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Assessment of Hygiene Practices

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 James Prah et al., IRJPH, 2018; 2:21

Research Article IRJPH (2018) 2:21

International Research Journal of Public Health

(ISSN:2573-380X)

Assessment of Hygiene Practices among Students at the University

of Cape Coast, Ghana
James Prah1,*, Mohammed Abdulai1, Obed Lasim2, Adelaide Ampofo-Asiama1

1
University of Cape Coast Hospital, University of Cape Coast, Ghana; 2Department of Health
Information Management, College of Health & Allied Sciences, University of Cape Coast, Ghana

ABSTRACT

Background: Proper hand hygiene practices have been shown to *Correspondence to Author:
prevent the spread of communicable diseases. Although diarrhoeal James Prah
diseases continue to be recorded among university students, there University of Cape Coast Hospital,
is paucity of studies focusing on hygiene behavior among university
University of Cape Coast, Ghana
students in Ghana. This study assessed hand washing behavior,
knowledge and practices among students of the University of Cape
Coast, Ghana. Methods: A cross sectional study was conducted
among 422 students from 4th January 2018 to 21st January 2018. A
pretested, structured questionnaire was used to collect all relevant How to cite this article:
data. Frequencies and percentages were used for categorical James Prah, Mohammed Abdulai,
data. Chi square and one –way ANOVA were used to determine Obed Lasim, Adelaide Ampofo-
associations between some selected variables. P values, <0.05 were Asiama.Assess-ment of Hygiene
considered significant. Results: The mean age of participants was
Practices among Students at the
21.7±2.9 years. The overall general hygiene behavior of students
University of Cape Coast,
was good with a mean score of 19.2±2.7. There was a significant
difference (p=0.001) in the mean scores of male and female students Ghana.International Re-search
with females scoring higher than their male colleagues. Predictors Journal of Public Health, 2018;
of hygiene behaviour among the students were their sex (R 2=0.164, 2:21.
p=0.001) and age group (R2=0.003, p=0.048). Only 52.1% of students
reported they always washed their hands with soap and water
after using the toilets. Ownership and use of hand sanitizer was low
(17.5%). Conclusion: Self-reported hand washing behavior among
UCC students is poor despite generally good knowledge of
students on hygiene. The findings highlight the need for regular
formal training of University students on proper hygiene practices eSciPub LLC, Houston, TX USA.
and to encourage hand washing by ensuring the availability of soap Website: http://escipub.com/
and water.
Keywords: Hygiene, hand washing, University of Cape Coast,
students, self-reported study
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 James Prah et al., IRJPH, 2018; 2:21

