided, a total of 870 articles were initially selected as related to the study topic. The abstracts were examined and scrutinized by two separate reviewers, and 81 were judged to be relevant to the study topic. After searching for full texts, only 63 papers were found legible, and 26 studies satisfied the set criteria and were thus selected for the review (see Figure 2).

Quality assessment

Quality assessment is a framework that aids researchers in reporting high-quality review findings (Harrison et al. 2021). It demonstrates the internal and external validity of the studies chosen for review (Maharaj & Harding 2016). It can be performed before or after data extraction. The quality of the studies was evaluated using the QualSysts appraisal checklist for quantitative and qualitative studies (Maddocks et al. 2019). The QualSysts appraisal checklist had 10 components: objective, design, context, connection to literature, sampling, data collection, analysis, credibility, conclusions, and reflexivity, with scores of Yes (2), Partial (1), and No (0). The checklist was used to assess the quality of each selected study. The calculated score was used to define the quality of the study as strong (score of >80%), good (70–80%), adequate (50–70%), or limited (<50%), as suggested by Lee et al. (2008). Based on the aforementioned score categories, studies with 50% or higher was chosen for the review. The majority of the research demonstrated defined objectives with proper design, including sampling, data collection, and analysis.

However, only a few of the studies showed reflexivity. The majority of the studies differed in terms of study population, sample size, research methodology used, diversity of respondents, and study sites. This hampered meta-analysis because the findings of the acquired data might be evaluated using a thematic analysis technique. Thematic analysis discovers themes or patterns in data that are important or interesting enough to be used to address research questions or make a statement about an issue (Maguire & Delahunt 2017).

Data synthesis and reporting

Synthesis is a stage in the systematic review process in which extracted data (individual study findings) are merged and analyzed (van den Berg et al. 2013). The data were extracted independently by two researchers. The studies included the author and year of publication, research aims, study population, samples, research methodology, significant findings, recommendations, and country. The information gathered was summarized using written words, tables, and figures. The data extraction and synthesis revealed the outcomes and impacts of the chosen research, as well as difficulties with technique and quality, such as the overall level of evidence and the degree of consistency in the findings. The integrative analysis method was used to analyze the collected data. An integrative analysis allows interpretation and reporting of the quantitative and qualitative findings in a single report (Fetters et al. 2013; Almalki 2016). Finally, a thematic approach was employed to identify and evaluate issues from each study that was chosen. Thematic approaches summarize the major concerns in vast amounts of data, aid in data handling, and result in a clear and ordered final report (Nowell et al. 2017). Themes were identified using an inductive technique by which conclusions are drawn by going from the specific to the general (Dawadi 2020).

Researchers were acquainted with the extracted data from each chosen study and coded it to characterize its contents. The codes were then merged to form themes, which were then reviewed to guarantee accuracy. This enabled researchers to develop and name themes before coming up with concise and easily comprehensible names for each theme. The final report was written based on the topics, which were supported by tables and figures.

The following criteria are used to describe the findings of this review: study settings, sample size and research procedures, participant characteristics, hand hygiene practices, factors influencing hand washing practices, and recommendations to enhance hand hygiene practices, as explained below.

Settings of the selected studies

The majority of studies (seven) originated in Nigeria (see Table 1). Furthermore, 9 of the 26 studies were conducted in both rural and urban settings, with the remaining 8 in urban, 7 in rural, and 2 in peri-urban settings.

Table 1

Setting of selected studies

Sample size and research techniques

While all the studies included a total of 9,622 students, the sample sizes in the selected studies ranged from 37 (Mbakaya & Lee 2019) to 1,193 (Seimetz et al. 2017). The majority of studies (12) acquired data through questionnaires (see Figure 3).
Figure 3

Research methods used in the selected studies.

Figure 3

Research methods used in the selected studies.

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Students' characteristics

The majority of participants in the chosen studies (4,054) were men, while the remainder (3,976) were women. Eight studies involved secondary school pupils, while 18 included primary school children.

Practices of hand hygiene

The findings revealed varying levels of hand hygiene practices in terms of hand washing frequency, hand cleaning after defecation, hand washing before and after eating, and hand washing before and after changing menstruation products (see Table 2).

