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Assessment of hand-washing habits among school students aged 6–18 years in Jordan

Authors:
  • Al Al- Bayt University, Jordan

Abstract and Figures

Abstract Appropriate hand-washing practice with an adequate level of frequency is an essential skill for leading healthy lives. A cross-sectional, school study was conducted over a period of 3 months (October-December, 2016). The participants were students from grade 1 to grade 12, randomly chosen from 14 public schools in Jordan. Complete data regarding their hand-washing habits was obtained. The Pearson chi-square test was computed. Odds ratio was calculated with a 95% confidence interval to show the effect size and the strength of relationship between variables. The findings showed that the majority of the students (97.5%) washed their hands with water, and nearly 70% of them used soap. Furthermore, the majority washed their hands after using the toilet (86.7%) and after touching rubbish (84.4%). Reasons for not washing their hands from the students' perspective included: ‘no need’ (70.8%) and ‘the hand-washing facilities were not clean’ (62.3%). The findings revealed that a low percentage of school students ignored hand-washing after different critical situations, this figure decreased with age. However, the practice should be improved further. Health promotion programmes should be implemented for students and their families in the community or in school settings. Keywords: Hand-washing, Hygiene, School students, Community health, Public health
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30 British Journal of School Nursing February 2017 Vol 12 No 1
Research
© 2017 MA Healthcare Ltd
Assessment of hand-washing
habits among school students
aged 6–18 years in Jordan
Appropriate hand-washing practice with an
adequate level of frequency is an essential skill
for leading healthy lives (Curtis et al, 2011;
Steiner-Asiedu et al, 2011). Hand-washing, especially
before eating, is considered as one of the primary
prevention techniques to protect children, adolescents
and adults from many communicable and infectious
diseases (ALBashtawy, 2015; Curtis et al, 2011; Scott et al,
2003; Roberts et al, 2000). Furthermore, hand-washing is
a prerequisite for normal growth and development in
society (Garbutt et al, 2007; Global Hand-washing Day,
2008; Steiner-Asiedu et al, 2011).
Schools are recognised by many as one of the most
important settings for health education and health-
Mohammed ALBashtawy, Associate professor,
Dean of Faculty of Nursing, Al al-Bayt University
Email: Mohammadbash@aabu.edu.jo
Abstract
Appropriate hand-washing practice with an adequate level of frequency
is an essential skill for leading healthy lives. A cross-sectional, school
study was conducted over a period of 3 months (October-December,
2016). The participants were students from grade 1 to grade 12,
randomly chosen from 14 public schools in Jordan. Complete data
regarding their hand-washing habits was obtained. The Pearson
chi-square test was computed. Odds ratio was calculated with a
95% condence interval to show the effect size and the strength of
relationship between variables. The ndings showed that the majority
of the students (97.5%) washed their hands with water, and nearly 70%
of them used soap. Furthermore, the majority washed their hands after
using the toilet (86.7%) and after touching rubbish (84.4%). Reasons for
not washing their hands from the students’ perspective included: ‘no
need’ (70.8%) and ‘the hand-washing facilities were not clean’ (62.3%).
The ndings revealed that a low percentage of school students ignored
hand-washing after different critical situations, this gure decreased
with age. However, the practice should be improved further. Health
promotion programmes should be implemented for students and their
families in the community or in school settings.
Key words
n Hand-washing n Hygiene n School students
n Community health n Public health
promotion programmes (ALBashtawy, 2015; Lopez-
Quintero et al, 2009; Sarkar, 2013). Health-care providers,
school nurses and teachers can give students the correct
knowledge, practice and a positive attitude toward general
hygiene and hand-washing (ALBashtawy, 2015; Lopez-
Quintero et al, 2009; Monto, 2002; Scott et al, 2003). Despite
the fact that hand-washing is a simple and virtually cost-
free technique, which every school makes accessible to all
students, many school children, especially in developing
countries, fail to wash their hands eectively (ALBashtawy,
2015; General Directorate of Health Promotion, Ministry of
Health of Turkey, 2012; Lopez-Quintero et al, 2009).