Background Coast. This study therefore provides a good

analysis of university students’ attitude and
The set of practices associated with the
practices pertinent to their personal hygiene
preservation of health and healthy living is
behaviour.
generally referred to as hygiene. Safe hygiene
practice includes a wide range of healthy Methods
behaviours, such as hand washing and safe This was a cross-sectional descriptive study that
faeces disposal. One of the most important used a quantitative research method to collect
practices that is central to the prevention of the data on the campus of the University of
spread of infectious diseases in the home and Cape Coast. The study was conducted
everyday life settings is hand hygiene [1]. In among residential students of the University
1846, Dr. Semmelweis showed that disinfection of Cape Coast from 4th January 2018-21st
of hands stopped the transfer of disease from January 2018.
cadavers to pregnant women [2]. Hand hygiene Using a hand washing prevalence of 34% found
is defined as hand washing or washing hands in an earlier study [6], a minimum sample of 345
and nails with soap and water or using a was calculated. This was adjusted to 380 to
waterless hand sanitizer. Practice of hand account for 10% possible loss of data.
hygiene can be difficult to perform due to many
Students from five halls of residence were
factors such as time constraints and the lack of
recruited into the study using the multistage
wash bowls and hand washing basins in most
sampling technique. A questionnaire was
schools. In situations where hand washing with
developed to obtain information on socio-
soap is not possible, a waterless hand sanitizer demographical variables, such as the
such as an alcohol hand gel can be used respondent's age, gender and level of
instead. Alcohol hand gels should not contain education. Hygiene behavior was assessed
not less than 60%v/v alcohol to be effective in by using a previously developed hygiene
killing germs. Hammond et al.(2000) showed in inventory (HI23) with some modifications. The
a research that a practice of good hand hygiene original HI23 was developed by Stevenson
by using an alcohol gel hand sanitizer among et al. (2009) in Australia and tested by
elementary school children greatly reduced Altun et al (2010) for validity and reliability in a
school absenteeism due to illness [3]. Even Turkish population [7, 8]. The coefficient alpha
though the university community is usually well was 0.79 for the HI23. The modified
organized, students continue to suffer from questionnaire used for this study had three
sanitation related diseases. Studies have shown sections that assessed students’ general
that the level of knowledge and hygiene hygiene behavior, food related hygiene and
practices of students in low to medium income knowledge on hand washing techniques.
countries like Ghana is low and must be Students’ general hygiene behavior was
improved [4]. Earlier studies on hygiene determined using 9 questions each with three
practices in students conducted in Ghana were different responses. An assumed score of 3 was
mostly done among primary and secondary level given to every correct answer, 2 for the less
students. These studies found poor hygiene appropriate, and finally 1, for a wrong practice.
behavior among students with inadequate These were summed up to make the general
sanitary facilities in most schools investigated hygiene behavior score. Mean scores for each
[5]. The University of Cape Coast experienced sex were subsequently calculated. The scores
an outbreak of cholera in 2016. That outbreak ranged from a minimum of 9 to a maximum of 27
clearly indicated that there was a need to with higher scores indicating better hygiene
investigate and document in detail the hygiene practices. The questionnaire was pre-tested on
behavior of students of the University of Cape
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 James Prah et al., IRJPH, 2018; 2:21
20 students who were residents in a privately the age group (20-24) years with 18 (19.7%) of
owned hostel and were not part of the study. them ≤19 years. The students who participated
The study proposal was reviewed by the in the study were at different levels (years) of
University of Cape Coast Institutional Review study, with most of them (201, 47.6%) in their
Board. Informed consent from all respondents first year of study (level 100).
was obtained through the use of consent forms. General Hygiene Behavior of Students
Data analyses The general hygiene behavior of participants’
Data entry, verification and analysis were all mean score was 19.2 ± 2.7 SD. There was a
done using SPSS (version 20.0). Data were significant difference (p=0.001) in the mean
analysed with appropriate measures of centrality scores of male students (18.3±2.4) and that of
(mean) and dispersion (standard deviation). the female students (20.6±2.6). The age group
Chisquare and one –way ANOVA were used to of students was significantly associated with
determine associations between some selected their hygiene behavior (p=0.001). There was
variables. P values, <0.05 were considered however, no significant association between
significant. students’ year of study (p=0.251) and their
hygiene behavior.
Results
The multiple linear regression analysis of sex of
A total of 422 students participated in the study.
respondents (R2=0.164, p=0.001) and their age
They comprised of 257 (60.9%) males and 165
group (R2=0.003, p=0.048) were significant in
(39.1%) females. The mean age of participants
determining the predictors of hygiene behavior
was 21.7±2.9SD. Their ages ranged from 15
among the students (Table 1).
years to 42 years. Most of the students were in

Table 1. Regression analysis of sex and age of respondents and their general hygiene
behavior
Model β SE β T Sig.