Table 2

Practices of hand hygiene

No.Hand hygiene practicesLevel of practicesFindingsCountryAuthors
Frequently hand washing A low frequency of hand washing 35% of secondary school students wash their hands frequently, and 34.7% never wash their hands in Anambra State Nigeria Ezeaka et al. (2020)  
52.2% of secondary school pupils always wash their hands in the Somolu Local Government Area Oluwole et al. (2020)  
84.3% of public senior secondary school pupils in Lagos State, Nigeria, cleansed their hands at school Wada & Oloruntoba (2021)  
Proper hand washing requires the use of soap and flowing water 53.3% of primary school children used simply plain water to wash their hands and only 25.7% used soap in Damote Woide District Ethiopia Admasie et al. (2022)  
88.2% of primary school pupils cleansed their hands with soap and 11.8% washed their hands just with water only in Yirgalem Town Eshetu et al. (2020)  
47.3% of public senior secondary school students cleansed their hands with soap and water at school in Lagos State Nigeria Wada & Oloruntoba (2021)  
52.1 and 28.3% of primary school washed their hands with simply plain water and water with soap, respectively, in children in Harar Ethiopia Berhanu et al. (2022)  
Washing hands after defecation Range of practice levels among the children 100% of public secondary school pupils cleaned their hands after using the public restrooms at home in the Somolu Local Government Area, Lagos. Only 89.2% of them, however, used soap and water. Nigeria Oluwole et al. (2020)  
93.6% of secondary school pupils in Mtwara cleaned their hands after using the toilets Tanzania Bishoge et al. (2022c)  
56% of public elementary school students washed their hands after visiting the toilet, whereas 40% cleansed their hands with soap after visiting the toilet in Kintampo Municipality Ghana Dajaan et al. (2018)  
73.6% of secondary school pupils in Ijebu Ode cleansed their hands with water and soap after using the toilets Nigeria Otto et al. (2022)  
Low level of washing hands after using the restroom Just 17% of primary school children wash their hands after defecation in Mareko District Ethiopia Shehmolo et al. (2021)  
Using soap and water to wash their hands after defecation Only 12.8% of elementary school pupils, for example, reported always washing their hands with soap after using the toilet Admasie et al. (2022)  
Approximately 62% of primary school pupils washing their hands with soap after visiting the toilet in Sebeta Town, Oromia Regional State Mekonnen et al. (2018)  
Washing hands before and after eating Students have a high and low degree of practice 100% of public primary school children reported washing their hands before and after eating in the Kintampo Municipality Ghana Dajaan et al. (2018)  
72.7 and 70.5% of primary school students cleansed their hands before and after eating, respectively Botswana Thakadu et al. (2018)  
30 and 10.7% of primary school pupils washed their hands before and after eating, respectively, in Mareko District Ethiopia Shehmolo et al. (2021)  
Hand washing before and after changing menstrual items  65 and 75% of school girls always washed their hands before changing or cup emptying, respectively Kenya Nyothach et al. (2015)  
10 and 7% of girls never washed their hands before and after changing menstruation pads 
Mild hand cleaning with soap and running water was recorded among secondary school students after changing menstruation items Nigeria Azuogu et al. (2016)  
No.Hand hygiene practicesLevel of practicesFindingsCountryAuthors
Frequently hand washing A low frequency of hand washing 35% of secondary school students wash their hands frequently, and 34.7% never wash their hands in Anambra State Nigeria Ezeaka et al. (2020)  
52.2% of secondary school pupils always wash their hands in the Somolu Local Government Area Oluwole et al. (2020)  
84.3% of public senior secondary school pupils in Lagos State, Nigeria, cleansed their hands at school Wada & Oloruntoba (2021)  
Proper hand washing requires the use of soap and flowing water 53.3% of primary school children used simply plain water to wash their hands and only 25.7% used soap in Damote Woide District Ethiopia Admasie et al. (2022)  
88.2% of primary school pupils cleansed their hands with soap and 11.8% washed their hands just with water only in Yirgalem Town Eshetu et al. (2020)  
47.3% of public senior secondary school students cleansed their hands with soap and water at school in Lagos State Nigeria Wada & Oloruntoba (2021)  
52.1 and 28.3% of primary school washed their hands with simply plain water and water with soap, respectively, in children in Harar Ethiopia Berhanu et al. (2022)  
Washing hands after defecation Range of practice levels among the children 100% of public secondary school pupils cleaned their hands after using the public restrooms at home in the Somolu Local Government Area, Lagos. Only 89.2% of them, however, used soap and water. Nigeria Oluwole et al. (2020)  
93.6% of secondary school pupils in Mtwara cleaned their hands after using the toilets Tanzania Bishoge et al. (2022c)  
56% of public elementary school students washed their hands after visiting the toilet, whereas 40% cleansed their hands with soap after visiting the toilet in Kintampo Municipality Ghana Dajaan et al. (2018)  
73.6% of secondary school pupils in Ijebu Ode cleansed their hands with water and soap after using the toilets Nigeria Otto et al. (2022)  
Low level of washing hands after using the restroom Just 17% of primary school children wash their hands after defecation in Mareko District Ethiopia Shehmolo et al. (2021)  
Using soap and water to wash their hands after defecation Only 12.8% of elementary school pupils, for example, reported always washing their hands with soap after using the toilet Admasie et al. (2022)  
Approximately 62% of primary school pupils washing their hands with soap after visiting the toilet in Sebeta Town, Oromia Regional State Mekonnen et al. (2018)  
Washing hands before and after eating Students have a high and low degree of practice 100% of public primary school children reported washing their hands before and after eating in the Kintampo Municipality Ghana Dajaan et al. (2018)  
72.7 and 70.5% of primary school students cleansed their hands before and after eating, respectively Botswana Thakadu et al. (2018)  
30 and 10.7% of primary school pupils washed their hands before and after eating, respectively, in Mareko District Ethiopia Shehmolo et al. (2021)  
Hand washing before and after changing menstrual items  65 and 75% of school girls always washed their hands before changing or cup emptying, respectively Kenya Nyothach et al. (2015)  
10 and 7% of girls never washed their hands before and after changing menstruation pads 
Mild hand cleaning with soap and running water was recorded among secondary school students after changing menstruation items Nigeria Azuogu et al. (2016)  

