Introduction

The term “hygiene” refers to the practice of keeping oneself and one’s surroundings clean, mainly in order to avoid illness or disease spread [1,2,3]. Hygiene is the process of cleansing an environment of any pathogens that could cause illness [4]. The majority of health problems affecting school students can be prevented by encouraging personal hygiene (PH) practices among schoolchildren and family members. Poor school sanitation and personal hygiene are the main problems with school setup, and it is still a high-risky habit among elementary school students [2, 4]. The majority of diarrheal disease-related illnesses could be avoided if schools had a reliable, safe water supply and good sanitation practices [2, 4].

Globally, there are 2.4 billion people who live without adequate sanitation; 758 million do not have access to improved water sources; and 673 million still defecate in the open field [5]. Beyond the immediate implications for the child’s health, poor HP in children can have major economic and social effects, including significant school absences; the spread of infectious agents to others; and lost workdays for parents and guardians. Around 1.9 billion educational days are lost due to sickness each year globally on average due to sickness that could be prevented [2, 4].Water-related illnesses account for approximately 443 million school days missed each year in the developing world, making them a major cause of school absences [6].

Over two million people die each year from diarrheal illnesses, with children being more at risk of dying from these infections [7]. Over 80% of diseases are linked to poor hygiene in underdeveloped countries [7]. Poor water, sanitation, hygiene (WASH) accounts for 60% of the burden of communicable diseases (CD) in Ethiopia, and over 250,000 children die yearly [6]. As a result, CDs are considered the major causes of illness, death, and disability in Ethiopia. Schools with poor hygiene and intense person-to-person contact are highly risky environment for children [6]. However, few schools in Ethiopia have a water supply and toilet facilities for sanitation and hygiene purposes [8].

Despite considerable evidence on PH problems among general population in Ethiopia, there is an evidence gap on PH among elementary school students. Moreover, there are limited evidence regarding personal hygiene practices among elementary school students the study area. In addition, students are at greater risk of acquiring diarrheal diseases, acute respiratory infections, and other personal hygiene-related diseases in schools. However, there is limited information on the factors affecting personal hygiene in elementary schools. Therefore, this study was aimed to determine the magnitude of personal hygiene and associated factors among elementary school students in Fiche town.

Methods and material

Study design and setting

An institution-based cross-sectional study design was used to determine personal hygiene practice and its associated factors among elementary school students in Fiche Town, Oromia region, Ethiopia. There were 13 primary schools in the town. Of these, eight were grade 5–8 schools, while five were grade 1–4 schools. Based on the data obtained from the education bureau, of the 9292 primary school students, 4818 were in grades 5–8 and enrolled in school for 2021/22 academic years. This study was conducted in elementary schools in Fiche town from April 29 to May 29, 2022, among all students who were in the secondary cycle (grades 5–8).

Population

Inclusion and exclusion criteria

All grade 5–8 students who admitted for 2021/22 academic year were included in the study. However, mentally and physically incapable students were excluded from the study.

Sample size determination

The sample size was calculated using a single population proportion formula by assuming 30% true population prevalence of good personal hygiene practice among the students [6], 5% margin of error, 95% confidence interval, and 1.5 design effect. Accordingly, the determined sample size was 323 students. By accounting for the design effect within the clusters (schools and grade) the sample size was increased by 1.5 design effect and the total sample size became 485 students. The sample size further increased by 10% for non-response rate and the total sample size of this study was 534 secondary cycle students.

Sampling procedure

A multi-stage probability sampling method with three stages was used. The first stage was schooled; the second classes; and the third individual students. There were 13 elementary schools in Fiche town; of these, eight schools had a full cycle from grade 1–8. Five schools were selected from the total 13 schools by a simple random sampling method. Of the total 3769 students who were enrolled in grades 5–8 in the 2021/22 academic year, 534 students were selected by proportion of the total number of students in school, and each student was selected by a simple random sampling method using a list of students’ names in each section as a sample frame [Fig. 1].

Fig. 1
figure 1

Schematic representation of the sampling procedure of students Fiche town, Oromia, Ethiopia, 2022

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Data collections tools and methods

A structured questionnaire was prepared based on a literature review [1, 6, 9,10,11]. It was prepared in English and translated into the local languages (Afan-Oromo and Amharic). The two-day training was provided for five data collectors and supervisors on the study objective, procedure, research ethics, and data collection tools. The students were selected by five teachers, who were school supervisors. After individual students were selected, study objectives and procedures were thoroughly explained for each selected student. Assent was obtained from each family of the student (by sending consent forms to their family) for those younger than 18 years, and written informed consent from students who were older than 18 years. Finally, the structured questions were administered by trained data collectors. The data collection process was supervised by the principal investigator and supervisors.