(Constant) 16.8 0.538 31.251 0.001

Age-group -0.382 0.194 -0.088 -1.978 0.048

Sex 2.279 0.251 0.404 9.086 0.001

Dependent variable: general hygiene behavior

Majority of the students (375, 88.5%) reported before use. With regards to their personal
that they always washed their hands before hygiene 189 (44.8%) said they never wear the
eating with them whilst about 69.9% (295) said same underclothes two days in a row with 33.4%
they always washed fruits and vegetables before (141) reporting that they sometimes do (Table
eating them. When they use a public toilet 294 2).
(69.7%) said they always cleaned the toilet seat
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 James Prah et al., IRJPH, 2018; 2:21
Table 2. General hygiene behavior of students
Behavior Always n (%) Sometimes n (%) Never n (%)

Upon returning from lectures do you wash your 146 (34.6) 201 (47.6) 75 (17.7)
hands?

Before eating food with your hands, do you wash 375(88.9) 41 (9.7) 6 (1.4)
your hands?

Before preparing food, do you wash your hands? 276 (65.4) 124 (29.3) 22 (5.2)

Do you wash fruits and vegetables before you eat 295 (69.9) 116 (27.5) 11 (2.6)
them?

When you use a public toilet, do you cover the seat 294 (69.7) 81 (19.2) 11 (2.6)
with paper or clean it before use?

Do you wear the same top or short two days in a 88 (20.9) 161 (38.2) 173 (41.0)
row?

Do you wear the same skirt or trousers two days in 130 (30.8) 191 (45.3) 101 (23.9)
a row?

Do you wear the same underclothes two days in a 92 (21.8) 141 (33.4) 189 (44.8)
row?

Do you go without a wash or shower or bath two 0 (0) 50 (11.8) 372 (88.2)
days in a row?

Food Related Hygiene On their hand washing practices, majority of

There was no significant difference (p=0.102) in respondents (220, 52.1%) said they always
the mean scores of male students (7.3±1.4) and wash their hands with soap and water. Some
female students (7.5±1.3) with regards to their respondents admitted skipping hand washing
food related hygiene behavior. Most after using the toilets. The main reasons why
respondents (293, 69.4%) said they always hand washing is skipped after using the toilets
wash their hands after handling raw foods and were reported as unavailability of soap (50.0%)
before handling cooked foods, only 150 and water (24.6%). About 15.6% (66) of
(35.5%) said they always use separate respondents said they usually skipped hand
chopping boards for raw and cooked foods. washing because they are busy. In the absence
of soap and water, 166 (39.3%) said they always
Students’ Knowledge on hand washing
use alcohol hand sanitizer whilst 51 (12.1%) do
Most of the respondents (339, 80.3%) correctly nothing. When asked how many times they
identified warm water as the best water for hand washed their hands on the average every day,
washing. When asked what the first step of hand the response of majority (50.5%) of respondents
washing was, 244 (57.8%) students knew was one to three times a day, only 26 (6.2%)
correctly that it was wetting hands with water. A said they washed their hands more than ten
significant proportion of students (43.6%) times a day. On the approximate time spent on
claimed that they have not received any formal each hand washing, most (143, 33.9%) students
training in hand washing and personal hygiene. said they use 5-10 seconds, whilst 22.3% (94)
Students’ Hand Washing Practices do not use any specific length of time (Table 3).
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 James Prah et al., IRJPH, 2018; 2:21
Table 3. Students’ Hand Washing Practices
Hand washing practice n %
Do you always wash your hands with soap and water upon visiting the toilets?
Yes 220 52.1
Sometimes 189 44.8
No 13 3.1
Reasons for skipping hand washing at school
Not necessary 22 5.2
Too busy 66 15.6
Always forget 19 4.5
Soap not available 211 50.0
Water not available 104 24.6
What do you usually use to clean/dry your hands after washing them?
Clean towel or paper towel 216 51.2
Air 29 6.9
Handkerchief 142 33.6
Clothes 22 5.2
Other 13 3.1
Where there is no soap and water what do you do when you visit the toilet?
Do nothing 51 12.1
Always use hand sanitizer 166 39.3
Sometimes use hand sanitizer 75 17.8
Use only water 13 30.8
On an average day, approximately how many times do you wash your hands?
1-3 212 50.5
4-6 132 31.3
7-10 51 12.1
>10 26 6.2
When you wash your hands, approximately how long do you wash them for?
5-10 seconds 143 33.9
15-20 Seconds 133 31.5
>1 minute 52 12.3
No specific length of time 94 22.3
Do you own and regularly use hand sanitizers?
Yes 74 17.5
No 348 82.5