Factors influencing hand washing practices

The review revealed that knowledge of hand hygiene, availability of hand washing facilities and materials at schools and homes, and influence of parents, teachers, and other relatives are major influential factors for hand washing practices among school students. However, personal and social factors such as illness prevention; forgetfulness; odor; media such as television, radios, and newspapers; gender; and age were also identified as influences of hand hygiene practices (see Table 3).

Table 3

Influential factors for hand washing practices among school students

No.FactorContribution to the hand hygiene practicesAuthors
Knowledge of hand hygiene When students have a high and adequate knowledge of hand washing and its associated benefits to human health, their hand hygiene practices improve Ezeaka et al. (2020)  
The adoption of sanitary hand drying procedures appeared to rise with the level of education of the students Ncube et al. (2020)  
Low levels of hygiene knowledge among students may have an impact on their academic performance since unsafe hygiene practices put them at risk of developing infectious diseases and skipping school Thakadu et al. (2018)  
High and proper understanding, however, does not guarantee high hand hygiene practices Otto et al. (2022)  
Most secondary school pupils (78.9%) had adequate understanding of WASH, but only a small proportion (less than 50%) actively performed WASH 
While elementary children had high knowledge (62.7%), only 39.1% practiced good hand washing 
Availability of hand washing facilities and materials at schools and homes 42.33% of primary school children reported a lack of water as a barrier to hand washing in the Kintampo Municipality of Ghana Dajaan et al. (2018)  
Insufficient provision of hand washing facilities at school prevented public elementary school children from putting their newly gained hand washing knowledge into practice in Imo State, Nigeria Nwajiuba et al. (2019)  
Lack of nearby water supply (46.2%) and a lack of soap (50%) were among the primary reasons for not practicing hand washing Oluwole et al. (2020)  
Hand washing among schoolchildren increased significantly after improvements in hygiene and sanitation facilities in Limpopo, South Africa Bulled et al. (2017)  
Influence of parents, teachers, and other relatives Primary school children whose referents were parents, teachers, and health professionals were more likely to practice proper hand washing practice than those whose referents were friends in Damote Woide District, South Ethiopia Admasie et al. (2022)  
There was a statistically significant relationship between parents’ degree of education and students’ hand hygiene practices. Students with better educated parents are more likely to practice proper hand hygiene than their peers Mekonnen et al. (2018), Oluwole et al. (2020)  
Personal and social factors influencing hand washing practice, such as illness prevention, forgetfulness, or odor Secondary school students believed that hand washing messages were about sensitization and disease prevention in Anambra State, Nigeria Ezeaka et al. (2020)  
Forgetfulness, laziness, and time constraints were cited as primary reasons for not practicing hand washing at home Oluwole et al. (2020)  
Other research included feeling getting rid of undesirable odors and emotional factors such as disgust, fear, and nurture as reasons for practicing hand hygiene Seimetz et al. (2017), Berhanu et al. (2022), Okello et al. (2019)  
Media such as television, radios, and newspapers Television (46.9%), radio (16.9%), booklets (0.3%), and newspapers (36%) were the sources of information on children's hand washing practices in Arba Minch town, Ethiopia Besh et al. (2016)  
Nearly three-quarters (73.6%) of Ethiopian students had learned about hand hygiene habits from television Berhanu et al. (2022)  
Gender-specific hand hygiene practices Female pupils exercised hand hygiene more than boys in Mtwara, Tanzania Bishoge et al. (2022c)  
Male students were observed to wash their hands substantially more than their female counterparts in Ebonyi state, Nigeria Azuogu et al. (2016)  
Male schoolchildren dried their hands more than female schoolchildren in Zimbabwe Ncube et al. (2020)  
Hand hygiene practices as they relate to age As children grew older, their cleanliness practices improved Bishoge et al. (2022c)  
Children over the age of 14 were more likely to employ suggested hand drying procedures than children under the age of 14 in Zimbabwe Ncube et al. (2020)  
Children of a higher age (14–18 years) were 1.42 times more likely to practice excellent hygiene than those of a lower age in Ethiopia Shehmolo et al. (2021)  
Young boys cleansed their hands more frequently than older boys, with an equal proportion of girls of both ages cleaning their hands in South Africa Bulled et al. (2017)  
The youngest children were eager to report classmates who did not wash their hands after using the toilets Okello et al. (2019)  
Other influential factors Residency was a significant predictor of correct hand washing practice, with students from rural areas less likely to practice regular hand washing than their urban counterparts (Adjusted Odds Ratio (AOR) = 0.53; 95% CI = 0.30, 0.94) in Ethiopia Mekonnen et al. (2018)  