Data analysis

The data was entered into Epi-Data, cleaned, and recoded. Data was exported to SPSS (Statistical Package for the Social Sciences) version 26 for analysis. Descriptive statistics such as frequency and percentage for categorical variables and mean with standard deviation for continuous variables were conducted. Data are presented in text, tables, and graphs. Multilevel logistic regression models were used to assess the factors associated with poor personal hygiene practices. A multilevel logistic regression analysis was applied to account for the corrections at the school, class, and individual levels. It also enables the partitioning of the total variation in the outcome within groups and between school, class, and individual variances by modelling cross-level interaction [12]. The first level was a school; the second level was classes; and the third level was individual student behaviour. Variables with a p-value ≤ 0.2 during bi-variable analysis were included in the multivariable model by the stepwise model-building method. Multi-collinearity between independent variables was checked by a variance inflation factor (VIF). Model fitness was checked by the Hosmer and Lemeshow goodness-of-fit tests. Adjusted odds ratios with 95% confidence intervals were estimated to show the strength and significance of the association between each independent and dependent variable. P \(\:\le\:\) 0.05 was used as a significant association.

Results

Socio-demographic characteristics of participants

From five elementary schools, 534 students were participated in this study with a response rate of 100%. Of 534 participates, 227 (42.5%) were male. The mean age ± standard deviation of the participants was 14.3\(\:\pm\:\) 1.7 years with the age range of 9 to 22 years. From the total of 534 students, grade five 91(17%), six 159 (29.8%), seven 139 (26%) and eight145 (27.2%) [Table 1].

Table 1 Socio-demography of participants in Fiche town, Oromia, Ethiopia, 2022 (N=534)
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Knowledge of personal hygiene

The majority of the students got personal hygiene information from their families 332 (65.4%). Nearly half (52.2%) of the students had good knowledge of personal hygiene, while 365 (68.5%) had good hand washing, and 449 (84.1%) had good oral hygiene. The majority of the students (84.1%) knew that hand washing is necessary before eating food, and 352 (65.9%) after defecation and 322 (60.4%) after eating food. The majority (90.1%) of elementary students understood cleaning teeth with a chewing stick/toothpaste and brush to prevent tooth decay and the unpleasant odor of breathing [Table 2].

Table 2 Knowledge of personal hygiene of participants in Fiche town, Oromia, Ethiopia, 2022(N=534)
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Magnitude of personal hygiene practice

More than half of the students had good hygiene practices, while 318 (59.60%) had good hand washing practice [Fig. 2]. Almost all (98.7%) elementary school students were practicing regular bathing. Of the students who took a bath, the majority (76.1%) took it once a week. Most (83.1%) of the students have experience of hand washing with soap or ash. The majority of the students (88.4%) brushed their teeth; of those who brushed their teeth with a brush and soap, 331 (62.0%) and only 147 (27.5%) brushed twice per day (morning and night). Almost all (97.6%) students washed their faces. Among those who washed their faces, 247 (46.3%) washed with soap twice a day, and 520 (97.4%) trimmed their nails regularly [Table 3].

Fig. 2
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Magnitude of hygiene practice of elementary school students in Fiche town, Oromia, Ethiopia, 2022

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Table 3 Magnitude on personal hygiene practices of elementary school students in Fiche town, Oromia, Ethiopia, 2022(N=534)
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About two thirds (65.5%) of the students stated that there was a weekly personal hygiene inspection in school. All elementary schools had latrine facilities in their compound, but the available latrines were not adequate for the number of students (i.e., the toilet to setting pit ratio was 0.009 for females and 0.008 for male students). One-fourth of the students practiced open field defecation.

The majority (87.1%) of students have received health education on personal hygiene which given by teachers (81.7%), health professionals (32.3%), non-governmental organizations (6.9%), school clubs (23.4%), and media (23.9%). Most (70%) of the students participated in hygiene-related clubs such as sanitation and hygiene (40.4%) and menstrual hygiene clubs (40.8%) [Table 4]. About two third (65.5%) of the students were stated as they had weekly personal hygiene inspection. Among the 401 students, 394 (73.8%) washed their hands after eating and 365 (68.4%) washed their hands after using the toilet. Nearly half of the students had hand washing practice after critical time [Fig. 3].

