Hand-Washing at Critical Times and Associated Factors Among Mothers/Caregivers of Under-Five Year Children in Nefas Silk Lafto Sub-City, Addis Ababa, Ethiopia

Health Services Research and Managerial Epidemiology, Volume 10, Year 2023

Interpretation

Background: Hand washing is the simplest, most affordable, and most effective means of limiting the spread of infections. Despite increasing efforts to improve hand washing at critical times (after defecation, after handling child/adult feces or cleaning child’s bottom, after cleaning the environment, before preparing food, and before eating food), mothers/caregivers of under-five children fail to conduct it; but the reason appears unclear. Thus, this study sought to identify hand washing at critical times and associated factors among mothers/caregivers of under-five children in Nefas Silk Lafto Sub-City, Addis Ababa, Ethiopia. Methods: A facility-based cross-sectional study was conducted on April 1-15, 2019, and 312 mothers/caregivers participated. A pretested questionnaire was used to collect data from participants by interviewer-administered technique and the data were analyzed with the Statistical Package for Social Science version 20. The factors were determined by conducting logistic regression and the crude odds ratio (COR) and adjusted odds ratio (AOR) with their respective 95% confidence intervals. All statistical tests were conducted at a 5% level of significance. Results: The study revealed that 232 (74.4%; 95% CI [69.6%-79.2%]) mothers/caregivers washed their hands at critical times. The illiterate mothers/caregivers and mothers/caregivers who lacked tap water inside the home or the backyard had 66% (AOR = 0.34; 95%CI [0.17-0.69]) and 62% (AOR = 0.38; 95%CI [0.18-0.80]) reduced odds of washing hands at critical times, respectively. Mothers/caregivers from middle had (AOR = 4.56; 95%CI [1.84-11.33]), richer had (AOR = 5.61; 95%CI [2.11-15.30]), and the richest had (AOR = 6.14; 95%CI [2.24-16.72]) times increased likelihood of washing hands at critical times than the poorest. Conclusion: The majority of mothers/caregivers practiced hand washing at critical times, and improving maternal literacy, household economy, and availability of water sources in the backyard are needed to maintain and enhance the practice. Study area: Nefas Silk Lafto Sub-City is one of the ten sub-cities in Addis Ababa. It borders the Kolfe Keranio, Lideta, Kirkos, Bole, and Akaki-Kaliti sub-cities. The sub-city is located between coordinates 8°56′57″ latitude and 38°43′58″ longitude. It is divided into 13 woredas and has total area coverage of 68.30 km2 (26.37 square miles) hectares of land. The total population of the sub-city was estimated to be 366,006 with male to female ratio of 1:1 in 2021. A population is being served by 10 public health centers, 2 public hospitals, 34 private clinics and health coverage of the sub-city is 100%.21 Regarding the water supply, about 95% of households get water from an improved source (piped water sources) and the estimated domestic per capita water consumption was 52 l/c/day. An improved sanitation coverage was below 10% (8%) in the sub-city and a hygiene index was medium (53%),22 and there were no sustainably functioning public hand washing facilities in the sub-city. Study design and period: Institution-based cross-sectional study was carried out on April 1-15, 2019. Study populations: A study populations were who visited health facility during the survey period. Sample size determination: The sample size was calculated manually using the single population proportion formula (n=(Z12)2p(1−p)d2) with the following assumptions; the expected proportion (p) of hand washing practice at critical times 89.6%,19 5% significance level (z = 1.96), 5% margin of error (d), 2 design effect and 10% expected nonresponse rate gave us a sample size of 315. Sampling procedures: Nefas Silk Lafto sub-city had 10 public health centers and 4 health centers (1 health center from each Woreda; woreda 1, 2, 4, and 12) were randomly selected by simple random sampling. The total sample required from each health center was allocated proportionally to the size of the under-five children in each health center catchment. The mothers/caregivers presenting to the health centers with their children for immunization and other childcare services were interviewed. They were selected with an interval of three via a systematic random sampling technique. Study variables: The dependent variable was hand washing at critical times. The independent variables were maternal literacy, paternal literacy, availability of tap water in the backyard, access to health education on hand washing, maternal knowledge on the purpose of hand washing at critical times, average family size, number of live children, and household wealth. Definition of terms: Mother/caregivers or fathers who could only read and write to those who achieved higher degrees were considered literate while those who could not read and write were considered as illiterate. A mother/caregiver had knowledge on the purpose of hand washing if she had information or heard of hand washing and believed that hand washing could prevent disease prevention. Health extension workers (nurses with a diploma in academic qualification and trained on urban health extension packages) and other health professionals were considered as health workers. Data collection: Data were collected by pre-oriented certified nurses with a diploma in academic qualification with strong supervision and follow-up by the supervisor and the investigators. A pretested structured questionnaire was used to collect the data and the interview was administered to the respondents in the Amharic language. One day orientation was given to the data collectors and a supervisor on the objective of the study, how to approach and interview the participants and keep the quality of the data. Before collecting the actual data, 5% of the sample size was pretested at other health facilities to validate the tool and the necessary correction was made to data collection tool. Data on socio-demographic/economic, information, and knowledge related to hand washing and hand washing practice of mother/caregiver were collected on a daily basis via interviewing a mother during the month of December 2019. Data analysis: The educational status of mothers/caregivers was categorized into poorly literate and literate because some of the expected cells violated chi-square assumption (contained value less than five) when the highest grade point achieved was assumed. The wealth index (indicator of living standard of household) was constructed through principal component analysis (PCA) from household assets. We ranked the extracted component into quintiles (five tiles); each quintile holding 20% of households, and the household that belongs to the first quintile was categorized as the poorest and the households that belong to the second, third, fourth, and fifth quintiles were categorized as poor, middle, rich, and the richest, respectively. The value/score one was assigned for a moment when a mother/caregiver had washed her hands with water and soap/substitutes and zero was assigned if a mother/caregiver did not. The scores were summed up to five and a mother/caregiver who had a total score of five was considered as washed her hands at critical times. If the sum of scores is less than five, a mother/caregiver was treated as did not wash her hands at critical moments. Descriptive statistics had been used to describe the study variables and logistic regression was undertaken to identify the factors associated with hand-washing practices. Multi-collinearity test among independent variables was checked at variance inflation factor less than 10 or tolerance greater than 0.1 and a chi-square test was carried out to check expected cells adequacy by cross-tabulation. The model fitness was checked by the Hosmer and Lemshaw model fitness test at nonsignificant p-value and a chi-square test was conducted to check the expected cells adequacy. Findings of descriptive analysis were presented by frequency and percentage, mean or median and the regression outputs were presented by crude and adjusted odds ratios with their 95% confidence intervals. In multivariable analyses, the level of significance was set at P = .05. Quality assurance: Translation and back translation of the questionnaire from English to Amharic and back to English by different individuals to check consistency was undertaken. At the end of each data collection day, data were checked for completeness and consistency, and a discussion with the research assistants was carried out. A unique identification number was assigned to each questionnaire after editing and checking completeness and consistency. After entering the data into SPSS 20, 10% sample was checked for correct entry and cleaning was also continued up to the end of the descriptive analysis.