Membership in a WASH club has been revealed to be one of the factors that promote students’ hand hygiene habits in Eastern Ethiopia Berhanu et al. (2022)  
Children who had visited model schools were 2.44 times more likely to have appropriate hygiene habits than those who had not in Ethiopia Mekonnen et al. (2018)  
No.FactorContribution to the hand hygiene practicesAuthors
Knowledge of hand hygiene When students have a high and adequate knowledge of hand washing and its associated benefits to human health, their hand hygiene practices improve Ezeaka et al. (2020)  
The adoption of sanitary hand drying procedures appeared to rise with the level of education of the students Ncube et al. (2020)  
Low levels of hygiene knowledge among students may have an impact on their academic performance since unsafe hygiene practices put them at risk of developing infectious diseases and skipping school Thakadu et al. (2018)  
High and proper understanding, however, does not guarantee high hand hygiene practices Otto et al. (2022)  
Most secondary school pupils (78.9%) had adequate understanding of WASH, but only a small proportion (less than 50%) actively performed WASH 
While elementary children had high knowledge (62.7%), only 39.1% practiced good hand washing 
Availability of hand washing facilities and materials at schools and homes 42.33% of primary school children reported a lack of water as a barrier to hand washing in the Kintampo Municipality of Ghana Dajaan et al. (2018)  
Insufficient provision of hand washing facilities at school prevented public elementary school children from putting their newly gained hand washing knowledge into practice in Imo State, Nigeria Nwajiuba et al. (2019)  
Lack of nearby water supply (46.2%) and a lack of soap (50%) were among the primary reasons for not practicing hand washing Oluwole et al. (2020)  
Hand washing among schoolchildren increased significantly after improvements in hygiene and sanitation facilities in Limpopo, South Africa Bulled et al. (2017)  
Influence of parents, teachers, and other relatives Primary school children whose referents were parents, teachers, and health professionals were more likely to practice proper hand washing practice than those whose referents were friends in Damote Woide District, South Ethiopia Admasie et al. (2022)  
There was a statistically significant relationship between parents’ degree of education and students’ hand hygiene practices. Students with better educated parents are more likely to practice proper hand hygiene than their peers Mekonnen et al. (2018), Oluwole et al. (2020)  
Personal and social factors influencing hand washing practice, such as illness prevention, forgetfulness, or odor Secondary school students believed that hand washing messages were about sensitization and disease prevention in Anambra State, Nigeria Ezeaka et al. (2020)  
Forgetfulness, laziness, and time constraints were cited as primary reasons for not practicing hand washing at home Oluwole et al. (2020)  
Other research included feeling getting rid of undesirable odors and emotional factors such as disgust, fear, and nurture as reasons for practicing hand hygiene Seimetz et al. (2017), Berhanu et al. (2022), Okello et al. (2019)  
Media such as television, radios, and newspapers Television (46.9%), radio (16.9%), booklets (0.3%), and newspapers (36%) were the sources of information on children's hand washing practices in Arba Minch town, Ethiopia Besh et al. (2016)  
Nearly three-quarters (73.6%) of Ethiopian students had learned about hand hygiene habits from television Berhanu et al. (2022)  
Gender-specific hand hygiene practices Female pupils exercised hand hygiene more than boys in Mtwara, Tanzania Bishoge et al. (2022c)  
Male students were observed to wash their hands substantially more than their female counterparts in Ebonyi state, Nigeria Azuogu et al. (2016)  
Male schoolchildren dried their hands more than female schoolchildren in Zimbabwe Ncube et al. (2020)  
Hand hygiene practices as they relate to age As children grew older, their cleanliness practices improved Bishoge et al. (2022c)  
Children over the age of 14 were more likely to employ suggested hand drying procedures than children under the age of 14 in Zimbabwe Ncube et al. (2020)  
Children of a higher age (14–18 years) were 1.42 times more likely to practice excellent hygiene than those of a lower age in Ethiopia Shehmolo et al. (2021)  
Young boys cleansed their hands more frequently than older boys, with an equal proportion of girls of both ages cleaning their hands in South Africa Bulled et al. (2017)  
The youngest children were eager to report classmates who did not wash their hands after using the toilets Okello et al. (2019)  
Other influential factors Residency was a significant predictor of correct hand washing practice, with students from rural areas less likely to practice regular hand washing than their urban counterparts (Adjusted Odds Ratio (AOR) = 0.53; 95% CI = 0.30, 0.94) in Ethiopia Mekonnen et al. (2018)  
Membership in a WASH club has been revealed to be one of the factors that promote students’ hand hygiene habits in Eastern Ethiopia Berhanu et al. (2022)  
Children who had visited model schools were 2.44 times more likely to have appropriate hygiene habits than those who had not in Ethiopia Mekonnen et al. (2018)  

