Open Access
8 December 2021 Handwashing Practice and Its Predictors Among Mothers of Children Aged 0 to 23 Months in South Ethiopia: Community Based Cross-Sectional Study
Temesgen Mekonen, Amha Admasie, Yakob Lencha Leka, Damene Darota, Fentaw Wassie Feleke
Author Affiliations +

BACKGROUND: Maternal handwashing practice is an important measure to prevent the spreading of childhood disease. Handwashing is still being practiced to a very low extent especially at critical times since the global prevalence of handwashing with soap was estimated at 19% by a systematic review after compiling 42 studies all over the world.

OBJECTIVE: To assess the handwashing practice and its predictors among mothers of children aged 0 to 23 months in Mareka District, south Ethiopia, 2020.

METHOD: A community-based cross-sectional study was conducted with a multistage sampling technique on 520 women having children aged 0 to 23 months in Mareka District. Data were collected by using interviewer-administered pre-tested structured questionnaires. Data were checked for completeness and entered into Epi data entry 4.6.2. The data were exported into SPSS version 22 for analysis with multivariate logistic regression analysis at P < .05.

RESULT: Mothers wash their hands with soap and water after visiting the latrine (27.1%), after cleaning the child’s bottom (28.5%), before cooking (6.2%), before eating (6.9%), and before feeding the child (21.2%). The most important predictors were water availability near the handwashing location with an adjusted odds ratio (AOR) 5.26 (95% CI 1.99-13.69) and soap availability near the handwashing location with AOR 0.40 (95% CI 0.18-0.89) for good handwashing practice.

CONCLUSION: The handwashing practice at critical times was low. The presences of water and soap near the handwashing location were the most important predictors. It is necessary to increase the provision of both water and soap near the handwashing location for improving handwashing with soap and water at key times.


Handwashing practice is the most affordable and effective means of stopping the spread of infection via faces, body fluids, and inanimate objects.1,2 It is a basic everyday process skill and behavior that should become a lifelong habit in order to enjoy a better quality of life3 though it is challenging to achieve universal handwashing behavior with soap. Handwashing with soap is important for mother—child paired aged 0 to 23 months. In addition to this due to the close proximity of children in household and child care settings, there is a high risk for the spread of infectious disease.4,5

Water, sanitation, and hygiene (WASH) interventions do not typically address these important sources to prevent harmful exposure to young kids.6 Hand hygiene habit formation was supported by the ease of access to hardware and reinforcement of key hygiene behaviors and handwashing with soap was significantly associated with the desire to smell nice, interpersonal influences, presence of handwashing places within paces of the kitchen and latrine, and key handwashing moments (ie, after eating and after cleaning child’s stools).7

An estimated 829 000 water sanitation and hygiene attributable deaths and 49.8 million disability-adjusted life years occurred from diarrheal diseases with an equivalent to 60% of all diarrheal deaths.8 It has been reported that the frequency of handwashing with soap before handling food or after using a toilet was observed in only between 0% and 34.0% of cases.9

As our culture decades, it is our hand use while we dine unlike the western we eat without spoons, forks, or knives. In spite of awareness on the consequences of eating without washing ones, bare hands lead to deaths and disability particularly concerning sanitation and hygiene aspects with mal-absorption nutrients that lead to malnutrition especially for long term consequences of stunting.29

Different studies in Ethiopia suggested that forgetting and a lack of any handwashing infrastructure hindered regular handwashing practice.4,5,10

Handwashing practice is one of the most cost-effective investments in public health and the economic benefits to the prevention of diarrhea, pneumonia, and community health-associated infections, which are extremely costly to individuals, healthcare systems, and countries.1113 Mothers are the immediate and reliable caregivers of children in many countries, and they play a central role in children’s health.14,15 Mothers’ handwashing practices have a significant effect on the maintenance of child health.16 About 88% of diarrhea-associated deaths are attributable to unsafe water, inadequate sanitation, and insufficient hygiene.17

