Handwashing Practice among Elementary Schoolchildren in Urban Setting, Mongolia: A School-Based Cross-Sectional Survey

Objectives Handwashing with soap is the simplest, most affordable, and cost-effective preventative intervention for reducing the burden of communicable diseases, including the COVID-19. This study was aimed at investigating elementary schoolchildren's handwashing practice at two critical moments, namely, before eating and after using the toilet and its associated factors. Methods The cross-sectional study was conducted at ten public secondary schools in Ulaanbaatar, Mongolia, between February and March 2019. Data were collected from all fifth-grade children's parents at the selected schools by using a self-reported questionnaire. Descriptive and multiple regression analyses were conducted using STATA/MP version 13.0. Results A total of 1507 parents/guardians of 5th-grade school children participated. Reported schoolchildren's handwashing practice for both critical moments was 50.1%. It was significantly associated with female gender (adjusted odds ratio [AOR] = 0.56 (95%CI = 0.45, 0.70)), number of siblings (AOR = 0.72 (95%CI = 0.61, 0.80)), and availability of handwashing amenity at school (AOR = 1.1595%CI = 0.86, 1.42)). Only 34% of children wash their hands with soap at school, and the most common reasons for skipping handwashing were an absence of soap (23.9%), lack of sink (14.5%), and the use of hand sanitizer (19.7%). Conclusions The school children's handwashing practice at two critical moments is considerably low. The main disabling factors of regular handwashing at school included insufficient handwashing facility and soap. Therefore, promoting HW facilities and innovative and participatory education for elementary schoolchildren should be prioritized.


Introduction
Despite global efforts, infectious diseases, particularly pneumonia and diarrhea, continue to be the leading cause of mortality and morbidity among children in low-and middle-income countries [1]. Handwashing (HW) with soap is the simplest, most affordable, and cost-effective preventative intervention for reducing the burden of these diseases [2]. It has been recommended as a critical prevention measure against the novel coronavirus disease (COVID-19) [3,4]. Systematic reviews of the health effects of HW with soap reported an estimated 23% to 48% and 21% of risk reduction in diarrhea [5] and acute respiratory infections [6], respectively. HW among schoolchildren also has a significant social and economic impact on the family and society by reducing school absenteeism and the loss of caregivers' workdays [7][8][9][10].
Although there are health and social benefits, HW practice remains significantly low globally. HW during two critical moments, namely, before eating and after toilet use, is the most used indicators of the practice in the population [11]. Studies among school children in low-and middleincome countries reported that 7% to 15% wash their hands after toilet use. Poor HW practices were associated with inadequate facilities in terms of both quantity and quality, lack of water supply and soap, and absence of norms or culture at the school or in the community [12]. Globally, approximately half of the schools do not have HW facilities with water and soap [11].
Mongolia is a lower-middle-income country where respiratory infection and diarrhea have steadily remained the leading causes of child morbidity and mortality [13]. Sanitation and hygiene are crucial public health challenges as 60% of households live in underdeveloped infrastructural and poor hygiene environments, including outdoor latrines and noncentralized water supply sources [8]. According to the WHO/UNICEF Joint Monitoring Program for Water Supply, Sanitation, and Hygiene (WASH), the national coverage [14] of basic hygiene services defined as HW facilities with water and soap in Mongolian schools was 41.4% in 2016. Moreover, 8 to 11% of high schoolchildren never or rarely wash their hands before eating and after using the toilet [15]. HW practice data among elementary school children in Mongolia is scarce. As they receive formal HW education at school, it is crucial to explore the practice among this population. Furthermore, acquiring proper HW practice at a young age is essential, as they are likely to be carried into adulthood [16,17].
Therefore, this study was aimed at exploring elementary schoolchildren's HW practice and the associated factors and constraints.