Recommendations to enhance hand hygiene practices

The authors of the studies reviewed suggested several recommendations for increasing students' hand cleanliness, as shown in Table 4. Most other authors advocated improving training to raise awareness and knowledge about hand washing. Others suggested mobilizing resources for hand washing, developing and implementing hand hygiene policies and regulations, and conducting additional research on the drivers of proper hand hygiene practices and interventions to improve hand hygiene in schools and communities.

Table 4

Recommendations to enhance hand hygiene practices

No.RecommendationsContribution to the hand hygiene practicesAuthors
Improving hand hygiene and environmental health education Advocating more effective hand washing education in Ghanaian schools Dajaan et al. (2018)  
Advocated for increasing students’ understanding of good hygiene habits through health education in order to promote good hygiene practice in Ethiopia Shehmolo et al. (2021)  
Ghana Education Service's Municipal Directorate should consider including hand washing education in school curricula, as well as increasing targeted health education sessions on hand washing and providing hand washing facilities in secondary schools Fianko & Gawu (2020)  
Ongoing educational efforts must be maintained in order to sustain positive sanitation and hygiene habits in Tanzania Bishoge et al. (2022c)  
Mobilization of resources for hand washing Hand washing facilities should be made available in all schools, so that students can put their knowledge into action Berhanu et al. (2022), Fianko & Gawu (2020)  
Strict monitoring of children's hand washing processes in order to reduce incorrect hand washing practices in these urban and rural locations Besh et al. (2016)  
There is a need to mobilize hand washing with soap and water during important moments to guarantee greater compliance Ezeaka et al. (2020)  
Induction of behavioral change in rural and urban settings in Burundi and Zimbabwe, and suitable infrastructure for hygiene services is essential Seimetz et al. (2017)  
Advocating for additional interventions targeting water points, functional hand washing kits, and hand hygiene awareness and practices as key components to be considered by the DRC school authorities in order to increase current WASH item coverage and improve hand washing practices Nlunda et al. (2023)  
Environmental health policy formulation and implementation There is a need to develop a school health policy to offer guidelines and infrastructure for implementing hand hygiene programs in low-resource nations like Malawi Mbakaya & Lee (2019)  
Policymakers and program implementers should constantly educate girls about the need of hand hygiene, aid schools in providing hygiene materials and facilities such as water and soap, and monitor that these services are supplied Nyothach et al. (2015)  
Further studies Future research should look at the drivers of pro-hygiene and sanitation behavior in different Botswana regions Thakadu et al. (2018)  
More research is needed to determine the significance of water quality (source and point of use) in hand washing where soap is scarce. 
Future studies may find it useful to analyze the WASH questionnaire using a model containing hypotheses and constructs Ncube et al. (2020)  
Advocating for more robust research designs in future studies, including the increased involvement of parents and more in the design of observational and qualitative studies in Ethiopia Admasie et al. (2022)  
Future research should look into the effects of the wider structural and social environment on students’ actions and, as a result, disease risk in South Africa Bulled et al. (2017)  
Nutritionists and health experts should educate homes and schools on a regular basis to ensure that all hygienic practices are followed Gitau et al. (2015)  
This includes hand washing, drinking water that has been treated or boiled, and the use of dish-racks at home to decrease illnesses, which would also reduce school absence in Kenya 