Sustainable Development Goals (SDGs) have focused on the development of healthy lives and well-being for all children and to reduce the number of under-5 children deaths by 10 million between 2017 and 2030.18,19 To achieve this goal, improving the hand hygiene of mothers and children is essential because hands are central to our day-to-day operations, and working with hands that may be contaminated for cooking and eating increases the transfer of contaminants which may cause ill health. Mothers play a dual role infant care, they are responsible for child hygiene (treating their faces, blowing their nostrils, etc.) and general housekeeper (preparing meals for the family, feeding children), and poor hygiene practices can increase the risk of disease spread to children. However, good handwashing practices are rare in low-income countries like Ethiopia,20 and findings suggested that hand washing at critical times such as after defecation or cleaning an infant’s perineum is not common practice.21,22

In Mareka District the 10 top causes of under-5 child morbidity and mortality were most of communicable disease like, typhoid fever, helimenthiasis, no bloody diarrhea and bloody diarrhea, and acute respiratory tract infections.23 Besides these the magnitude of handwashing practice among mothers of children aged 0 to 23 months not identified, however children’s sick with different preventable communicable diseases. Therefore, the aim of this study is initiated to assess handwashing practice and associated factors among mothers’ who have children aged 0 to 23 months in Mareka District, south Ethiopia.


Study setting and period

The study was conducted in Mareka district, Dawro zone, south Ethiopia from August 15 to September 15, 2020. Mareka district was one of the 11 districts in the Dawro zone. It is 455 km far from Addis Ababa which is the capital city of Ethiopia, and 311 km from Hawassa which was the capital city of the SNNPR state.

According to the projection of the Ethiopian census, the district had a total population of 63 022 of which 32 141 were males and 30 881 females. There were 3239 under 2-year-old children. There was 1 health center and 15 functional health posts in the district.23 The communities largely depended on agriculture for their livelihood. The staple food in the highland was locally known as enset (kocho), whereas corn and sorghum were common in low land areas. Common cash crops were wheat and teff.

Study design: A community-based cross-sectional study was conducted

Source population: All mothers having children aged 0 to 23 months living in Mareka district were the source population. Respondents drawn from the randomly selected rural kebeles were considered as the study population.

Exclusion and inclusion criteria: Mothers having children aged 0 to 23 months were excluded if they were not residents for more than 6 months in the district.

Sample size determination: The sample size was determined using single population proportion formula with the prevalence of 81% of the poor handwashing practice among mothers of children 6 to 59 months might not be clean even in the absence of dirt in Aman sub-city Benchi Maji zone south Ethiopia, 2017.24 The assumption was used to calculate the required sample size with the confidence interval of (95%), the margin of error (5%), and the design effect of 2. Finally, adding a 10% none response rate.


The actual sample size was 236 considering 10% of non-response rates and with the design effect of 2, the minimum final total sample size was 520.

Sampling technique and procedure: Mareka district has been selected purposively. A multistage sampling technique was employed. The selected district had a total of 15 kebeles, which were stratified into 2 urban and 13 rural kebeles. The 1 kebele from urban and 4 from rural were selected randomly. The list of mothers having children aged 0 to 23 months were available from the local health extension roaster. The sample size would be distributed to this 5 selected kebele based on the proportional size of mothers having children aged 0 to 23 months. The study units were selected using a systematic random sampling method (Figure 1).

Figure 1.

Schematic representations of the sampling procedure and sampling technique for handwashing practice of mother-child paired and its predictors in Mareka district, South Ethiopia.


