Household determinants of observed handwashing among primary schoolchildren in Hebron, Palestine: a cross-sectional study

Objective To assess observed handwashing before eating among primary schoolchildren in a fragile setting in Palestine and examine how this behaviour is associated with household-level and guardian-related determinants. Design Cross-sectional baseline study embedded within a school-based cluster randomised controlled trial of a hand hygiene intervention. The trial is registered on ClinicalTrials.gov ( NCT05964478 ), and this manuscript reports pre-results baseline findings alongside additional cross-sectional household survey data. Setting Public primary schools in rural and semiurban areas of the Hebron governorate, Palestine, February–March 2023. Participants Fifth and sixth grade schoolchildren enrolled in the trial and their co-resident guardians. Children were observed at school and guardians completed a questionnaire at home. Primary and secondary outcome measures The primary outcome was observed handwashing of both hands with water before eating at school, recorded by trained enumerators during a standardised snack break. Household-level and guardian-level determinants were derived from a structured questionnaire covering five domains: sociodemographic characteristics of guardian and child; household access to handwashing; guardian’s health and handwashing knowledge; guardian’s self-reported handwashing behaviour; and guardian-reported child handwashing at home. Associations between determinants and observed handwashing were estimated using generalised linear mixed-effects models with school as a random effect; effect modification by whether the responding guardian was the mother was explored. Results Observation and survey data were available for 931 child–guardian pairs across 26 schools. Overall, 37% of the fifth and sixth grade children were observed washing their hands before eating at school, while 44% of guardians expressed high confidence that their child would do so and 84% exhibited good handwashing knowledge themselves. Poor guardian’s self-reported handwashing behaviour was associated with a lower likelihood of children’s observed handwashing at school (adjusted OR (OR adj ): 0.68; 95% CI 0.47 to 0.99), particularly when the guardian was the mother (OR adj : 0.55; 95% CI 0.40 to 0.90). Household water quality was perceived as poor by 95% of guardians. Poor perception was associated with lower likelihood of children washing hands at school (OR adj : 0.41; 95% CI 0.20 to 0.90). Conclusions In this fragile, water-insecure setting, low levels of observed handwashing before eating and the associations with guardian behaviours and household-level factors suggest that school-based handwashing promotion may be strengthened by complementary strategies that also engage households.