Fig. 3
figure 3

Shows the percentage distribution of (Use soap/ash during hand washing before eating (A), Always wash hands with soap/ash after eating (B), Always wash hand with soap/ash after visiting toilet (C) and hand washing after critical time (D) in Fiche town, Oromia, Ethiopia, 2022

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Table 4 Source of information about personal hygiene of participants in Fiche town, Oromia, Ethiopia, 2022
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The children in this study area had diarrhea the last two weeks before data collection 43(8.1%) and headaches 86(16.1%) (Fig. 4).

Fig. 4
figure 4

Shows that students having illness before the last two weeks of data collection among elementary school students in Fiche town, Oromia, Ethiopia, 2022

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Factors associated with personal hygiene practice

Being female students (COR = 1.9, 95% CI (1.3– 2.7); p < 0.001), having mother who attended primary and secondary school (COR = 2.1, 95% CI (1.4 − 3.1); p = 0.001) and Diploma or above (COR = 1.9, 95%CI (1.1–3.2), p = 0.013) were significantly associated with personal hygiene practice Family size less than or equal to five (COR = 1.8, 95% CI (1.3–2.6), p = 0.001), Being received health education on personal hygiene (COR = 3.2, 95% CI: 1.9–5.4; p < 0.001), being participated in health-related clubs (COR = 2.1, 95% CI (1.4–3.0); p < 0.001); and being trained in personal hygiene (COR = 1.5, 95% CI(1.1 − 2.2); p = 0.017) were significantly associated with personal hygiene practice in unadjusted analysis. Moreover, availability of school personal hygiene inspection (COR = 2.1, 95% CI (1.5–3.0, p < 0.001), having good knowledge on oral hygiene, (COR = 2.0, 95% CI (1.3 − 3.2); p < 0.000), hand washing (COR = 2.2, 95% CI (1.5 − 3.1); p < 0.001), and personal hygiene (COR = 2.4, 95% CI (1.7 − 3.4); p < 0.001) were significantly associated with personal hygiene [Table 5].

Table 5 Multilevel logistic model analysis Factors Associated with Personal Hygiene Practice among elementary school students in Fiche town, Oromia, Ethiopia, 2022(N=534)
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In multivariate multilevel logistic regression model, being female student (AOR = 1.8, 95% CI (1.1 − 2.8); p = 0.013), availability of school personal hygiene inspection (AOR = 1.9, 95% CI (1.1 − 3.2); p = 0.015), and good knowledge towards overall personal hygiene (AOR = 2.3, 95% CI (1.3 − 4.1); p = 0.005) were significantly associated with good personal hygiene practice [Table 5].

Discussion

This study was conducted to determine personal hygiene practices and their associated factors among elementary school (grades 5–8) students. It revealed that, more than half of the students had a good overall personal hygiene (PH), hand washing (HW), latrine use (LU), and oral hygiene (OH) practices. Personal hygiene knowledge, hygiene inspection in school, and being a female student were significantly associated with personal hygiene practice.

The magnitude of overall good PH was 59.2%, which was higher than the findings of a similar study reported from Mareko District [6]. This discrepancy could be due to the level of knowledge of children about personal hygiene and the fact that the residence of the previous study was only in town. However, in the current study, the students resided in both urban, semi-urban, and rural areas, which could have an effect on personal hygiene practices. In contrast, the results of the current study are similar to those of the previously reported studies [13]. In the present study, the overall personal hygiene knowledge of students was half, which was higher than the survey study reported by rural students from China [14]. This difference may be due to the setting of the study. In the current study, the students were residents of mixed setups, while the participants in the study reported from China were purely rural residents [14].

In the current study area, all elementary schools had toilets, compared with the national minister of education’s report (2017) that 76% of schools in Ethiopia have latrines [15]. In the current study area, all elementary schools had toilets, compared with the national minister of education’s report (2017) that 76% of schools in Ethiopia have latrines [15]. In the present study, good LU practice was found to be 62.5%. This finding was higher than the findings of a previous study reported from Mareko District, in which 46% of students practice LU [6]. Moreover, the present study result on latrine use practice was higher than the previous study reported from Chencha District (33.3%) [16] and Sigmo (39%) [17]. The availability of separate toilets by sex (48.0%) and toilet privacy (30.8%) were the main motivators that encouraged students to use the toilet in the present study. This result is in agreement with to the study reported by Mareko 50% [6]. The result shows that the students stated that 33.1% of the school latrines were inaccessible to students irrespective of their physical disabilities, and 66.9% of the school children stated latrines were not accessible to younger students. This could be due to the design problem (21.8%), the distance from the rooms (12.6%), or the fact that 222 (62.2%) had no reason.