No.RecommendationsContribution to the hand hygiene practicesAuthors
Improving hand hygiene and environmental health education Advocating more effective hand washing education in Ghanaian schools Dajaan et al. (2018)  
Advocated for increasing students’ understanding of good hygiene habits through health education in order to promote good hygiene practice in Ethiopia Shehmolo et al. (2021)  
Ghana Education Service's Municipal Directorate should consider including hand washing education in school curricula, as well as increasing targeted health education sessions on hand washing and providing hand washing facilities in secondary schools Fianko & Gawu (2020)  
Ongoing educational efforts must be maintained in order to sustain positive sanitation and hygiene habits in Tanzania Bishoge et al. (2022c)  
Mobilization of resources for hand washing Hand washing facilities should be made available in all schools, so that students can put their knowledge into action Berhanu et al. (2022), Fianko & Gawu (2020)  
Strict monitoring of children's hand washing processes in order to reduce incorrect hand washing practices in these urban and rural locations Besh et al. (2016)  
There is a need to mobilize hand washing with soap and water during important moments to guarantee greater compliance Ezeaka et al. (2020)  
Induction of behavioral change in rural and urban settings in Burundi and Zimbabwe, and suitable infrastructure for hygiene services is essential Seimetz et al. (2017)  
Advocating for additional interventions targeting water points, functional hand washing kits, and hand hygiene awareness and practices as key components to be considered by the DRC school authorities in order to increase current WASH item coverage and improve hand washing practices Nlunda et al. (2023)  
Environmental health policy formulation and implementation There is a need to develop a school health policy to offer guidelines and infrastructure for implementing hand hygiene programs in low-resource nations like Malawi Mbakaya & Lee (2019)  
Policymakers and program implementers should constantly educate girls about the need of hand hygiene, aid schools in providing hygiene materials and facilities such as water and soap, and monitor that these services are supplied Nyothach et al. (2015)  
Further studies Future research should look at the drivers of pro-hygiene and sanitation behavior in different Botswana regions Thakadu et al. (2018)  
More research is needed to determine the significance of water quality (source and point of use) in hand washing where soap is scarce. 
Future studies may find it useful to analyze the WASH questionnaire using a model containing hypotheses and constructs Ncube et al. (2020)  
Advocating for more robust research designs in future studies, including the increased involvement of parents and more in the design of observational and qualitative studies in Ethiopia Admasie et al. (2022)  
Future research should look into the effects of the wider structural and social environment on students’ actions and, as a result, disease risk in South Africa Bulled et al. (2017)  
Nutritionists and health experts should educate homes and schools on a regular basis to ensure that all hygienic practices are followed Gitau et al. (2015)  
This includes hand washing, drinking water that has been treated or boiled, and the use of dish-racks at home to decrease illnesses, which would also reduce school absence in Kenya 

This study summarized and evaluated current knowledge of hand hygiene practices among elementary and secondary school students in SSA, with more studies (seven and six) being undertaken in Nigeria and Ethiopia, respectively. Increased studies in Nigeria and Ethiopia may be due in part to the fact that Nigeria and Ethiopia are the most populated nations in SSA (Gambino et al. 2014) and have the most higher education institutions, such as universities, polytechnics, monotechnics, and research institutes (Odeyemi et al. 2019).