Study
Setting. This school-based cross-sectional study was conducted in Ulaanbaatar, the capital of Mongolia. The city is divided into nine districts with similar residential characteristics, namely, "apartment/urban" and "ger/suburban"(traditional dwellings). More than half of the 3,238,500 inhabitants of the country reside in Ulaanbaatar [18,19]. The prevalence of infectious diseases in the city is higher than the national average, which may be attributed to high population density, unsanitary conditions, and unhygienic practices, specifically in the ger areas [19,20].
In Mongolia, 12-year secondary education is provided primarily through public schools. In most cases, elementary (grades 1-5), lower (grades 6-9), and upper (grades 10-12) secondary education levels are combined into one school, with an average of 1,500 to 2,000 children. The Ministry of Education and Science is the central administrative body that formulates the national education policy and sets the standards and curriculum. Therefore, the budget finance and infrastructure of the schools are similar, specifically in the capital city [21].
This study was conducted in one of the six central districts of Ulaanbaatar, which accounted for 16% (22/134) of public schools in the city [22]. The district population in 2018 was 145,335, approximately 10% of the Ulaanbaatar population.

Study Participants.
This study is a part of a clusterrandomized trial on the effectiveness of exercise interventions for children's academic achievement and health. Study sampling and methodology details of the original study have been written elsewhere [23,24]. Briefly, ten public schools were recruited from 22 schools in the selected district. Schools that provided only upper secondary education (n = 10) or those for children with special needs (n = 2) were excluded. All fifth-grade children at the recruited schools were eligible. After identifying the children, the researchers sent an invitation letter with informed consent for their parents. In our study, the participants were parents or primary guardians who provided written informed consent.
2.3. Data Collection. Data were collected between February and March 2019 using a self-reported questionnaire. The questionnaire comprised three sections and 23 questions: (a) sociodemographic characteristics including parents' education, number of family members, household income, housing condition, and the child's age and sex; (b) children's HW practice and frequency, HW at two critical moments, and presence of infectious illness two weeks prior to the study; and (c) HW facilities at school, reasons to skip regular HW, and provision of HW education.
This study used sociodemographic questions from the National Household Survey of Mongolia [22]. The most commonly used school survey questionnaire developed by the UNICEF/WHO to explore children's HW practice in Mongolia and other countries was adapted [25][26][27]. The forward and back translations were conducted by independent translators fluent in English and Mongolian. The chief investigator and two researchers synthesized and revised the translated versions. Content and face validity of the questionnaire were conducted by involving schoolteachers and a small group of schoolchildren.
Data were collected by ten senior university students who attended a five-day training workshop of the main study that covered the aim of the study, research ethics, content of questionnaires, interview instructions, and guides developed by the research team. The questionnaire was sent to the primary guardians or parents in an enclosed envelope. They were asked to return it after completion.

Data Analysis.
Children's HW practice was the independent variable of this study. It was defined based on the response to HW before eating and after using the toilet. On a 4-point Likert scale ranging from "always" to "never," the children were asked to respond whether they washed their hands before and after. The responses "always" or "usually" for both moments were categorized as "washers," and other responses as "nonwashers." The explanatory variables were sex, number of children in the family (≤2 or ≥3 children), housing type (ger/simple house or apartment), monthly household income (below; above 700,000 MNT was equal to about USD 280), maternal education (≤10; ≥11 years), HW education at school (no/ yes), school area (urban/apartment vs. suburban (ger and mixed area)), and availability of HW amenities and sink (not available/only sink or soap available/both available).
Descriptions of the sociodemographic characteristics, HW practices, and barriers at school were presented as percentages, frequency (n), or mean (standard deviation, SD) values. Univariate and multivariable logistic regression analyses were performed to identify factors associated with HW practice and expressed as odds ratios (ORs) and adjusted odds ratios (AORs) and their corresponding 95% confidence intervals (CIs). The statistical significance threshold was set at p < 0:05. Data analysis was performed using STATA/MP version 13.0 (STATA Corp. LP, College Station, TX, USA).

Ethical
Consideration. This study was approved by the ethics committee of the Mongolian National University of Medical Sciences (approval no. 3/18/2018-12-21). Written informed consent was obtained from the parents or primary guardians of the children.

Results
There were 55 fifth-grade classes in the 10 participating secondary schools. On average, there were six (range: 4 to 8) fifth-grade classes and 150 ± 23:6 (93-231) schoolchildren per school. The number of children per class was 27 ± 8:5 (28-71). The questionnaire was distributed to 1,836 children, and 1,693 were returned. A total of 1,507 completed questionnaires were analyzed.
3.1. Characteristics of Participants. Sociodemographic and school characteristics are shown in Table 1. The mean age of the schoolchildren was ten (±0.32) years. Half of them were boys and had more than two siblings. Over 60% attended schools in urban areas.
Approximately 55% of the mothers had more than ten years of education, 54.8% of households lived in apartments, and 63.1% reported more than 700,000 MNT as household income. Table 2, school children's HW practice was assessed by two critical moments. Among 1458 children, 25.7% and 35.3% reported that they wash their hands "always" and "usually" before eating, whereas 22.8% and 47.8% of 1,439 children washed their hands "always" and "usually" after the toilet, respectively.

