Knowledge, Attitude and Practice (KAP) and compliance of handwashing among elementary schoolchildren in an urban setting, Mongolia: a school-based cross-sectional study

概要

論

文

概

要

〇論 文 題 目
Knowledge, Attitude and Practice (KAP) and
compliance of handwashing among elementary
schoolchildren in an urban setting, Mongolia: a schoolbased cross-sectional study
（モンゴル都市部の小学生の手洗いについての知識、態
度、実践、およびコンプライアンスについての横断研
究）

〇指導教員
人間総合科学研究科
竹熊

カツマタ

（所

属）

看護科学専攻（博士後期課程）

麻子

教授

筑波大学大学院人間総合科学研究科
看護科学専攻（博士後期課程）
（氏
名）
Munguntuul Enkhbat

Purpose: The purpose of this study was to investigate handwashing practices and their
associated factors among elementary school children in an urban setting in Mongolia.
Participants and Methods: This cross-sectional study was conducted at a public
school in Bayangol District, Ulaanbaatar, the capital city of Mongolia. Out of 18 public
schools in the district, the school was purposively selected because the hygiene
facilities, including sinks, were built during oral hygiene intervention projects by the
government. The study participants were all children in the 3rd to 5th grade (8-10 years
old) at the selected school. The study was conducted in two phases: preparation and
implementation. The study preparation phase included a) school handwashing
environment assessment, b) obtaining official approval and team training, and c) the
pilot study. The second phase consisted of: a) environmental arrangement, b)
participant recruitment, and c) data collection. The inclusion criteria were 3rd to 5th
graders who submitted written consent from the parents or guardians, agreed to
participate, and had age-appropriate literacy in Mongolian. This study used a selfreported handwashing questionnaire, a handwashing observation checklist, and photos
of the hand after washing. We also retrieved sociodemographic information from the
school database, including children’s age, gender, parents’ education and employment,
and living conditions.
Results: A total of 829 third to fifth graders at the selected school were eligible, 802 of
whom provided informed consent to participate in the study.
Among the 749 participants who completed the self-report questionnaire, the mean age
was 9.3 years old (SD=0.1), ranging from 8 to 10 years, and 9.1% (n=368) were male.
Approximately 70% of children (513/749) reside in an apartment with a toilet, running
water, and a central sewage system. Sixty-six percent (495/749) of mothers and 45%
(n=337) of fathers had above a college education. Twenty percent of the mothers were
unemployed or staying home with young children, whereas 4.9% of the fathers were
unemployed.
The mean handwashing knowledge score was 9.7 (SD=2.6), and the 25th and 75th IQR
were 2 and 15, respectively. Approximately 27% (n=202) of the children had a score
of > 12 and were categorized as having sufficient knowledge. After adjustment for
variables, odds ratio was 1.70 (95% CI 1.16 – 2.48) in girls compared to boys, and 1.96

(95% CI 1.16 – 3.30) in 4th graders and 1.81 (95% CI 1.161-2.94) in 5th graders
compared to 3rd graders.
The attitude score ranged from 0 to 10, and 324 (44.4%) children scored > 9 and were
categorized as having a positive attitude towards handwashing. After adjusting for
sociodemographic characteristics, adjusted odds ratio was 1.77 (95% CI 1.23-2.55) in
girls referred to boys, and 2.7 (95% CI 1.67-4.37) in the 4th graders and 2.3 (95% CI
1.44-3.68) in the 5th graders referred to 3rd graders. Knowledgeable children were more
likely to had positive attitude toward the handwashing of this study participants, with
an estimated odds ratio of 3.17 (95% CI 2.11-4.77).
Among 741 children who completed the questions regarding handwashing practice at
four critical moments, 154 (20.7%) responded every time for all moments and were
categorized as having proper handwashing practice. After adjustment for
sociodemographic characteristics, grade level was significantly associated with proper
handwashing practices. Adjusted odds ratio was 0.55 (95% CI 0.33-0.91) in 5th graders
referred to 3rd graders.
Among the 701 children who completed handwashing at four critical moments and
handwashing skill observation, 306 (43.6 %) performed 3-4 rubbing steps out of 6.
Only 25 children (3.5 %) performed all six rubbing steps. Children who had proper
handwashing practices were more likely to complete rubbing steps (p=0.001).
Discussion: This is the first study on elementary schoolchildren’s handwashing
practice using multiple tools, including the KAP self-reported questionnaire,
observation of handwashing skills by researcher assistance, and handwashing
performance by demonstrated photo after washing hands, and explored associated
factors. Among the elementary schoolchildren, 26.5% and 44.4% had sufficient
knowledge and positive handwashing attitudes, respectively. Girls and those with
higher grades had better knowledge and attitudes. About 20% of children wash their
hands every time for four critical moments, and higher graders had better practice. The
study found lower rates of handwashing knowledge, attitude, and practice among
elementary school children despite having adequately equipped handwashing facilities.
This finding may indicate the ineffectiveness of health education in schools. Therefore,
it is necessary to explore effective, interactive, initiative, participatory, and feasible
interventions to improve health practices and hygiene in Mongolian schools.
Conclusion: Even though handwashing is the easiest, simplest, and most cost-effective
measure for reducing the burden of infectious diseases, schoolchildren’s handwashing

knowledge, attitude, and practice are considerably low. Of the 749 participants, the
proportion of children who had sufficient knowledge, positive attitudes, and proper
handwashing practices was 27%, 45%, and 20.7%, respectively. Boys and lower
graders were less likely to have sufficient knowledge, positive attitudes, and proper
handwashing practices. Only 33% of children performed more than three steps out of
the six hand rubbing steps recommended by the WHO. The findings suggest that despite
adequate handwashing stations and supplies provided at the school, Mongolian
elementary schoolchildren’s handwashing knowledge, attitude, and practice are limited
and require improvement. ...