While some studies revealed a high level of hand hygiene practices, others revealed a low level of hand hygiene practices, indicating that the overall level of hand hygiene practices was moderate and good. This is somewhat noteworthy in comparison to other research (Eshuchi 2013; Mbouthieu Teumta et al. 2019; More et al. 2022; Vijayalakshmi et al. 2023) that reported low levels of hand hygiene practices in developing countries. However, greater efforts are needed to guarantee adequate hand hygiene practices at the school and community levels. This will assist in reducing the transmission of infectious diseases such as salmonellosis and respiratory infections such as influenza, colds, and COVID-19 (Natnael et al. 2022; Seid Id et al. 2022). Hand hygiene is an intervention used worldwide.

Throughout the selected studies, some factors were reported to influence hand hygiene practices. Knowledge was reported to be a motivator for students to practice hand hygiene. However, not all students with hygiene awareness and knowledge performed good hand hygiene (Wada & Oloruntoba 2021). This is because hand hygiene habits are dependent on other factors, such as the availability of hand washing facilities and materials (Shao et al. 2021; Berhanu et al. 2022; Bishoge et al. 2022b; Melaku & Addis 2023). Students may have a high degree of awareness and understanding about hand hygiene, but they are more likely to engage in poor hand washing habits if they do not have access to resources such as water, soap, and working faucets. They are unable to put their newly acquired hand washing knowledge into practice due to a lack of equipment and facilities (Nwajiuba et al. 2019), resulting in poor hand hygiene practices (Dajaan et al. 2018). As a result, while the participants had adequate knowledge about WASH, not all of it translated into practice. As it takes time and effort to wash hands, the possibility of adherence is dependent upon the availability of water, soap, and functional hand washing facilities.

Furthermore, hand hygiene seized an essential opportunity for reducing the risk of COVID-19 (WHO 2020c). The public's understanding of hand hygiene has grown through media, training, workshops, and seminars. This improved the public's hand hygiene behaviors and practices, particularly among school pupils. To ensure adequate hand hygiene practices, hand washing facilities were established in most public spaces, particularly schools. However, insufficient water supply was a barrier that necessitated an effective strategy for water management and supply in SSA (Amuakwa-Mensah et al. 2021).

To guarantee proper hand hygiene, more hygiene supplies and facilities, such as running water and soaps, should be provided in schools and homes (Melaku & Addis 2023). This is because the availability of hand washing stations with soap near bathrooms and areas where food is prepared and consumed encourages staff and students to follow appropriate hand washing practices (CDC 2023). They also assist girls in managing their menstruation in a healthy manner. Thus, more hygiene materials and facilities, such as running water and soaps, should be offered in schools and homes to ensure good hand hygiene. This is because the availability of hand washing stations with soap near toilets and near where food is prepared and consumed helps staff and students practice good hand washing habits (Sultana et al. 2021). They also help girls manage menstruation hygienically.

Furthermore, the use of media such as television and radios is critical for improving hand hygiene habits by communicating critical information and knowledge about environmental health, including cleanliness (Bishoge et al. 2022a). For example, the media has done a good job of informing people about how to prevent COVID-19 (Anwar et al. 2020; Islam et al. 2021; Suzuki et al. 2023). In addition, social media sites and platforms such as Facebook, YouTube, Instagram, LinkedIn, Twitter, and WhatsApp play a vital role in boosting learning about hygiene issues (Abbas et al. 2019; Chen & Wang 2021; Faruk et al. 2022). However, school students may struggle to strike a beneficial balance between social media use and other schoolwork (Kessy & Pessa 2022). Furthermore, the media can disseminate fake news or material that is detrimental to kids' learning (Nygren et al. 2020). Thus, teachers, parents, and guardians should manage students' usage of social media, news outlets, and web searches, so that they can make informed decisions about the value of the sources they use and the information gained (Faix 2018).