Data collection procedure and quality assurance

Data were collected using interviewer-administered questionnaires. The questionnaire has socio-demographic, economic factors, availability of handwashing facility of handwashing practice questions. The questionnaire was developed originally in English and translated to the Amharic and Dawrgna language, and then the Amharic and Dawrgna language was translated to English to see the consistencies of both versions. Data were collected by 3 trained health professionals (diploma nurses) who have good communication skills. Two BSc nurses supervised the data collection process on daily basis. Data collectors informed the mothers about all details of the research purpose and procedures and what is expected of them, potential risks and benefits in order to encourage accurate and honest responses, and also the way how information was handled and also responded to any questions raised by study participants. Data quality was ensured during questionnaire development data collection, entry, and analysis. Before the actual data collection, a pre-test would be done to check the quality of the instrument. During data collection, 2 bachelor degree nurse supervisors and 3 diploma nurse data collectors with previous experience were recruited, and trained. A code was given to the questionnaires during data collection so that errors were timely addressed. The filled questionnaires were checked for completeness and consistency by the data collectors, supervisor, and principal investigator on a daily basis. The children’s age was assessed by local health extension roaster, vaccination status card, BCG scar, and mother recalled. When there is a discrepancy it was corrected by checking the documentation of health extension roster and vaccination card especially during mothers unable to recall.

Data processing and analysis

After cleaning and editing, the data was entered into Epi-data version 4.6.2 and exported to the statistical package for social sciences (SPSS) software version 22 for further analysis. The result was presented using descriptive statistics such as frequency, percentage, and mean (±SD). The bivariable and multivariable logistic regression analyses were used to identify the potential predictors of the outcome variable. Independent variables that remain statistically significant in the bivariable analysis at P < .25 were entered into a multivariable logistic regression model. The overall percentage of the model accurately classified was 73.4%, with Hosmer and Lemeshow goodness-of-fit test P-value of .443, indicating the model fits well. Finally, the statistical association was declared at a 95% confidence interval with an adjusted odds ratio at the multivariable logistic regression model.

Definition of terms

Handwashing: is the act of cleaning hands with water and soap for a purpose of removing soil, dirt, and microorganisms.25

Handwashing practice: is routinely/through the life/action of washing surfaces of lathered hands, followed by rinsing under a stream of water with soap in the critical time of before preparing food, before eating food, after eating food, after cleaning baby the baby bottom, after disposing child feces and after visiting toilet.24,26

Critical time: washing hand before preparing food, before eating food, after eating, after cleaning baby, and after visiting toilet.26

Good maternal handwashing practice: when mothers who have given birth or give care for child score at least 3 and above out of 5 handwashing practice questions.24,26


Socio-demographic characteristics

The mean handwashing age of the mothers was 20.8 years and the median monthly household income was ETB 1440. About 43.8% of mothers were in the age group of 25 to 34 years and nearly half 51.2% of them had not attended the class. Most of the respondents were unemployed 72.3% and one-third 33.3% of them belonged to orthodox and more than half 52.5% were protestant by religion. Two-thirds 65.6% of the respondents lived in rural families (Table 1).

Table 1.

Socio-demographic and socio-economic factors of handwashing practice among mothers of children aged from 0 to 23 months in Mareka district, South Ethiopia in 2020.


Handwashing practice

About 27.1% of the mothers having children aged 0 to 23 months wash their hands with soap and water after visiting the latrine, 28.5% wash after cleaning their child’s bottom, 6.2% before cooking, 6.9% washed hands before eating, and only 21.2% washed before feeding the child. The overall good handwashing practice was 21.50% (Figure 2).

Figure 2.

Handwashing practice of mothers of children aged from 0 to 23 months in Mareka district, South Ethiopia, 2020.


Predisposing factors of handwashing

Near to one-third of mother’s 31.9% adhered to can cause diseases, fewer 30.4% of respondents need soap to wash their hands after toilet visit and more than half of the respondents don’t need soap to wash their hands after a toilet visit 69.6%. Greater than half of them wash their hands with soap if hand looks like dirty 51.2% (Table 2).

Table 2.

Predisposing factors of handwashing practice among mothers of children aged from 0 to 23 months in Mareka district, South Ethiopia in 2020.


Reinforcing factors for mothers handwashing practices

Of the total participants, 5.6%, and 85.0%, had got high pressure to wash their hands from husbands, and health professionals respectively. Only 6.3% of mothers having children aged 0 to 23 months participated in hygiene and sanitation promotion activities from any health programs (Table 3).