AI Digest

Study Justification:

The study aimed to investigate hand washing at critical times and associated factors among mothers/caregivers of under-five children in Nefas Silk Lafto Sub-City, Addis Ababa, Ethiopia. Hand washing is a simple and effective way to prevent the spread of infections, yet many mothers/caregivers fail to practice it consistently. This study aimed to identify the reasons behind this behavior and provide recommendations for improvement.

Highlights:

– 74.4% of mothers/caregivers washed their hands at critical times.
– Illiterate mothers/caregivers and those without tap water in the home or backyard had reduced odds of hand washing.
– Mothers/caregivers from middle, richer, and richest households had increased likelihood of hand washing.
– Improving maternal literacy, household economy, and availability of water sources in the backyard are needed to enhance hand washing practices.

Recommendations:

1. Improve maternal literacy: Implement educational programs to enhance literacy among mothers/caregivers, focusing on the importance of hand washing and its role in preventing infections.
2. Increase access to tap water: Ensure that all households have access to tap water, both inside the home and in the backyard, to facilitate hand washing at critical times.
3. Promote hygiene education: Conduct health education campaigns to raise awareness about the importance of hand washing at critical times and provide information on proper hand washing techniques.
4. Address socioeconomic disparities: Implement interventions to improve household economy, particularly among the poorest families, to enable them to afford necessary resources for hand washing.