Several studies conducted worldwide have discussed
the problem of general hygiene and hand-washing
among school students. One study showed that nearly
one third of all deaths in Africa and South Asia
are related to infectious diseases, and another study
in India (Kosek et al, 2003) revealed that 30% of
all morbidities can be considered as water-related
infections. In Nigeria, Oyibo (2012) found that school
children aged 6–14 years had low average knowledge
and practice scores on general hygiene (74.6% and
54.9% respectively). Furthermore, Oyibo showed that
fewer than 30% of students washed their hands after
using the toilet (Oyibo, 2012). In Colombia, a study
of 2 024 school children revealed that only a third
washed their hands after going to the toilet (Lopez-
Quintero et al, 2009). Nandrup-Bus (2009) stated that
mandatory hand-washing in the school setting can
clearly reduce the percentage of absenteeism due to
infectious diseases.
In Jordan, the situation is no dierent and many
studies have discussed general hygiene practice
among school children with regard to mouth care,
tooth brushing and hair care (ALBashtawy, 2012a;
ALBashtawy, 2012b; ALBashtawy and Hasna, 2012;
Khamaiseh and ALBashtawy, 2013). However, only one
study (ALBashtawy, 2015) discusses the frequency of
hand-washing in some situations, although not in depth.
It showed that only one in four students washed their
hands before eating, 10% aer eating, and 70% aer
using the toilet (ALBashtawy, 2015).
erefore, this new study was carried out to assess
hand-washing among school students aged 6–18 years in
Mafraq Governorate, Jordan.
February 2017 Vol 12 No 1 British Journal of School Nursing 31
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Research questions
nWhat are the hand-washing habits of school students?
nWhat reasons do they give for not washing their hands?
nWho encourages them to wash their hands?
Methods
A cross-sectional, school study was conducted over a
period of 3 months (October–December, 2016). The
participants were school students from grades 1 to 12,
randomly chosen from 14 public schools (7 girls’ schools,
7 boys’ schools) located in Mafraq Governorate, Jordan,
using a multistage sampling technique.
Permission was granted rst by the Ethical Approval
Committee of a public university and then obtained from
the District Education Oce of Mafraq Governorate.
Procedure
Letters delineating the study’s aims, questionnaires, and a
consent form were sent to parents or guardians, and given
to the students to take home a week before the study. The
first form was to be signed by parents or guardians, giving
permission for the child to take part. An informed assent
form was signed by the students themselves if they agreed
to participate in the study.
Complete data regarding their hand-washing habits was
obtained only from those who returned the two completed
consent forms. On the day of data collection, school
students in the 14 schools were invited to participate in
this study.
All the students were given an explanation in class by
the researcher, conrming that their contribution in the
survey was voluntary and that they had the choice to leave
at any stage, without any consequences. Clarication on
how to respond to the questions about their hand-washing
habits was also given to the students.
Of the 3 173 chool students initially invited to
participate, only 2 609 returned the two consent forms
and were present on the day of data collection. e overall
response rate was 82.2%.
Measures
The questionnaire was adapted from previous studies
conducted in English (ALBashtawy, 2015; General Directorate
of Health Promotion, Ministry of Health of Turkey, 2012;
Pati et al, 2014). The final draft was discussed by a panel of
academics (three in public health and three in paediatric
health) for the content and validity, and revised accordingly,
especially to ensure easier understanding in Arabic.
A pilot study was carried out 3 days before the nal data
collection time, with 62 students from dierent grades (32
boys, 30 girls).e pilot study results were not included in
the nal data analysis. Students needed 20 to 35 minutes
to complete all parts of the survey.
The questionnaire
The questionnaire, translated from English into Arabic,
contained a total of ten questions, divided into three
parts. The first part (six questions) asked for socio-
demographic data: the participants gender, age, grade,
place of residence and parents’ level of education. The
second part (three questions) covered the following
topics: substances used for hand-washing during the
previous month, their own reasons for not washing
their hands, and a question asking who encouraged
them to wash their hands. The third part (one question)
asked the students about the frequency of their hand-
washing habits in different situations, measured on a
5-item Likert scale (never, rarely, sometimes, mostly,
and always).