In the current study, hand-washing facilities near the toilet were 38.4% higher compared to the national minister of education’s report of 4.4%. This might be due to the fact that the study area is smaller than the national survey. Good hand washing practice among elementary school children in Fiche town was found to be 59.6%. This is very high compared with a study in Mareko (23%) [6], Yirgalem Town (39.1%) [7], Debark Town (52.2%) [18], Arba Minch Town (22.3%) [19], and Sebeta Town (32%) [20]. This could be due to the availability of sanitation facilities in the study areas. However, the present study result is similar to a study reported from India (60%) [21]. More than half (59.7%) of the students were always washing their hands with soap or ash at critical times. This result was lower than the results reported in studies conducted in Yirgalem town (88.2%) [7], Bangladesh (71.6%) [22], and the United Arab Emirate (71%) [23]. However, the present study result is higher than the studies reported from Mareko (26.8%) [6] and India (29.1%) [24]. This difference is most probably due to the difference in the knowledge level of the students about hand washing.

Two-thirds of the students had good knowledge of handwashing practices. This was similar to the study reported from Hosanna town (66.1%) [25]. However, the result of the current study on knowledge of washing hands with soap is much lower than study reported from Yirgalem (89%) [8], Bangladesh (89%) [22] and Saudi Arabia (90%) [3]. This difference most probably due to the high sample size used in the current study and the educational status of the family.

The proportion of oral hygiene knowledge among the students was 84.1%. However, among elementary school students in Fiche town, good oral hygiene practice was 55.2%. This result was higher than the previous studies reported from different settings. For instance, the studies reported from Ghana (79.9%) [13] and India (70.4%) [26], in Southeast Serbia (54.5%) [27] reported a lower proportion of oral hygiene knowledge. This difference might be due to sample size and oral hygiene-related culture in different study areas.

Almost half (53.2%) of the students were brushing their teeth once a day. The students who brushed their teeth for less than 60 s were 47.9%, which is Debre Tabor [28]. At Fiche Town Elementary School, 27.5% of students brush their teeth twice a day. This result was much smaller than a study conducted in Saudi Arabia in which 71.7% of elementary school students brushed their teeth [3]. This difference could be due to differences in study area culture, economic status, and sample size.

Female students were 1.8 times more likely to have good hygiene practices compared with male students. This result was supported by the fact that male students are 0.42 less likely to have good personal hygiene practices in Côte d’Ivoire [29] and in Bangladesh [30]. The majority (98%) of men and women agree that washing hands after toileting is important [31]. Moreover, 91% of women and 84% of men are more likely to report the importance of handwashing after toilet use [31].

The students who had good knowledge of personal hygiene were 2.3 times more likely to have good personal hygiene practice compared with those who had poor knowledge, and knowledge significantly determined personal hygiene practice. The present study result is supported by a study reported by Mareko [32] in which personal hygiene practice is 5.1 times higher among those with high knowledge. Moreover, the current study findings are similar to those reported in Debark Town [18].

Diarrheal diseases alone were responsible for 43 (8.1%) of the school absences in the present study. The current study result is smaller (28.8%) than the results of the study reported by Mareko [6]. This is most probably due to the water treatment with chlorine 381 (71.9%) and the study area and time. In this study, almost one-third of the elementary school students were suffering from one or more morbidities related to poor personal hygiene practices in the past two weeks.

Limitation

The nature of the study design and the self-reported data collection tools recall bias (remember the last two weeks of illness and the last dental follow-up). The cross-sectional study design means that because exposure and outcome are simultaneously measured, there is generally no evidence of a temporal relationship between exposure and outcome, which could not enable us to investigate the cause-and-effect relationship.

Conclusion

The overall personal hygiene practice among elementary school children in the study area was minimal. Innervations that would be implemented by schools, teachers, health extension workers, and WASH project officers are required to raise knowledge on personal hygiene practice among elementary students and increase the availability of regular personal hygiene inspections. The availability of personal hygiene facilities at home and in school is crucial to promoting personal hygiene practice. Further research that triangulates quantitative and qualitative data is recommended for a holistic understanding of the problem.