Prevalence and Factors Associated with Hygiene Behaviours among In-School Adolescents in Ghana

: (1) Background: Despite a global call to act to resolve communicable diseases caused by lack of clean water, sanitation, and hygiene, many people in low- and middle-income countries continue to die each year. In this study, we looked at in-school adolescents’ oral and hand hygiene activities in Ghana, as well as the factors that inﬂuence them. (2) Methods: This was a cross-sectional study that utilised data on 1348 in-school adolescents from the 2012 global school-based health survey. Using Stata software version 14.2, descriptive and inferential statistics were used to analyze the data. All statistical analyses were considered signiﬁcant at p -value < 0.05. (3) Results: The prevalence of good hygiene behaviour was 62.6% and 79.9% for good oral hygiene and good hand hygiene, respectively. In-school adolescents who were truant were 31% (AOR = 0.69, 95% CI = 0.51–0.92) and 28% (AOR = 0.72, 95% CI = 0.54–0.87), respectively, less likely to practise good hand and oral hygiene compared to those who were not. Adolescents whose parents supervised their homework, however, had higher probabilities of practising good hand (AOR = 2.30, 95% CI = 1.64–2.31) and oral (AOR = 2.34, 95% CI = 1.80–3.04) hygiene respectively. Adolescents aged 18 years and above were 1.33 times more likely to practice good oral hygiene than younger adolescents (AOR=1.33, 95% CI = 1.07–1.66). Adolescents who were bullied had lower odds of practicing good hand hygiene (AOR = 0.70, 95% CI = 0.52–0.94). (4) Conclusions: While good hygiene behaviour remains a major strategy in decreasing the prevalence of communicable diseases, the less than 65% prevalence of hand hygiene we observed in the current study is indicative of the country’s inability to achieve water, hygiene and sanitation for all by the year 2030. To accelerate progress towards meeting the Sustainable Development Goal 6.2, there is a need for the implementation of innovative interventions which seek to promote good hygiene behaviours among adolescents and the expansion of existing interventions, such as the WASH initiative, in schools. Such interventions should focus more on younger adolescents, those who are truant, and adolescents who suffer from bullying in school.


Introduction
There has been a global call to act towards addressing diseases resulting from insufficient water, sanitation, and hygiene [1] because, the avoidance and control of communicable diseases continue to be a world challenge [2,3]. This is surprising given that the effectiveness of hygiene behaviour in the prevention of contagious diseases (such as diarrhoea, trachoma, schistosomiasis, infectious hepatitis, dental plaque and caries, periodontal disease, and other faecal-oral diseases) has been noted in the literature [3]. Good handwashing has been defined as "washing hands with soap and water after defecation and before eating food" [4]. Good oral hygiene has also been defined as brushing of teeth at least twice a day [5].
Even though bad hygiene practices in low-and middle-income countries (LMICs) can be avoided, active public health programmes must focus on identifying those who are most vulnerable [6]. As a result, research into the sociodemographic factors that influence hygiene behaviours, especially among adolescents, is pertinent.
Previous studies on the determinants of hygiene behaviour among adolescents have mostly been conducted in countries such as India [7,8], Saudi Arabia [9], and Lebanon [10], with the focus often being on oral hygiene [11][12][13][14]. Generally, male sex [15], low socioeconomic status [16], rural residence, smoking, alcohol and cannabis usage, insufficient exercise, and infrequent fruit and vegetable intake have all been linked to poor oral hygiene among adolescents in these studies. In addition, a few studies on hand hygiene [17] and sleep hygiene [18] have been conducted.
In the context of Africa, studies on hygiene behaviours include studies by Vivas et al. [19], Okemwa et al. [20], and Siziya et al. [15] in Ethiopia, Kenya, and Zambia, respectively. Okemwa et al. [20], and Siziya et al. [15], for instance, discovered that female students brushed their teeth more often than male students. Similar studies conducted in Ghana include Blay et al. [21], Danquah et al. [22], Annor and Baiden [23], Yawson and Hesse [24], Mariwah et al. [25], Monney et al. [26], and Scott et al. [27]. Monney et al. [26], who studied hand hygiene in School Feeding Program-affected schools in Ghana, is one of the studies that is directly linked to the current research. However, Monney et al. [26] were unable to provide a comprehensive picture of the factors associated with hygiene behaviours among in-school adolescents by focusing only on schools participating in the School Feeding Program. In order to fill this gap in the literature, we examined the correlates of hygiene behaviours among Ghanaian in-school adolescents aged 12-18 years, using data from the nationally representative Global School-Based Health Survey. The current research is important because it has the potential to establish priorities for successful hygiene initiatives at the school level. The findings could also be vital to the school health education programme.