Data analysis
Data were entered, and then analysed using SPSS, version
20. Means, percentages, and standard deviations (SD)
were computed, then the Pearson chi-square test. The
odds ratio was calculated with a 95% confidence interval
to show the effect size and the strength of relationship
between variables. The P-value was considered significant
at P<0.05.
Results
The total number of participants was 2 609 (1 376 boys
and 1 233 girls). Their ages ranged from 6 to 18 years, with
a mean of 9.2 (SD= 6.2). Nearly 30% of the participants
were from the age groups 12–15 years and nearly two
thirds lived in urban areas. Nearly 70% of them had
parents educated at least to secondary level (see Table 1 ).
Table 1. Socio-demographic
characteristics of participants
Characteristics No of students (%) Mean (SD)
Gender
Boys
Girls
Total
1376 (52.7)
1233 (47.3)
2609 (100)
Age groups
6–8
9–11
12–15
16–18
704 (27.0)
683 (26.2)
752 (28.8)
470 (18.0)
9.2 (6.2)
Place of residence
Rural
Urban
839 (32.2)
1770 (67.8)
Mother’s education
Less than secondary
education
Secondary and/or
further education
1852 (71.0)
757 (29.0)
Father’s education
Less than secondary
education
Secondary and/or
further education
811 (31.1)
1798 (68.9)
32 British Journal of School Nursing February 2017 Vol 12 No 1
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Table 2. Substances used for hand-washing in the previous month
*Substance Boys (1376)
n (%)
Girls (1233)
n (%)
Total (2609)
n (%)
Water 1352 (98.3) 1191 (96.6) 2543 (97.5)
Soap 764 (55.5) 1022 (82.9) 1786 (68.5)
Disinfectant 118 (8.6) 403 (32.7) 521 (20.0)
Others 45 (3.3) 53 (4.3) 98 (3.8)
* More than one response
Table 3. Distribution of hand-washing habits among students
*Habits Frequencies
Never
(%)
Rarely
(%)
Sometimes
(%)
Mostly
(%)
Always
(%)
Before eating 3.7 6.2 15.2 19.5 55.4
After eating 1.1 6.3 10.9 16.4 65.3
Before using
the toilet 32.7 40.4 11.1 9.7 6.1
After using
the toilet 2.0 3.7 2.6 5.0 86.7
When I come
back from school 5.6 5.3 9.6 39.4 40.1
After shaking
hands with
people
40.4 36.6 8.6 8.2 6.2
After touching
an animal 3.7 25.9 18.5 21.5 30.4
After waking up
in the morning 2.4 4.4 10.6 3.0 79.6
When my
hands are dirty 0.8 3.2 4.1 10.2 81.7
Before preparing
meals 16.9 8.8 19.5 12.9 41.9
After exchanging
money 83.2 7.7 2.0 5.0 2.1
After cleaning
my ears 4.3 6.9 5.9 10.7 72.2
After cleaning
my nose 7.1 12.3 8.8 5.2 66.6
After sneezing 32.6 36.8 4.1 9.0 17.5
After rubbing
my eyes 20.6 37.8 31.4 6.4 3.8
After touching
rubbish 2.9 5.0 1.0 6.7 84.4
After comb
my hair 19.8 6.6 6.6 42.3 24.7
After playing 17.7 18.2 4.9 9.3 49.9
After picking
up anything
from the ground
1.7 30.1 15.1 31.9 21.2
After wearing
slippers 9.6 14.4 35.9 32.4 7.7
February 2017 Vol 12 No 1 British Journal of School Nursing 33
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e majority of the school students (97.5%) washed
their hands with water, nearly 70% of them used soap and
only a h used disinfectant substances over the previous
month (see Tab l e 2).
Tabl e 3 shows that the majority of the students washed
their hands aer using the toilet (86.7%) and aer touching
rubbish (84.4%), followed by when their hands were dirty
(81.7%). e reasons for not washing their hands included:
‘no need’ (70.8%), hand-washing facilities that were not
clean (62.3%), or soap and hand-washing facilities that
were not easily accessible (33.3%) (see Tab le 4).