Discussion The overall general hygiene behavior score

General hygiene behavior obtained by respondents was good (mean score
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 James Prah et al., IRJPH, 2018; 2:21
of 19.2±2.4 out of a possible maximum score of 34.6% of all respondents always washed their
27). General hygiene behavior among female hands with soap and water upon returning from
students was significantly higher than their male lectures.
counterparts. Some previous studies have About 69.7% of respondents reported that they
shown that hand washing behavior among usually cover their toilet seats with paper or
university students is strongly gendered. clean it before use. It is important to adopt good
Females have been found to be more likely to personal hygiene habits when using a toilet in
wash their hands than males [6, 9, 10]. Overall, order to avoid contracting an illness. Toilet seats
most of the students reported that they always are known to be hot beds for bacteria and
washed their hands upon visiting the toilets. This viruses. Common bacteria usually found on toilet
finding is at variance with an earlier study seats include Streptococcus, Staphylococcus, E
conducted among University of Cape Coast coli and Shigella. Viruses such as common cold
students in 2012, which revealed that only 34% viruses, hepatitis A virus, and other sexually
of participants actually washed their hands after transmitted organisms can be found on toilet
leaving the toilet [6]. The difference is because seats as well [16]. Even though the risk of getting
the earlier study was observational in design and infected with microbes on toilet seats is minimal,
also involved a different generation of students. good practices such as cleaning toilet seats
The level of reported hand washing after before use can further reduce risk of infection
defecation found in this study is however especially in the presence of cuts or sores in the
comparable to the 68.2% found in a similar self- anal region. In a study that examined the survival
report study among Dominican University and environmental spread of salmonella from
students [11]. Nevertheless, this level of self- domestic toilets, the results suggested that
reported hand washing after using the toilet is during diarrhoeal illness, there is considerable
unacceptably low considering the fact that risk of spread of salmonella infection through
everyone who uses a toilet must wash his/her contaminated hands and surfaces in the toilet
hands. Safe hygiene, of which hand washing is area [17].
a key component, has been widely recognized
Knowledge on hand washing
to be one of the most cost-effective means of
preventing contagious diseases [12]. Rates of Majority (80.3%) of the students knew correctly
hand washing after defecation have been found that the best water for hand washing was warm
to be low globally. Curtis et al (2009), reviewed water. This level of knowledge is higher than the
13 observational studies on hand washing with 28.5% found among some university students in
soap after defecation in low-income countries Bangladesh [18]. Even though warm water does
and found an average rate of just 17% [13]. In not kill germs, it has been commonly
Ghana, rates of hand washing with soap among recommended for two reasons. Warm water is
the general population have also been found to usually more comfortable to use than cold water.
be low. Scott et al (2007), reported a Ghana Again modern soaps are designed to be most
national survey that indicated that only 4% of effective in warm water [19, 20]. Many of the
mothers washed their hands with soap after students (57.8%) were able to correctly identify
using the toilets [14]. A work place based survey the first step in hand washing to be the wetting
found that only 30% of respondents washed their of hands with water. However, a significant
hands with soap and water after using the toilets proportion of the respondents (42.2%) did not
[15]. Students are known to be very busy and know the first step in hand washing. This could
active and should therefore develop the habit of probably be because almost half (43.6%) of the
regularly washing their hands with soap and respondents reported that they had not received
water. It is therefore worrying to note that only any formal training in hand washing. Some
earlier studies conducted in the United Kingdom
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 James Prah et al., IRJPH, 2018; 2:21
and China had shown that training in hand students should be encouraged to acquire and
hygiene had a positive relationship with hand use personal hand sanitizers to use when