Data Source
Data for this study came from the Global School-Based Health Survey (GSHS) of Ghana, which was conducted in 2012. The information was gathered as part of the GSHS, which was conducted as a collaborative project between the World Health Organisation (WHO) and the US Centers for Disease Control and Prevention (CDC). The GSHS has collected behavioural and health information from in-school adolescents [28]. To ensure that representative samples of the population were collected, the GSHS used a cross-sectional method. Closed-ended systematic questionnaires were used to collect information. The survey used a two-stage cluster sampling procedure to select 25 Senior High Schools from Ghana's 10 regions at the time. A total of 1984 students took part in the research. Only students with complete cases on the variables under consideration (n = 1348) were included in our analysis. A detailed description of the meths was reported in a previous study [29]. The dataset is available for free at http://www.who.int/ncds/surveillance/ gshs/datasets/en/ (accessed on 27 January 2021). We relied on the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement in conducting this study and writing the manuscript.

Outcome Variables
Two outcome variables were employed in this study. These are oral hygiene and hand hygiene. Hand hygiene was derived from three questions: (a) "During the past 30 days, how often did you wash your hands before eating?"; (b) "During the past 30 days, how often did you use soap when washing your hands?"; and (c) "During the past 30 days, how often did you wash your hands after using the toilet or latrine?" The responses for these questions were 1 = never, 2 = rarely, 3 = sometimes, 4 = most of the times, 5 = always. Each question was dichotomously recoded as never/rarely/sometimes/most of the time = "0" and always = 1. An index was generated where all the respondents who indicated always (1) in all the questions (a-c) were deemed as practising "good hand hygiene", coded as "1", and the rest were coded as practising poor hand hygiene, coded as "0". With oral hygiene, students were asked "During the past 30 days, how many times per day did you usually clean or brush your teeth? The responses were 1 = "I did not clean or brush my teeth during the past 30 days"; 2 = Less than 1 time per day; 3 = 1 time per day; 4 = 2 times per day; 5 = 3 times per day;, 6 = 4 or more times per day. A dichotomous variable was created where 1-3 (1 = "I did not clean or brush my teeth during the past 30 days"; 2 = Less than 1 time per day; 3 = 1 time per day) were coded as "0" and 4-6 (4 = 2 times per day; 5 = 3 times per day; 6 = 4 or more times per day) coded as "1". The codes 0 and 1 represented poor oral hygiene and good oral hygiene [6]. The questionnaire was developed and administered in the English language (see Supplementary Materials).

Explanatory Variables
The estimations contained twenty-one explanatory variables. Sex, age, hunger, grade, tobacco, alcohol use, fighting, truancy, bullying, assaulted, injury, having close friends, depression, suicidal ideation, suicidal intention, suicidal attempt, peer support, parental supervision, parental connectedness, parental bonding, and parental intrusion were among the factors considered. The variables were chosen because they were available in the GSHS dataset and had been shown to be predictors of oral and hand hygiene in previous studies [3,6,10,15,20]. Detailed descriptions of the variables are presented in Table 1.

Suicidal ideation
During the past 12 months, did you ever seriously consider attempting suicide?

Suicidal Attempt
During the past 12 months, how many times did you actually attempt suicide?
During the past 12 months, how many times did you actually attempt suicide?

Statistical Analyses
Descriptive statistics were used to describe the sample. After that both bivariable and multivariable analyses were conducted. Pearson's chi-square tests were employed for the bivariable analyses. The explanatory variables which showed significant associations with oral hygiene and hand hygiene were used for the multivariable analysis. Variance inflation factor was used to check multicollinearity (Mean VIF = 1.3, Max VIF = 2.0, Minimum VIF = 1.0). Based on the fact that the outcome variables were dichotomously coded, binary logistic regression models were used. Stata version 14.2 (Stata Corporation, College Station, TX, USA) for Mac OS was used for the analysis. The regression analysis results were presented as Crude Odds Ratios (COR) and Adjusted Odds Ratios (AOR). Previous research [3,4,8,13,18] and a priori knowledge influenced the reference categories for all explanatory variables. The 95% confidence intervals on both sides are shown. Statistical significance is shown by p-values of less than or equal to 5%. Because of the study's multistage stratified cluster sample nature, the recorded 95% confidence intervals and p-value have been modified.

Ethical Clearance
The GSHS questionnaires were tested in advance to ensure that the survey items were understood properly. All ethical protocols for the use of students were followed in accordance with the Ghana Education Services (GES). The GES, the chosen classes, and the classroom teachers were all asked for written permission. Both students and their parents signed written informed consent forms. For students who were minors, parental permission was sought. Figure 1 presents the prevalence of hygiene behaviours among the participants. Handwashing with soap, before eating, and after visiting the toilet were 30.8%, 67.4%, and 63.6%, respectively. The prevalence of good oral hygiene was 62.6% among in-school adolescents. The overall prevalence of good hand hygiene was 79.9%.  Table 2 represents the bivariable relationships between the explanatory variables and hygiene behaviours among in-school adolescents. Age (p < 0.05), suicidal plan (p < 0.001), suicidal attempt (p < 0.001), truancy (p < 0.05), being bullied (p < 0.01), parental supervision (p < 0.001), parental connectedness (p < 0.01), parental bonding (p < 0.001), and parental intrusion (p < 0.01) were statistically associated with good hand hygiene. The associated factors of good oral hygiene were hunger (p < 0.05), tobacco use (p < 0.05), alcohol use (p < 0.001), physical fight (p < 0.01), truancy (p < 0.001), being bullied (p < 0.01), physical attack (p < 0.05), parental supervision (p < 0.001), parental connectedness (p < 0.01), and parental bonding (p < 0.001).