Linear regression analysis (odds ratio) revealed that the
frequency of hand-washing aer the toilet was highest
among the 16–18 years age group (1.73), followed by
students living in urban areas (1.36), then students whose
mothers had secondary or higher levels of study (1.27),
and girls (1.24) (see Tab l e 5 ).
School students reported that families (62.1%) and
teachers (48.3%), followed by friends and peer groups
(44.3%) were the sources that encouraged them most to
wash their hands (see Tab l e 6 ).
Discussion
This study was conducted to investigate the hand-washing
habits among primary and secondary public school
students aged 6–18 years in the north Jordan governorate
of Mafraq. It was the rst in-depth study of this kind to
shed light on this habit in Jordan.
Hand-washing with soap and water is an easy, speedy,
and eective way to prevent many infectious and
communicable diseases (Nguyen, 2010). In the current
study, only 68.5% of the school students washed their
hands with soap and water and less than a h used
disinfectant substances. In a hand-washing survey in
Turkey in 2012, it was found that just over half the
population washed their hands with soap (General
Directorate of Health Promotion, Ministry of Health of
Turkey, 2012).
Many studies have shown that washing hands before
eating and aer using the toilet are critical for the
primary prevention of many diseases (ALBashtawy, 2015;
General Directorate of Health Promotion, Ministry of
Health of Turkey, 2012). e ndings show that dierent
proportions of school students always washed their hands
in dierent situations: 86.7% aer using the toilet, 84.4%
aer touching rubbish, 81.7% when their hands were dirty,
and 55.4% before eating. Worldwide, the gures dier.
Halder et al (2010), in their study in Bangladesh, found
that nearly 70% of the students washed their hands aer
using the toilet, 87.3% before eating and 83.2% when their
hands became dirty. In other countries, the frequency
of hand-washing before meals ranged from 35% to 80%
(Aunger et al, 2009; Ray et al, 2006; Ray et al, 2009; Jeong
et, 2007).
In the current study, ndings showed that systematic
hand-washing aer using the toilet was higher among girls
(91.6%) than boys (81.8%) with statistically signicant
dierences. Furthermore, these habits increased with
age (78.3% among the 6–8 age group, compared to
95.9% among those aged 16–18). ese results compare
favourably to some other studies conducted in Africa
(Sarkar, 2013; Ahmadu et al, 2013; Oyibo, 2012) and
India (Vivas et al, 2010). One possible explanation for
the higher proportion of girls could be a greater concern
for personal appearance and being seen as role models
(ALBashtawy et al, 2015). Several studies found that the
score for hygiene among girls is higher than for boys
(ALBashtawy et al, 2016; ALBashtawy, 2014; Garbutt et
al, 2007; Jeong et al, 2007; Luby et al, 2005). Improved
hand-washing as they grow older may be explained by
students becoming more independent and better able to
achieve personal hygiene by themselves, together with
greater awareness during their growth and development,
and sharing new knowledge and practice from the
school, teachers, friends and their families (ALBashtawy
et al, 2015; ALBashtawy et al, 2014; Ahmadu et al, 2013).
Ahmadu et al (2013) in Nigeria revealed that general
hygiene among school children was 74.0%, and that
personal hygiene in general improved as the children
became older.
In the current study, the main sources of encouragement
regarding basic hand-washing are family and school
teachers, followed by friends. is emphasises the
essential role of parents and schools in teaching children
Table 4. Reasons for not washing hands
from school students’ perspective
*Reasons Total (%)
No time 611 (23.4)
No need 1847 (70.8)
Forgetting 516 (19.8)
Soap and hand-washing facilities are not easily
accessible 869 (33.3)
Hand-washing facilities are not clean 1625 (62.3)
Hand-washing facilities are not available 496 (19.0)
Others 399 (15.3)
* More than one response
34 British Journal of School Nursing February 2017 Vol 12 No 1
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about basic personal hygiene, including hand-washing.