Table 3.

Reinforcing factors of handwashing practice among mothers of children aged from 0 to 23 months in Mareka district, South Ethiopia, 2020.


Enabling factors for mothers handwashing practice (n = 520)

In the observed residences of the respondents there were 5.4% had a basin and 94.6% were no basin assigned to wash their hands on the station. From the total observed only 3.8% of toilets had soap or ash and 9.4% of them with water available. About 1 in 3 (33%) mothers having children aged 0 to 23 months knew the importance of handwashing practice water with soap. But majority 96.2% and 90.6% of the observed residences had no soap or ash and water near to toilet respectively (Table 4).

Table 4.

Enabling factors of handwashing practice among mothers of children aged from 0 to 23 months in Mareka district, South Ethiopia, 2020.


Factors associated with handwashing practice

In multivariate logistic regression analysis, maternal age, presence of water, and soap near to latrine were significantly associated with the handwashing practice of mothers having children aged 0 to 23 months. Maternal age, soap, and water near to latrine were significantly associated with maternal handwashing practice, AOR 0.44 (95% CI 0.20-0.63), AOR 0.40 (95% CI 0.18-0.89), and AOR 5.26 (95% CI 1.99-13.89) respectively (Table 5).

Table 5.

Factors associated with handwashing practice among mothers of children aged from 0 to 23 months in Mareka district, South Ethiopia, 2020.



In this study handwashing practice with soap among mothers having children aged 0 to 23 months was 21.5%. it was lower than studies revealed from Northwest Ethiopia 39.1%.27 Similar studies revealed from India showed that handwashing practice with soap was 79.49%.28 Similarly, multiple studies showed that handwashing practice with soap was still challenging for universal practice. It is confirmed by the global prevalence of handwashing with soap was estimated nearly 1 among 5 19% with a systematic review after compiling 42 studies all over the world.11,29 It was also only 8% households had handwashing facilities in Ethiopia which was very low.10 On the other hand, multiple studies have shown that washing hands with soap or ash can reduce the risk of diarrheal diseases by 42% to 47% and this might save a million lives every year. Washing hands with soap and water also helps in the reduction of respiratory tract infections, and stunting among children.3032 This difference might be due to sampling size, study design, setting, climate, tradition, poverty status, and water sanitation and hygiene intervention strategies.

In this study, there was a significant association between handwashing practices and maternal age. It is supported by studies in India28 the younger age-groups handwashing practices were found to be better. A significant association was also observed between presence of water and soap for better handwashing practice at critical times. Therefore handwashing is incorporated along with safe water and sanitations essential interventions for reduction of malnutrition globally and is part of national nutritional programs in many countries.21,29

Global Hygiene Council, World Health Organization and celebrations such as global handwashing day (15 October) emphasize various avenues which promote behavior change toward improved handwashing practices. These may include improvement of water supply at the household or community level as well as hygiene promotion interventions. The practice of handwashing with soap has been prominent in the last few years on the international hygiene agenda. The guiding vision of global handwashing day is a local and global culture of handwashing with the need for soap to wash hands after visiting the toilet. Multimodal programmers for increasing hand hygiene compliance are now recommended as the most reliable, evidence-based method for ensuring sustainable improvement in handwashing practice. In resource constraint countries like Ethiopia should also be motivated and supported who have better penetration among the rural communities toward the promotion of behavior change communication activities at the village level to promote proper and regular hand-washing practices.17,32

Limitation of the study

This study is a cross-sectional study that cannot assess the cause-effect relationship.


In conclusion, the handwashing practice was low. Presences of water and soap near to the handwashing location were significantly associated with handwashing practice for mothers having children aged 0 to 23 months. It is necessary to increase the provision of both water and soap near to the handwashing location for improving handwashing with soap and water at key times.


Special thanks to Wolaita Sodo University for ethical approval of the study.