hygiene compliance among medical staff [21, necessary. Hand sanitizers must however not be
22]. This finding highlights the need for hand used if hands are visibly dirty or greasy. Most
hygiene campaigns and training programs for all (50.5%) of the students said they washed their
students. Some studies have also found that the hand about one to three times on an average
presence of hand hygiene posters in wash day. This frequency of hand washing is low
rooms encouraged hand hygiene among compared to what was found in a Turkish study
students. In an American College study, it was in which most of the university students
demonstrated that when rest rooms contained surveyed reported that they washed their hands
hand washing signs, subjects used soap more 6-10 times a day [29]. It is not possible to define
than subjects in rest rooms that had no signs a universally recommended number of hand
[23]. Therefore messages highlighting correct washes a day because it depends on the type of
hand washing techniques or reminders to use activities one is engaged in. However,
soap and water may increase compliance. considering the busy and adventurous nature of
Practices towards hand washing students, the frequency of hand washing
obtained in this study is woefully inadequate to
Majority of respondents (52.1%) reported that it
prevent infection. Only 43.8% of respondents in
was their practice to always wash their hands
this study reported that they washed their hands
with soap and water. Unavailability of soap and
for more than 15 seconds before rinsing. The
water were cited by students to be the main
Centers for Disease Control and Prevention
reasons why they sometimes skip hand
(CDC) in 2012 recommended that hands should
washing. Poor water supply was also mentioned
be rubbed with soap for 15 to 20 seconds before
as one of the main obstacles to hand washing in
rinsing thoroughly [28]. In an observational
an earlier university study [18]. Therefore this
study, only about 5% of respondents spent more
implies that if hand hygiene practice among
than 15 seconds in combined washing, rubbing,
students is to be improved then authorities
and rinsing of their hands. The inadequate
should ensure continues supply or availability of
length of hand washing reported by students in
water and soap. When there is no soap and
this study can be addressed with regular hand
water, many of the students reported that they
washing training programs.
always or sometimes use hand sanitizers.
Alcohol based hand sanitizers are waterless Conclusion
hand hygiene agents that have been widely Even though the overall hygiene behavior of
accepted and used globally. The correct use of students was good as most students reported
hand sanitizer does not require water, it is less that they always used soap and water to wash
time consuming and does not require hand their hands, there were still significant numbers
drying with potentially contaminated surfaces of students who did not regularly practice proper
[25]. A number of efficacy studies have hand washing. Information on personal hygiene
demonstrated that hand sanitizers are as or and how to properly use sanitary facilities on
more efficacious than hand washing with plain campus should be included in student’s hand
soap and water [26, 27]. The Centers for books. The environmental health section of the
Disease Control and Prevention recommends University Health Services should organize
that students should wash their hands often with hygiene training to all students regularly.
soap and water or use a hand sanitizer Competing
especially after cough or sneezing [28]. Thus in
The authors declare no competing interests.
settings where soap and water are not always
available, or cannot be easily accessed,
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 James Prah et al., IRJPH, 2018; 2:21
Authors’ contributions 11. Afolabi OO, Adewumi EO, Medavarapu S,
Ige1TO, Alao OJ, Dada OE. A Study to Ascertain
James Prah contributed to the conception of the the Practice of Hand Hygiene among Medical
research idea, designing study, data analysis Students in Commonwealth of Dominica. Arch
and writing of manuscript, Obed Lasim, Med. 2016;8:5
Mohammed Abdulai, and Adelaide Ampofo- 12. Curtis V. Talking dirty: how to save a million lives.
International Journal of Environmental Health
Asiama contributed to collection of data
Research. 2003;13: S73–S79.
and revision of paper. All the authors have 13. Curtis VA, Danquah LO, Aunger RV. (2009)
read and agreed to the final manuscript. Planned, motivated and habitual hygiene
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