Study design and settings
Community based cross-sectional study was conducted from May 1 to 20, 2018 to assess hand washing practice at critical times and associated factors among mothers in Debark town in North Gondar zone of the Amhara region, northwest Ethiopia. It has a total population of 25,350 people. It is divided in to 3 kebeles (smallest administrative unit). The town has 1 hospital, 1 health center, 2 medium clinics, 4 primary clinic and 6 pharmacies [12].
Sample size determination
Single population proportion formula was used to determine the sample size with the following assumptions: p = 38.7 (approximated to 39) (magnitude of hand washing practice at the critical times from Addis Ababa in 2017 [13]), 95% confidence interval, z = the standard normal tabulated value, and α = level of significance and 5% margin of error (d).
$$ n=\frac{{\left({z}_{\frac{a}{2}}\right)}^2\times p\times \left(1-p\right)}{d^2}=\frac{(1.96)^2\times 0.39\times \left(1-0.39\right)}{(0.05)^2}=366 $$
Considering, 10% non-response rate, the final sample became 402.
Sampling procedures
Simple random sampling technique was used to select study participants. The study participants were selected from the 3 kebeles using simple random sampling technique. The total number of mothers of under five children in the study area was 4070. The number of participants was allocated proportionally based on the number of mothers of under- five at each Kebele. Data collectors went house to house and collect the data through walk through approach randomly. The names and locations of mothers of under-five were found from health extension workers’ log book.
Data collection procedures
A semi-structured, pre-tested questionnaire adapted from different literature was used to collect data (Additional file 1). Two graduating class Environmental Health students were involved in the data collection process. Training was given for the data collectors regarding the data collection tool, techniques of interview and selection of study participants using simple random sampling. The data collectors visited all selected households and interviewed selected mothers of under-five children. The interview was supervised by the primary investigator. The collected data were checked by the data collectors immediately after finalising the questionnaire before they left the house. Data completeness, quality, and consistency were checked daily.
Operational definition
Hand washing practice at the critical times
Respondents were asked 16 practice questions (Cronbach’s alpha 0.80) whether they wash their hands with water and soap with a 4-scale Likert (1-always, 2-usually, 3-sometimes and 4-never) after toilet visit, before eating, after eating, before and after food preparation, before breastfeeding, after handling babies’ faeces, changing babies’ diapers, after touching money, after touching skin, after patient care, after touching raw food, after touching work cloth, after handling garbage, after handling liquid waste, after sneezing and coughing, before handling raw food and before serving food. The responses forwarded by study participants were dichotomised as 1 for always and usually and 0 for sometimes and never. The responses were added, and the mean was computed. Those participants who scored mean and above mean of the practice questions were considered as having good self-reported hand washing practice.
Knowledge about hand washing practice at critical times
Respondents were asked 14 knowledge questions (Cronbach’s alpha 0.82) about their knowledge of critical times of hand washing, whether the respondents ever heard about hand washing at critical times, importance of hand washing at critical times, whether the respondents know that hand washing at critical times reduces gastrointestinal diseases, the disease transmitted by not washing hands, recommended length of time for washing hands, whether they know that hand can transfer disease-causing microorganisms, the role of proper hand washing for prevention of infectious disease such as respiratory infection, knowledge of role of mothers in their children’s hand hygiene, whether they know that long nails can harbour and easily spread bacteria, whether the respondents know that they have to wash their hands after handling babies’ stools, knowledge of hand washing before feeding child, after touching money, after handling garbage, after sneezing and coughing and after defecation. The correct answers were coded as 1 and the wrong answers as 0. Those study participants who scored mean and above mean of the sum of the knowledge questions were considered as having good knowledge.
Attitude about hand washing practice at critical times
Respondents were asked about their views for 14 attitudinal questions (Cronbach’s alpha 0.78) with a 4-scale Likert (1-strongly agree, 2-agree, 3-disagree and 4-strongly disagree) dichotomised as desirable and none desirable attitude. Those study participants who scored mean and above mean of the attitude questions were considered as holding the desirable attitude.
Data management and statistical analysis
Data were entered using Epi-info version 7 and exported into SPSS version 21 for further analysis. For most variables, data were presented by frequencies and percentages. Binary logistic regression analysis was used to choose variables for the multivariable binary logistic regression analysis. Variables with p ≤ 0.2 during univariable binary logistic regression analysis were entered into multivariable binary logistic regression analysis for controlling the possible effect of confounders. Finally, variables which had significant association with hand washing practice at critical times were identified on the basis of AOR with 95% CI and p ≤ 0.05. Hosmer and Lemeshow goodness- of -fit test was used to check model fitness.