Author Contributions

TM: conceived and designed the study, performed analysis, interpreted the data. AA, DD, YLL, and FWF involved in the analysis, interpretation of the data. FWF and DD prepare the original manuscript draft. All authors critically reviewed and approved the final manuscript.

Ethical Considerations

It was obtained from Wolaita Sodo University institutional review board (IRB). Permission letter was written from the school of public health for the main study to Mareka district main administrative office for the pre-test.

Availability of Data and Materials

The data sets analyzed during the current study are available from the corresponding author.



Besha B , Guche H . Assessment of hand washing practice and it’s associated factors among first cycle primary school children in Arba Minch town, Ethiopia, 2015. Epidemiology. 2016;6:2161. Google Scholar


Moncion K , Young K , Tunis M , Rempel S , Stirling R , Zhao L . Effectiveness of hand hygiene practices in preventing influenza virus infection in the community setting: a systematic review. Can Commun Dis Rep. 2019;45(1):12–20. Google Scholar


Abhay BM , Nandika SR , Partha R , Chetana KV , Srijith SN , Sriniwas T . Differences of hand hygiene and its correlates among school going children in rural and urban area of Karnataka, India. Arch Med. 2016;8:1–5. Google Scholar


Greenland K , Iradati E , Ati A , Maskoen YY , Aunger R . The context and practice of handwashing among new mothers in Serang, Indonesia: a formative research study. BMC Public Health. 2013;13:830. Google Scholar


Contzen N , Meili IH , Mosler HJ . Changing handwashing behaviour in southern Ethiopia: a longitudinal study on infrastructural and commitment interventions. Soc Sci Med. 2015;124:103–114. Google Scholar


Ss D . Knowledge and practice of handwashing among mothers of under five children in rural coastal South India. Int J Med Public Health. 2011;1:33–38. Google Scholar


Rabbi SE , Dey NC . Exploring the gap between hand washing knowledge and practices in Bangladesh: a cross-sectional comparative study. BMC Public Health. 2013;13:89. Google Scholar


Prüss-Ustün A , Wolf J , Bartram J , et al. Burden of disease from inadequate water, sanitation and hygiene for selected adverse health outcomes: an updated analysis with a focus on low- and middle-income countries. Int J Hyg Environ Health. 2019;222:765–777. Google Scholar


Hasan MM . Investment in Health Within the Agriculture, Water, Sanitation and Hygiene Nexus for Rural Households in Bangladesh. Rheinische Friedrich-Wilhelms-Universität; 2018. Google Scholar


Odo DB , Mekonnen AG . Availability and factors influencing community level handwashing facility in Ethiopia: implication for prevention of infectious diseases. PLoS One. 2021;16:e0243228. Google Scholar


Murray CJ , Lopez AD , Black R , et al. Global burden of disease 2005: call for collaborators. Lancet. 2007;370:109–110. Google Scholar


Biran A , Schmidt WP , Varadharajan KS , et al. Effect of a behaviour-change intervention on handwashing with soap in India (SuperAmma): a cluster-randomised trial. Lancet Glob Health. 2014;2:e145–e154. Google Scholar


Monse B , Benzian H , Naliponguit E , Belizario V , Schratz A , van Palenstein Helderman W . The fit for school health outcome study – a longitudinal survey to assess health impacts of an integrated school health programme in the Philippines. BMC Public Health. 2013;13:256. Google Scholar


Chen C-C , Chiou SJ , Ting CC , et al. Immigrant-native differences in caries-related knowledge, attitude, and oral health behaviors: a cross-sectional study in Taiwan. BMC Oral Health. 2014;14:3. Google Scholar


Al-Zahrani AM , Al-Mushayt AS , Otaibi MF , Wyne AH . Knowledge and attitude of Saudi mothers towards their preschool children’s oral health. Pak J Med Sci. 2014;30:720–724. Google Scholar


Bertrand WE , Walmus BF . Maternal knowledge, attitudes and practice as predictors of diarrhoeal disease in young children. Int J Epidemiol. 1983;12:205–210. Google Scholar