The study reveals that hand hygiene practices are influenced by other factors, such as parental and teacher influence, and personal and social factors, such as the desire to prevent contagion, odors, living conditions, attitudes, gender, age, and school modernization (Berhanu et al. 2022; Gizaw et al. 2023). These elements are critical considerations when attempting to enhance students' hand hygiene practices. Moreover, gender and age equalities among pupils must also be considered to promote fair and inclusive hygiene services in schools and households (Kayser et al. 2019). Because the groups have diverse lifestyles, hygiene interventions should take into account that students have various needs based on their gender and age (Barata & Maricoto 2019).

Furthermore, the reviewed studies provided recommendations for proper hand hygiene practices in SSA. Further efforts are recommended to strengthen hygiene systems and services at school levels. These efforts include improving hand hygiene and environmental health education and mobilizing resources such as increasing hand washing facilities and materials (Fianko & Gawu 2020; Berhanu et al. 2022). There should be development and implementation of health policies and conducting additional research on the determinants of pro-hygiene and sanitation behaviors across different regions, as well as the effects of the extended structural and social environment on students' behaviors and subsequent disease risks (Seimetz et al. 2017). Likewise, when there is a high level of student hand hygiene practices, it is recommended that environmental health information distribution initiatives, including hand hygiene, be maintained to preserve it.

Implications of this study

Hand hygiene is part of WASH, which is very important for students' health. To keep students healthy, all schools should prioritize WASH improvements. This is because WASH is a critical method for combating the global spread of infectious illnesses (Shrestha et al. 2022). To improve children's lives, the government and other developmental stakeholders should provide improved WASH through the provision of health education as well as WASH materials and facilities. There are limited reviews that provide detailed and comprehensive analyses of hand hygiene practices and their associated influential factors as well as ways to influence hand hygiene among school students in SSA. As a result, this study fills that void by offering evidence from the available literature on the state of hand hygiene practices among SSA school students. It provides a complete summary of the factors that influence school children's hand hygiene behaviors. It adds to the understanding of hand hygiene behaviors and practices, and policymakers should use the evidence to amend or enhance policies addressing the need for improved cleanliness in SSA schools. The government and other stakeholders, such as UNICEF, the United Nations Educational, Scientific and Cultural Organization, and other private organizations, should work together to address this issue since appropriate hygiene practices help ensure that school students are healthy enough to attend classes and learn.

Moreover, hand hygiene practices differ according to the age and class level of the students and the locations and regions of the schools. Hence, hand hygiene interventions need to be implemented according to the issues described above.

Limitations of this study

The reviewed papers showed substantial heterogeneity in sample size, which prevented a meta-analysis from being performed. Small sample sizes were used in some of the investigations (Katikiro 2016; Pasewaldt et al. 2019; Fianko & Gawu 2020). The statistical procedures utilized in the meta-analysis give smaller sample size studies less weight than they deserve. Most meta-analyses include data from one or more small studies that lack the ability to identify an intervention effect on their own (Turner et al. 2013). Furthermore, a few of the examined studies used questionnaires, which were not all pretested and verified before use. The use of untested and invalidated questionnaires in the population of interest may result in measurement error, and any conclusions reached cannot be established with absolute certainty (Tsang et al. 2017). Despite the constraints of the sample and research methodology, the study provides a clear analysis of students' hand hygiene practices and the factors that influence these practices.

This review provides critical and systematic accessible evidence from recently published studies on hand hygiene practices among primary and secondary school pupils. This demonstrates that students in SSA wash their hands regularly, after defecation, and before and after eating. More students' hand hygiene practices were recorded during and after COVID-19 because hand washing was the greatest strategy to prevent the spread of COVID-19 among people. Hand hygiene during the pandemic also increased due to fear. It demonstrates that various factors, such as knowledge, hand washing facilities and materials, influence from parents and teachers or others, personal and social factors, media, gender, age, and other factors, such as place of living, attitudes, and school modernity, can all influence hand hygiene practices. This study's findings contribute to the body of knowledge on the issue. It is recommended that hand hygiene is promoted in schools and communities by teaching and reinforcing hand washing and increasing access to hand hygiene infrastructure and supplies to ensure proper hand hygiene practices that prevent the spread of infectious diseases and thus reduce students' absenteeism, which affects academic performance.

The development of this review was supported by the National Institute for Medical Research, which trained researchers on the systematic review and meta-analysis that facilitated the writing of this paper.

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.

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