Key Role Players:

1. Ministry of Health: Responsible for developing and implementing policies related to hygiene and sanitation, as well as coordinating interventions to improve hand washing practices.
2. Local Health Authorities: Responsible for overseeing health facilities and implementing health education programs at the community level.
3. Health Extension Workers: Trained professionals who can deliver health education messages and provide guidance on proper hand washing techniques to mothers/caregivers.
4. Non-Governmental Organizations (NGOs): Collaborate with government agencies to implement hygiene promotion programs and provide resources to improve hand washing practices.

Cost Items for Planning Recommendations:

1. Education Programs: Allocate funds for the development and implementation of educational programs targeting mothers/caregivers to improve literacy and raise awareness about hand washing.
2. Infrastructure Development: Invest in improving water supply infrastructure to ensure all households have access to tap water, both inside the home and in the backyard.
3. Health Education Campaigns: Allocate funds for the design and implementation of health education campaigns to promote hand washing at critical times.
4. Capacity Building: Provide training and capacity building programs for health extension workers and other health professionals to effectively deliver health education messages and support behavior change.
Please note that the cost items provided are general categories and the actual cost will depend on the specific context and implementation strategies.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a facility-based cross-sectional study with a sample size of 312 mothers/caregivers. The study used a pretested questionnaire and conducted logistic regression to determine factors associated with hand washing at critical times. The study provides specific percentages and odds ratios with confidence intervals. However, the study design is cross-sectional, which limits the ability to establish causality. To improve the evidence, future research could consider a longitudinal design to better understand the temporal relationship between factors and hand washing practices. Additionally, the study could include a larger sample size and use a more representative sampling method to enhance generalizability.