Children's HW Practice. As shown in
After excluding missing data on HW practice questions, the data of 1,374 children remained for further analysis. Half (n = 690) of those reported that they wash their hands "always" or "usually" before and after and were categorized as "washers." About 20% reported they wash their hands "sometimes" or "never," whereas 30.2% reported "always" or "usually" for one of the moments. These two groups are referred to as "nonwashers" as shown in Figure 1.

Associated Factors with Schoolchildren's HW Practice.
The analysis of school children's HW practice and associated factors is shown in Table 3. Boys and children who have more than three siblings were less likely to wash their hands frequently at the two critical moments compared to girls (adjusted odds ratio ½AOR = 0:56 [95% confidence interval ½CI = 0:45, 0:70]) and those with fewer siblings (AOR = 0:76 [95%CI = 0:61, 0:94]), respectively. Children's HW practice at these two critical moments were significantly associated with the availability of sink and soap at school (AOR = 1:42 [95%CI = 1:04, 1:88]). There was no significant association between HW practice and housing type, income, HW education at school, or school location. One-third of 1,507 (33.5%) children fell sick two weeks before the study, and the majority (81%) indicated respiratory symptoms. However, no significant association was found between illness and HW practice in our study (data not shown).

HW Practice at School and Reasons for Skipping.
Schoolchildren's HW practice at school was assessed by the frequency, soap usage, HW facility location, and barriers of regular HW (Table 4). The reported frequency of fewer than six times per day among 1,507 children was 84.9%. A total of 1,492 participants completed the question "Did your child wash their hands today at school?" and among them, 34.1% washed their hands with soap, whereas 13.0% did not wash their hands at all. Approximately 85% of 1,507 children reported that they washed their hands in the toilet. HW was skipped at school because of the absence of soap (23.9%), lack of sink (14.5%), and use of hand sanitizer (19.7%). About 12% of 1,485 respondents specified other

