Limited handwashing facility and associated factors in sub-Saharan Africa: pooled prevalence and multilevel analysis of 29 sub-Saharan Africa countries from demographic health survey data

Handwashing is a fundamental principle and a low-cost method of minimizing communicable diseases transmission [1, 2]. Hand hygiene is seen as a critical intervention strategy for pandemic public health threats. According to evidence from systematic reviews and clinical interventions, handwashing with soap can reduce the risk of diarrheal infection by 30% to 47% [3‐5] and the risk of acute respiratory infections by 16% [6]. Pervious meta-analysis finding showed that, an increase in hand hygiene resulted reductions in gastrointestinal and respiratory illness [7]. Based on a joint report of the World Health Organization (WHO) and United Nations Children's Fund (UNICEF), two out of every five people in the world have limited handwashing facility (lack water plus detergents), with a high percentage of these people coming from the least developed countries [8]. As a result, many people died due to infectious diseases that could have been prevented by proper hand hygiene. Study done in forty-four countries indicated that 35.5% of the population are living with a limited handwashing facility (lacks soap and/or water) [9]. In sub-Saharan Africa, the coverage of limited handwashing facility is 85% [8, 10]. Evidence from Ethiopia Demographic Health Survey (EDHS) indicated that, 53.04% of households have limited handwashing facility (handwashing places available but neither water nor detergent observed on-premises [11].

Based on WHO report, over 270 million confirmed cases of coronavirus and more than 5 million confirmed deaths were registered globally [12]. The recent coronavirus (COVID-19) pandemic is a threat to people who are living in resource-limited countries including sub-Saharan Africa (SSA). Although it can be prevented by effective handwashing practices [8, 9]. According to WHO, unsafe water, inadequate sanitation, or insufficient hand hygiene causes 88% of diarrhea cases worldwide. This diarrheal disease kills 1.5 million people per year, the vast majority of whom are children [13]. Effective hand hygiene requires sufficient water from reliable sources, preferably onsite, and accessible handwashing facilities that facilitate hygiene behaviors [14]. However, access to water and soap is deficient especially in low and middle—income countries. Handwashing with soap and water is the most effective means of preventing COVID-19 infection, both mechanically and by altering viral integrity [15]. Soap molecules break the outer lipid membrane of the microbe, causing viral fragments to run away with water [15]. Handwashing is a routine exercise for people in rich countries, but it is not for people in developing [16]. Water and soap are still in short supply in rural areas and urban slums [16]. In the absence of soap and water, hand sanitizers are used to clean hands. However, the potential problematic health outcomes and flammability of alcohol-based sanitizers [17], as well as the high cost of these products [18], have been identified as barriers to their adoption.

Previous studies found that, factors such as educational level of the household head [11], media exposure [11] and household income status [11, 19], access to water and sanitation [11], household size [19] were determinants for both presence and absence of handwashing facility. To the best of our knowledge, only two previous studies on handwashing facility have been done in Sub-Saharan Africa. The first study looked at differences in access to water and soap in relation to wealth index and residence; while the second utilized a linear regression model to find variables of basic handwashing facility. Therefore, the study aims to determine the magnitude of limited handwashing facility and identify its determinants using a relatively efficient model. The study's findings will assist policymakers in many countries in establishing basic handwashing facility programs, which will help to reduce the spread of public infectious diseases and support future research.

The pooled prevalence of limited handwashing facility (lack of water and/or soap) in this study was 66.16%, with a 95% confidence interval of (59.67%—72.65%).This result was higher than that of a surveys conducted in 44 countries [9] and Ethiopia [11], where the population living in households with a limited handwashing facility was 35.5 ± 23.7% and 54.04% respectively. The discrepancy in magnitude from 44 countries might be due to the differences in socio-economic characteristics of countries. In our case, the majority of countries (61.17%) were classified as low income according to the World Bank classification, 2019. In the case of Ethiopia, there was a small sample size and there might be the difference in fixation of the outcome variable. However, the current finding was lower than the Joint monitoring program (WHO & UNICEF) report in 2017, which found that 85% of sub-Saharan Africans have limited handwashing facility [10]. The explanation for this could be that the report includes all SSA countries, but in our case, we only included 29 countries. Besides, the households might not change in awareness and income status to basic handwashing facility within the year range.

Individual, household, and community-level factors for handwashing facility were all included in this study. Based on multilevel regression model, household heads with older age was significant and a protective factor of limited handwashing facility. The finding is supported by different studies [23‐25], where older household heads had low limited handwashing facility than younger household heads. This could be because older people's immune systems deteriorate with age, and they may require care to avoid infection. The age difference in this study highlights the necessity for the government to establish and implement age-specific educational programs or campaigns.