Abstract

Study area: Nefas Silk Lafto Sub-City is one of the ten sub-cities in Addis Ababa. It borders the Kolfe Keranio, Lideta, Kirkos, Bole, and Akaki-Kaliti sub-cities. The sub-city is located between coordinates 8°56′57″ latitude and 38°43′58″ longitude. It is divided into 13 woredas and has total area coverage of 68.30 km2 (26.37 square miles) hectares of land. The total population of the sub-city was estimated to be 366,006 with male to female ratio of 1:1 in 2021. A population is being served by 10 public health centers, 2 public hospitals, 34 private clinics and health coverage of the sub-city is 100%.21 Regarding the water supply, about 95% of households get water from an improved source (piped water sources) and the estimated domestic per capita water consumption was 52 l/c/day. An improved sanitation coverage was below 10% (8%) in the sub-city and a hygiene index was medium (53%),22 and there were no sustainably functioning public hand washing facilities in the sub-city. Study design and period: Institution-based cross-sectional study was carried out on April 1-15, 2019. Study populations: A study populations were who visited health facility during the survey period. Sample size determination: The sample size was calculated manually using the single population proportion formula (n=(Z12)2p(1−p)d2) with the following assumptions; the expected proportion (p) of hand washing practice at critical times 89.6%,19 5% significance level (z = 1.96), 5% margin of error (d), 2 design effect and 10% expected nonresponse rate gave us a sample size of 315. Sampling procedures: Nefas Silk Lafto sub-city had 10 public health centers and 4 health centers (1 health center from each Woreda; woreda 1, 2, 4, and 12) were randomly selected by simple random sampling. The total sample required from each health center was allocated proportionally to the size of the under-five children in each health center catchment. The mothers/caregivers presenting to the health centers with their children for immunization and other childcare services were interviewed. They were selected with an interval of three via a systematic random sampling technique. Study variables: The dependent variable was hand washing at critical times. The independent variables were maternal literacy, paternal literacy, availability of tap water in the backyard, access to health education on hand washing, maternal knowledge on the purpose of hand washing at critical times, average family size, number of live children, and household wealth. Definition of terms: Mother/caregivers or fathers who could only read and write to those who achieved higher degrees were considered literate while those who could not read and write were considered as illiterate. A mother/caregiver had knowledge on the purpose of hand washing if she had information or heard of hand washing and believed that hand washing could prevent disease prevention. Health extension workers (nurses with a diploma in academic qualification and trained on urban health extension packages) and other health professionals were considered as health workers. Data collection: Data were collected by pre-oriented certified nurses with a diploma in academic qualification with strong supervision and follow-up by the supervisor and the investigators. A pretested structured questionnaire was used to collect the data and the interview was administered to the respondents in the Amharic language. One day orientation was given to the data collectors and a supervisor on the objective of the study, how to approach and interview the participants and keep the quality of the data. Before collecting the actual data, 5% of the sample size was pretested at other health facilities to validate the tool and the necessary correction was made to data collection tool. Data on socio-demographic/economic, information, and knowledge related to hand washing and hand washing practice of mother/caregiver were collected on a daily basis via interviewing a mother during the month of December 2019. Data analysis: The educational status of mothers/caregivers was categorized into poorly literate and literate because some of the expected cells violated chi-square assumption (contained value less than five) when the highest grade point achieved was assumed. The wealth index (indicator of living standard of household) was constructed through principal component analysis (PCA) from household assets. We ranked the extracted component into quintiles (five tiles); each quintile holding 20% of households, and the household that belongs to the first quintile was categorized as the poorest and the households that belong to the second, third, fourth, and fifth quintiles were categorized as poor, middle, rich, and the richest, respectively. The value/score one was assigned for a moment when a mother/caregiver had washed her hands with water and soap/substitutes and zero was assigned if a mother/caregiver did not. The scores were summed up to five and a mother/caregiver who had a total score of five was considered as washed her hands at critical times. If the sum of scores is less than five, a mother/caregiver was treated as did not wash her hands at critical moments. Descriptive statistics had been used to describe the study variables and logistic regression was undertaken to identify the factors associated with hand-washing practices. Multi-collinearity test among independent variables was checked at variance inflation factor less than 10 or tolerance greater than 0.1 and a chi-square test was carried out to check expected cells adequacy by cross-tabulation. The model fitness was checked by the Hosmer and Lemshaw model fitness test at nonsignificant p-value and a chi-square test was conducted to check the expected cells adequacy. Findings of descriptive analysis were presented by frequency and percentage, mean or median and the regression outputs were presented by crude and adjusted odds ratios with their 95% confidence intervals. In multivariable analyses, the level of significance was set at P = .05. Quality assurance: Translation and back translation of the questionnaire from English to Amharic and back to English by different individuals to check consistency was undertaken. At the end of each data collection day, data were checked for completeness and consistency, and a discussion with the research assistants was carried out. A unique identification number was assigned to each questionnaire after editing and checking completeness and consistency. After entering the data into SPSS 20, 10% sample was checked for correct entry and cleaning was also continued up to the end of the descriptive analysis.

Materials

N/A

Innovations

Based on the provided information, here are some potential innovations that can be used to improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop and implement mobile applications that provide information and reminders to mothers/caregivers about the importance of hand washing at critical times. These apps can also provide educational resources on maternal health and hygiene practices.

2. Community Health Workers: Train and deploy community health workers to educate mothers/caregivers about the importance of hand washing at critical times and provide support in implementing this practice. These workers can also conduct home visits to reinforce the message and address any barriers or challenges faced by mothers/caregivers.

3. Water and Sanitation Infrastructure: Improve access to tap water in households and ensure the availability of water sources in the backyard. This can be achieved through infrastructure development projects that focus on expanding water supply networks and promoting the use of improved sanitation facilities.

4. Health Education Campaigns: Conduct targeted health education campaigns that raise awareness about the benefits of hand washing at critical times. These campaigns can utilize various communication channels such as radio, television, social media, and community gatherings to reach a wide audience.

5. Maternal Literacy Programs: Implement programs that focus on improving maternal literacy levels, as illiterate mothers/caregivers were found to have reduced odds of washing hands at critical times. These programs can provide basic literacy skills and also include health-related information and practices.

6. Public Hand Washing Facilities: Establish sustainably functioning public hand washing facilities in the study area. These facilities can be strategically located in public spaces, health centers, and schools to ensure easy access for mothers/caregivers.

It is important to note that the specific context and needs of the study area should be considered when implementing these innovations. Additionally, a comprehensive approach that addresses multiple factors influencing hand washing practices should be adopted to achieve sustainable improvements in maternal health access.