Discussion
Using data from the 2012 Global School-Based Health Survey, we examined hygiene behaviours and their related factors among in-school adolescents in Ghana. The prevalences of good oral and hand hygiene behaviours were 62.6% and 79.9%, respectively [30]. Handwashing with soap, before eating, and after using the restroom were all done by 30.8%, 67.4%, and 63.6% of people, respectively. The prevalence of good oral and hand hygiene among in-school adolescents in Ghana that we observed in this study was higher than that recorded in other literature [6,21].This higher prevalence of good oral and hand hygiene among adolescents could be explained by the good personal and sanitation education practice instilled among in-school adolescents in basic schools in all regions in Ghana by the government and its partners as part of Ministry of Education's Education Strategic Plan (ESP) 2010-2020, including the Water, Sanitation, and Hygiene (WASH) Policy which has the objective of expanding and improving school health, sanitation, and safety systems [31][32][33]. WASH in schools ensures access to clean drinking water, enhances sanitation, and encourages long-term wellbeing [34]. The less than 65% prevalence of hand hygiene we observed, however, implies that the country is far from achieving Sustainable Development Goal (SDG) 6.2, which encourages all developing countries across the globe to achieve access to adequate and equitable sanitation and hygiene for all by 2030 [35]. There is, therefore, the need to accelerate the implementation of WASH and other interventions that have proven successful.
Being truant and bullied in school were predictors of poor hygiene practices. Truancy, for instance, reduced the probability of practising good oral and hand hygiene among in-school adolescents. Our finding regarding truancy confirms a previous study by Peltzer and Pengpid [6] in which the authors noted that school attendance constitutes a protective factor which influences adolescents' good hygiene behaviour. Being bullied in school also reduced the chances of adolescents practising good oral hygiene in our study. The need for school authorities and other education stakeholders to institute measures to address bullying and truancy in schools is, therefore, essential.
Parental supervision served as an important predictor which promoted good hygiene behaviour among the in-school adolescents. Thus, in-school adolescents whose parents supervised their homework had higher odds of practising good hand and oral hygiene than those whose parents did not supervise their homework. The finding regarding parental supervision corroborates the postulations of Peltzer and Pengpid [6] that parental support reduces the risk of poor hygiene behaviour among adolescents. This finding highlights the role of parental support in promoting good lifestyles among adolescents in Ghana. Apart from supporting children in doing their homework, parents in Ghana are also instrumental in teaching their children other good hygiene habits such as brushing and flossing teeth, having regular baths or showers, proper washing of hands, and covering their mouth when they cough.
Other results revealed that older adolescents were more likely to practice good oral hygiene than younger ones. This could be because they have a better knowledge of the probable negative outcomes of not practising good oral hygiene and, therefore, have become more conscious of their overall hygiene behaviours [35]. Our findings are congruent with other studies which have argued that older adolescents more often practice good oral hygiene than younger ones [36,37]. Current findings, thus, point to the need for interventions such as WASH and educational programmes on hygiene behaviour to be implemented more extensively in basic schools where mainly younger adolescents are on the academic ladder.

Limitations
Despite the important findings of this study, it is important to point the potential limitations. The study was conducted only in schools. The results are, therefore, not generalisable to the general adolescent population. Furthermore, based on the crosssectional nature of the data, it was difficult to establish causality among the study variables. There is also the possibility of social desirability biases by over-reporting the prevalence of hygiene behaviour practices [38,39]. Additionally, there is the possibility of under-reporting some of the variables we controlled for such as suicidal plan, suicidal attempt, ever going hungry, alcohol use, and being bullied. The dataset is also relatively old. However, that is the current version of the Global School-Based Student Health Survey for Ghana.

Conclusions
Good hygiene habits remain a key strategy for minimizing the spread of communicable diseases. The current study's finding on hand hygiene use reflects the country's inability to provide universal access to water, sanitation, and hygiene. To meet SDG 6.2, which calls for all people to have adequate access to and equitable sanitation and hygiene by 2030, new initiatives aimed at promoting hygiene behaviours among adolescents, as well as the extension of existing interventions like the WASH initiative in schools, are needed. Such interventions could focus more on addressing the hygiene needs of younger adolescents, those who are truant, and adolescents who suffer from bullying in school. Interventions targeting increased parental support in improving hygiene behaviours are also essential in promoting better hygiene practices among in-school adolescents. Funding: We sincerely thank Bielefeld University, Germany for providing financial support through the Open Access Publication Fund for the article processing charge.
Institutional Review Board Statement: Not applicable.

Informed Consent Statement:
The GSHS questionnaires were tested in advance to ensure that the survey items were understood properly. All ethical protocols for the use of students were followed in accordance with the Ghana Education Service's (GES). The GES, the chosen classes, and the classroom teachers were all asked for written permissions. Both students and their parents signed written informed consent forms. For students who were minors, parental permission was sought.