Lopez-Quintero et al (2009), in their study in Colombia,
revealed that the most reported sources of information
regarding hand-washing were parents (88.5%), followed
by teachers (66.7%).
Health-care providers, parents, school nurses and
school sta can play a crucial part as role models.
Families, parents and teachers are likely to transmit their
attitude towards hygiene and their practices to their
ospring and students (ALBashtawy, 2014; Vivas et al,
2010; Ahmadu et al, 2013; Oyibo, 2012; Lopez-Quintero
et al, 2009). In the current study, hand-washing was
found to improve with the increased level of parents
education. is may be explained by the fact that the
level of education is one of the basic determinants of a
family’s socio-economic, income and professional levels
(ALBashtawy, 2014; Al-ghzawi et al, 2014; General
Directorate of Health Promotion, Ministry of Health of
Turkey, 2012; Luby, 2008; Ocaktan et al, 2010 ). Several
studies showed that there is a signicant relationship
between parents’ level of education and their socio-
economic position, and hand-washing practice (Dongre
et al, 2006; Luby, 2008; Ocaktan et al, 2010; Moussa et
al, 2015).
Sufficient hand-washing facilities should be easily
available and accessible to all school students, taking
into account the number of students in each school. In
the current study the students reported many reasons
for not washing their hands: 70.8% reported ‘no need’
to do so, 82.3% said that the facilities were not clean,
Table 5. Socio-demographic
characteristics of participants
Characteristics
Always washing hands after using
the toilet (%) P-value OR (CI-95%)
Yes No
Gender
Boys
Girls
81.8
91.6
18.2
8.4
<0.010 1.00
1.24 (1.06-1.38)
Age groups
6–8
9–11
12–15
16–18
78.3
83.6
88.5
95.4
21.7
16.4
11.5
4.6
<0.001
1.00
1.27 (1.11-1.39)
1.40 (1.28-1.61)
1.73 (1.48-1.89)
Place of residence
Rural
Urban
89.3
84.1
10.7
15.9
<0.001
1.00
1.36 (1.18-1.46)
Mother’s education
Less than secondary
education
Secondary and/or
further education
84.6
88.8
15.4
11.2
<0.001
1.00
1.27 (1.08-1.32)
Father’s education
Less than secondary
education
Secondary and/or
further education
85.5
87.9
14.5
12.1
<0.010
1.00
1.19 (1.11-1.35)
Table 6. Who encourages the students to wash their hands?
*Who encourages hand-washing Total
Family 1620 (62.1)
Friends and peer groups 1155 (44.3)
Teachers 1260 (48.3)
Mass media, internet database 1051 (40.3)
School curriculum 868 (33.3)
Others 195 (7.0)
* More than one response
February 2017 Vol 12 No 1 British Journal of School Nursing 35
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and nearly a third commented that soap and the
washing facilities were not easily accessible. Lopez-
Quintero (2009) concluded that many developing
countries reported a lack of water and soap in their
schools. However, Afroza (2007) stated that water, soap
and hand-washing facilities were found in the majority
of schools.
e logistic regression analysis showed that the number
of students ‘always washing hands aer using the toilet’
is higher among urban students (89.3%) than rural ones
(84.1%). ese results are congruent with other studies
carried out worldwide (General Directorate of Health
Promotion, Ministry of Health of Turkey, 2012; Ray, 2006;
Paliwal et al, 2014).
e ndings of this study suggest a need for easy and
clear materials for teaching hand-washing to students
through many parts of the school curriculum. Moreover,
health-promotion programmes by school nurses and
health providers to raise the knowledge, attitude and
practices of the students and their families regarding
basic personal hygiene and eective hand-washing should
be developed and implemented (Assefa and Kumie,
2014; AlAzzam et al, 2016; ALBashtawy et al, 2016;
ALBashtawy, 2014; Dube and January, 2012; Khamaiseh
and ALBashtawy, 2015; Tawalbeh et al, 2015).
Limitations
The current study assessing the hand-washing habits
among school students was limited to self-reported data,
requiring caution especially towards non-normative
findings. Furthermore, some bias may occur from over-
reporting normal or good habits.