According to the current study, having low media exposure in the community had higher effect on the presence of limited handwashing facility. The result was supported by different studies [11, 24], where having limited handwashing facility were increased with no having radio and television. Radio and television are powerful and efficient ways to conduct coordinated national awareness campaigns [11]. These devices can send messages to a huge number of people at the same time. Radio is highly vital for reaching out to handwashing messages, especially in remote rural areas where there is no electrical supply. Television is also very important for handwashing demonstration techniques. Handwashing campaigns through media results in lower health consequences for the community [24]. This finding revealed that each county's administration may improve handwashing facility by expanding mass media coverage in both rural and urban areas.

Countries with low and lower middle-income levels were associated with the presence of limited handwashing facilities; this finding was supported by different studies [19, 26‐29], which found that the richest households were more likely to have effective handwashing facility than the poorest households. However, this finding was inconsistent with studies done in developing countries [23, 30], where countries with higher Gross Domestic Product have limited handwashing facility. The current study is interesting in that those countries with lower financial status cannot afford to pay for water services, and purchasing soap/detergents may be crucial factor. The government can address this issue by providing targeted sanitation and hygiene subsidies in the community.

Households who travel more than 30 min round trip to get their water source had a limited handwashing facility. This finding was reinforced by research in Kenya [28]. But it contradicted another study [23], which found that households having a water supply in their dwelling were less likely to have a handwashing facility. The reason for the disparity could be that households are less motivated to use water for handwashing and do not perceive themselves to be susceptible to infection [23]. However, when water is brought from a distance, the person's handwashing activities are less likely to occur at a vital period. If people acquire their water from a remote location, people may prefer to save water for drinking rather than washing hands. The findings indicated that handwashing facility may be enhanced if the government provided an accessible water supply system.

Our study also found that communities with a low educational level were more likely to have limited handwashing facility. This finding is supported by evidence that those who received basic handwashing education were more likely to have handwashing facility [1]. It was also supported by the previous studies [23, 26, 28], where having effective handwashing facility were gradually increased with the increment of the education level of the head of the household. Health education is critical in raising information about the ability to wash hands with soap since uneducated household heads did not know the facilities needed for proper handwashing [31]. Lack of hand hygiene knowledge with other factors such as limited resources of a household may have a positive effect on the presence of limited handwashing facility particularly in low- income countries. However, evidence suggests that health education program on handwashing are more important than investing in handwashing facilities [32]. To improve handwashing facility, the government should increase community awareness and behavior through mass media campaigns and community-level education.

According to our findings, households with more children have limited handwashing facility. This is a contradictory pattern from East African countries [23], where handwashing facility is less prevalent in households without children. The possible explanation in our situation might be that a household with many children is costly to have a basic handwashing facility, and children lack proper use of the available handwashing facility. Having a large number of children, on the other hand, could be a big opportunity for future home hygiene practice since they are more sensitive to learning and are very likely to adopt healthy behaviors at a younger age [33].

Residence was also another factor for the limited handwashing facility. In this study, being rural residents were more likely to have limited handwashing facility than urban areas. The finding was supported by other evidences [23, 24, 27]. Challenges in rural locations related to the cost of obtaining soap or clean water may be the reason for the presence of limited handwashing facility [23, 26]. The reason might be that the rural individuals lacked the necessary education and information on risk of infection related to having limited handwashing facility. Thus, improving educational levels of rural households will close the gap between urban and rural areas. Moreover, the government can improve handwashing facilities by implementing a handwashing health service package program.

Unimproved sanitation facilities were associated with limited handwashing facility. The finding was supported by suggested evidences [26, 28], households with a shared type of sanitation facility were less likely to have an effective handwashing facility. Unimproved sanitation and unprotected water sources are also indicated as having limited handwashing facility [26]. One possible justification for this is that poor designed sanitation facilities in household may lacked water and soap on-premises to wash hands after toilet visit. The like hood of having a limited handwashing facility was higher in a mobile type of handwashing facility. This was supported by another study, which found a higher prevalence of handwashing with soap in areas having a handwashing station within 10 paces of the kitchen [19]. The finding is expected that utilizing soap and water for handwashing is inconvenient unless there is a fixed location. The government should demonstrate how to install improved sanitation with handwashing facility using locally available materials.

In this study, the pooled prevalence of limited handwashing facility (without water and or soap) is 66.16%. West African region had the highest prevalence of limited handwashing facility when compared to others regions in sub-Saharan Africa. The prevalence of limited handwashing facility increase when income level reduced. The age of the household head, location of the handwashing facility, number of under-five children, household size, sanitation facility, residence, income level, community-level media exposure, and education were a determinant factors for limited handwashing facility.