UNICEF. Progress for Children: A Report Card on Water and Sanitation. UNICEF; 2006. Google Scholar


Nadeem M , Adil S , Hunnain F , Nawaz SMN . Predictive model of under-five mortality in developing countries: evidence from multiple indicators cluster survey Punjab. Qual Quant. 2021;1–18. Google Scholar


WHO. Reduce Under-Five Mortality to at Least as Low as 25 Per 1000 Live Births in Every Country. WHO; 2015. Google Scholar


Alula SB , Dejene EM , Terefe ML , Abinet AS , Bazie M . Knowledge, attitude and practice on hand washing and associated factors among public primary schools children in Hosanna town, southern Ethiopia. J Public Health Epidemiol. 2018;10:205–214. Google Scholar


Reddy B V , Kusuma YS , Pandav CS , Goswami AK , Krishnan A . Water and sanitation hygiene practices for under-five children among households of Sugali tribe of Chittoor district, Andhra Pradesh, India. J Environ Public Health. Published online May 31, 2017. doi: Google Scholar


Curtis VA , Danquah LO , Aunger RV . Planned, motivated and habitual hygiene behaviour: an eleven country review. Health Educ Res. 2009;24:655–673. Google Scholar


Mareka District Health Office. Mareka District. Mareka District Health Office; 2020. Google Scholar


Meleko A . Assessment of magnitude of hand washing practice and its determinant factors among mothers/caretakers in Aman sub-city, Bench Maji zone, southwest Ethiopia, 2017. Glob J Reprod Med. 2018;3:67–74. Google Scholar


Vujcic J , Ram PK , Campbell D , Carroll K . Periodic overview of handwashing literature: summary of selected peer-reviewed and grey literature published; 2012.  https://globalhandwashingorg/wp-content/uploads/2015/03/Jan-July-2012-Handwashing-Research-Summary-pdf Google Scholar


Asekun-Olarinmoye Esther O , Olubukola O , Adebimpe Wasiu O , Asekun-Olarinmoye IO . Hand washing: knowledge, attitude and practice amongst mothers of under-five children in Osogbo, Osun state, Nigeria. Hand. 2014;4:40–49. Google Scholar


Adimasu A , Baye Dagnew T . Mother’s handwashing practices and health outcomes of under-five children in northwest Ethiopia. Pediatr Health Med Ther. 2020;11:101. Google Scholar


Pandve H , Chawla P , Giri P , Fernandez K , Singru S . Study of hand washing practices in rural community of Pune, India. Int J Community Med Public Health. 2016;3:190–193. Google Scholar


Phillips RM , Vujcic J , Boscoe A , et al. Soap is not enough: handwashing practices and knowledge in refugee camps, Maban County, South Sudan. Confl Health. 2015;9:39. Google Scholar


Kwami CS , Godfrey S , Gavilan H , Lakhanpaul M , Parikh P . Water, sanitation, and hygiene: linkages with stunting in rural Ethiopia. Int J Environ Res Public Health. 2019;16:3793. Google Scholar


Bekele T , Rahman B , Rawstorne P . The effect of access to water, sanitation and handwashing facilities on child growth indicators: evidence from the Ethiopia demographic and health survey 2016. PLoS One. 2020;15:e0239313. Google Scholar


Waller A , Lakhanpaul M , Godfrey S , Parikh P . Multiple and complex links between babyWASH and stunting: an evidence synthesis. J Water Sanit Hyg Dev. 2020;10:786–805. Google Scholar
© The Author(s) 2021
Temesgen Mekonen, Amha Admasie, Yakob Lencha Leka, Damene Darota, and Fentaw Wassie Feleke "Handwashing Practice and Its Predictors Among Mothers of Children Aged 0 to 23 Months in South Ethiopia: Community Based Cross-Sectional Study," Environmental Health Insights 15(1), (8 December 2021).
Received: 23 May 2021; Accepted: 28 October 2021; Published: 8 December 2021
children aged 0 to 23 months
critical time
handwashing practice
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