Conclusions
The findings revealed that a low percentage of
school students ignored hand-washing after different
critical situations, and this figure decreased with age.
Nevertheless, the practice should be improved further.
Health promotion and health education programmes
should be implemented for students and their families
in the community or in school settings. School nurses
and school staff also have a crucial role in teaching and
encouraging good hand-washing practice. BJSN
Conict of interest: None declared
Acknowledgment: e researcher would like to thank the
school students, their families and teachers for their help
and cooperation.
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... Bu nedenle, küçük yaşlarda öğrenilen kişisel hijyen uygulamalarının kalıcı bir davranış haline gelmesinin daha kolay olacağı düşünüldüğünde ilköğretim çağında verilen hijyen eğitimleri çok önemlidir. El yıkama işlemi basit ve uygulanabilir olmasına ve el yıkamanın öneminin kişiler tarafından bilinmesine rağmen doğru el yıkama davranışının yeterli düzeyde olmadığı belirtilmektedir (2,7,8,14,15). Bu durum hijyen eğitiminin daha farklı ve etkili yöntemlerle yapılması gerektiğini göstermektedir. ...
... Bireyin, ailenin ve toplumun sağlığını korumak, geliştirmek ve doğru sağlık davranışları kazanmasını sağlamak amacıyla planlı biçimde eğitim vermek, toplumda sağlıklı /hasta bireylerle en çok iletişim halinde olan hemşirelerin temel görevleri arasında yer almaktadır (3,14,(16)(17)(18)(19)(20). Amerika Ulusal Okul Hemşireleri Birliği (National Association of School Nurses-NASN) tarafından yayınlanan "Okul Hemşireleri Uygulamaları; Rolleri ve Standartları"nda sağlık eğitimi okul hemşireliği rol ve standartları arasında belirtilmiştir (21). ...
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... In addition, hand washing facilities in public places should be kept clean since some people have reported not washing their hands after using the toilet because the hand washing facilities were visibly dirty [15]. ...
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... A study conducted by [16] on assessment of practice of hand-washing among different school going students to evaluate hand washing practices of school children. The results showed that the majority of the students (97.5%) used water for hand washing, and only 70% of them used soap. ...
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For children, maintenance of personal hygiene helps to improve the quality of life and longevity. This is of particular importance in a slum community with compromised living situation. This study was undertaken to find out the knowledge and practice of personal hygiene among the primary school children living in a slum area, to identify any misconception among them regarding the maintenance of personal hygiene, to find out their morbidity pattern, and also to elicit the relationship between practice of personal hygiene among the children and the literacy status of their mother. A cross-sectional observational study was conducted among 104 primary school children of a primary school situated in the slum area of Chetla, Kolkata, India with the help of a predesigned, pre-tested and structured questionnaire. Data were analyzed statistically by simple proportions and tests of significance. It was found that the female students were more knowledgeable than the male students regarding the maintenance of personal hygiene. There was a wide gap between practice and knowledge of personal hygiene among the primary school children living in the slum area. Even, misconceptions do exist on certain indicators of personal hygiene among the students. Statistically significant association was observed between practices of personal hygiene among the primary school children and the literacy status of their mother. Future of a society depends considerably on the health of its children. The parents and the school teachers, as constructive shapers of children's health behaviors, should play a responsible role in early education of children on personal hygiene.
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Numerous studies have shown that social support improves health behaviors in patients with coronary artery disease (CAD). The purpose of this study was to examine the relationship between adherence to a healthy lifestyle, and social support and selected sociodemographics among patients with CAD. Cross-sectional descriptive design was used. A convenient sample of 153 patients with CAD was recruited from the cardiac clinic in an educational hospital in the north of Jordan. One hundred and thirty-three patients completed the interview. Social support was the most significant predictor-t(124) = 9.51, p < .001-which explained 60% of variance in adherence to a healthy lifestyle. Providing patients with adequate social support improves adherence to a healthy lifestyle. More attention should be given to the elderly and patients with low income to enhance adherence to a healthy lifestyle. The applications of this study in practice provide a guide for nursing clinical assessment of social support for patients facing CAD.