AI Innovations Description

The recommendation based on the study mentioned is to implement a comprehensive intervention program to improve hand-washing practices among mothers/caregivers of under-five children in Nefas Silk Lafto Sub-City, Addis Ababa, Ethiopia. This program should focus on the following areas:

1. Health education: Conduct regular health education sessions targeting mothers/caregivers to increase their knowledge and awareness about the importance of hand washing at critical times. Emphasize the role of hand washing in preventing the spread of infections and improving maternal and child health.

2. Literacy programs: Develop literacy programs specifically tailored for illiterate mothers/caregivers to improve their understanding of health-related information, including the importance of hand washing. Collaborate with local educational institutions and community organizations to provide accessible and culturally appropriate literacy classes.

3. Access to water: Improve access to tap water inside the home or in the backyard for households in Nefas Silk Lafto Sub-City. Collaborate with local authorities and water supply agencies to ensure reliable and safe water sources are available to all households, especially those with under-five children.

4. Infrastructure development: Establish sustainably functioning public hand washing facilities in strategic locations within the sub-city. These facilities should be easily accessible to mothers/caregivers and equipped with soap or hand sanitizers. Collaborate with local authorities and community leaders to identify suitable locations and ensure regular maintenance of these facilities.

5. Behavior change communication: Implement behavior change communication campaigns using various channels such as radio, television, community meetings, and social media. These campaigns should promote the benefits of hand washing at critical times and address any misconceptions or barriers that mothers/caregivers may have.

6. Monitoring and evaluation: Establish a monitoring and evaluation system to assess the effectiveness of the intervention program. Regularly collect data on hand-washing practices among mothers/caregivers and use this information to identify areas for improvement and make necessary adjustments to the program.

By implementing these recommendations, it is expected that access to maternal health will be improved through increased hand-washing practices among mothers/caregivers of under-five children in Nefas Silk Lafto Sub-City, Addis Ababa, Ethiopia.

AI Innovations Methodology

Based on the provided study, here are some potential recommendations to improve access to maternal health:

1. Health Education Programs: Implement comprehensive health education programs that specifically target mothers and caregivers of under-five children. These programs should focus on raising awareness about the importance of hand washing at critical times and provide information on proper hand washing techniques.

2. Infrastructure Improvement: Improve access to tap water inside homes or in the backyard of households. This can be achieved through the installation of water supply systems or the promotion of water storage solutions, such as rainwater harvesting.

3. Maternal Literacy Programs: Develop and implement literacy programs for illiterate mothers and caregivers. These programs can help improve their understanding of health-related information, including the importance of hand washing, and empower them to make informed decisions regarding their own and their children’s health.

4. Community Engagement: Engage community leaders, local organizations, and health extension workers to promote and support hand washing practices. This can be done through community awareness campaigns, training sessions, and the establishment of community-based hand washing facilities.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Baseline Data Collection: Collect baseline data on the current hand washing practices among mothers and caregivers of under-five children in the study area. This can be done through surveys, interviews, or observations.

2. Intervention Implementation: Implement the recommended interventions, such as health education programs, infrastructure improvements, and maternal literacy programs, in the study area. Ensure that the interventions are properly implemented and reach the target population.

3. Data Collection after Intervention: Collect data on hand washing practices after the implementation of the interventions. This can be done using the same methods as the baseline data collection.

4. Data Analysis: Analyze the data collected before and after the interventions to assess the impact of the recommendations on improving access to maternal health. Compare the hand washing practices before and after the interventions and calculate the changes in percentages or odds ratios.

5. Interpretation of Results: Interpret the results of the data analysis to determine the effectiveness of the interventions in improving access to maternal health. Identify any significant changes in hand washing practices and assess the overall impact of the recommendations.

6. Recommendations and Future Steps: Based on the results, provide recommendations for further improvements and identify any additional interventions that may be needed to sustain and enhance the practice of hand washing at critical times among mothers and caregivers of under-five children.

It is important to note that the methodology described above is a general framework and can be adapted and modified based on the specific context and resources available for the study.

Author

Dima Health

Identifiers:

DOI: 10.1177/23333928231153011

Research Areas:

Community Interventions, Environmental, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Male & Female