Discussion
To the best of our knowledge, this is the first study with a considerably large sample of elementary school children focused on HW practice and their associated factors in an urban setting in Mongolia. HW practice is a significant school health and infection prevention concern, as the school environment has intense person-to-person contact levels that are susceptible to infection and spread to the community. The study findings are crucial to promoting frequent and proper HW practice among schoolchildren during the two critical moments, specifically during COVID-19 [5,6,[28][29][30][31][32][33][34][35].
This study recruited 1,507 fifth-grade schoolchildren who attended public schools (n = 10) in one of the nine districts of Ulaanbaatar. Among the 1,374 children who completed the questionnaire, 19.7% and 30.2% reported that they washed their hands "sometimes" or "never," respectively, for both or one of the two critical moments. Thus, approximately 50% of elementary school children were nonwashers or had poor HW practices. These findings are similar to those of a previous WHO school-based survey in Mongolia conducted at 59 public schools in 2013. A total of 5,393 children aged 12 to 18 years participated in the study, and 25.2% and 26.9% had "never" and "sometimes" washed their hands, respectively, before eating and after toilet use [15]. Our study findings indicated poor HW practices among Mongolian elementary schoolchildren. The possible explanations could be the low priority and intensity of HW education, the traditional teaching approach, lack of hygiene facilities, poor communication between school and community, and lack of parental guidance. These factors have been documented in previous studies conducted in similar countries [12,36].
This study was aimed at identifying the factors related to HW practice among elementary school children, such as sex, number of children in the family, housing type, monthly household income, school location, and availability of HW education and amenities at school. The results of this study indicated that boys were less likely to wash their hands than girls (AOR = 0:59 [95% CI 0.45, 0.70]). A similar finding of sex differences in HW practice has been reported in school-based studies conducted in Zambia and Mexico [37,38]. A school-based randomized controlled trial study in Zambia examined the effectiveness of a soap-on-a-rope intervention on HW practice with soap by recruiting 50 schools and 10,732 children and found boys were less likely to wash their hands in both control and intervention groups at baseline (AOR = 0:72 [95%CI = 0:66, 0:80]) [37]. Another study of school nurse inspections on the availability of supplies in Mexico found that girls' bathrooms had a significantly higher probability of being supplied with soap and hand dryers or towels [39].
In our study, children with more than two siblings were significantly less likely to wash their hands (AOR = 0:76 [95%CI = 0:61, 0:94]). A similar finding reported in the previous study in Korea suggested that when the number of children increases, parents' or guardians' guidance and time for the child's education and enforcing health behaviors will decrease [40].
In this study, 65.6% of 1,507 children reported that they wash their hands three to five times daily, and 15% washed their hands more than six times. This finding suggests that HW frequency among children was insufficient compared to the recommended frequency of ten times per day by the WHO/UNICEF Joint Monitoring WASH program [41]. This study also found that the availability of HW sinks, soaps, and insufficient time were the most common reasons for skipping HW at school. Only 32.9% of children reported that HW facilities with water and soap were available. The main HW place was the toilet. Only 9.2% of children washed their hands in the classroom, which implies that many children could not wash their hands before school lunch. Similar to the UNICEF analysis [42] of the situation of Mongolian children in 2014, our study suggested that insufficient facilities and lack of soap supply and time are key constraints to frequent and proper HW at school. During the last two decades, most schools in Ulaanbaatar have been overcrowded (38-54 children per class), with limited sanitation facilities [15]. The Mongolian National WASH guideline states that the sink-to-student ratio is 1 : 40, which corresponds to the minimum standard by the WHO [27]; however, 25% of public schools have not met the standards [43]. This indicates that the Mongolian government has to take action to improve sanitation infrastructure, construct new schools or expand school areas, and reinforce guidelines and policies.
In our study, 76.6% of children attended the HW education class; however, half of them reported insufficient HW practice. This may indicate the ineffectiveness of the promotion and provision of health education among children. In Mongolia, a 45-minute session on HW education by the national curriculum, which is primarily a knowledge-based and didactic teaching approach, is provided for fourthgrade children by the class teachers. Teachers' overload in teaching activities has been widely documented [44].  Figure 1: Children's handwashing practice for two critical moments (N = 1374). Note: washer is defined as one who washes hands always or usually both before eating and after using the toilet; nonwasher is defined as one who washes hands always or usually at only one of the critical moments or is not a regular washer at both moments. Note: * * * p < 0:001; * * p < 0:01; * p < 0:05.

Journal of Environmental and Public Health
Shortage and limited availability of resources, including teaching aids [36,45] and traditional teaching approaches, are ineffective in acquiring skills and changing behaviors [46]. Suggested effective educational interventions to improve schoolchildren's HW are child-centered, participatory, and practical learning education that involves innovative and low-cost applications with soap such as soap-ona-rope [37], soap placed in the net hanging on the faucet, interactive, participatory HW education, user-friendly printed educational and HW guidelines [47][48][49], and school nurses' regular inspections for HW facilities and supplies [38]. Therefore, it is necessary to explore effective and feasible interventions to improve health practice and hygiene facilities in Mongolian schools.
Along with a large sample of elementary schoolchildren and a valid questionnaire, this study had a few limitations. First, as this was a cross-sectional study; causal relationships for all variables related to the study indicators could not be determined. Second, a self-reported questionnaire regarding HW practice was used. Proper HW practice is a socially desirable behavior; thus, self-response would be overreported.

Conclusion
Our findings suggest that schoolchildren's HW practice at two critical moments are considerably low (50.1%). Male gender, number of household children, and availability of handwashing amenity at school were associated factors with poor handwashing practice. The main barriers to regular HW practice at school are insufficient facilities and soaps. Therefore, promoting HW facilities and interventions should be prioritized. Most (76.6%) children reported receiving formal HW education at school, but the application of the practice was low. Consequently, Mongolian education policymakers should consider innovative and participatory HW education for elementary schoolchildren.

Data Availability
The data used to support the findings of this study are available from the corresponding author upon request.

Conflicts of Interest
The authors declare that they have no competing interests.

Authors' Contributions
GT and ME conceptualized and designed the study and created the analysis plan. ME contributed to the data collection, data entry, and cleaning. GT and ME conducted the analysis and wrote the first draft. OE contributed to manuscript writing. All authors have critically read the text, contributed with inputs and revisions, and approved the final manuscript.