Handwashing practices and associated factors among primary school children in Ethiopia: a systematic review and meta-analysis

Poor hand hygiene remains a major contributor to fecal-oral disease transmission, childhood illness, and school absenteeism in low-income countries such as Ethiopia. This study synthesized national evidence to estimate the pooled prevalence of proper handwashing practices and identify associated factors among primary school children in Ethiopia. Following PRISMA 2020 guidelines, we searched PubMed/MEDLINE, HINARI, African Journals Online (AJOL), CINAHL, Web of Science, and Google Scholar for studies published through 2024. Data were extracted into Microsoft Excel and analyzed in Stata version 17. A DerSimonian-Laird random-effects model was used to estimate pooled prevalence and odds ratios (ORs) with 95% confidence intervals (CIs). Heterogeneity was assessed using the I 2 statistic, and publication bias was evaluated using Egger’s regression test and funnel plots. Univariable and multivariable meta-regression and subgroup analyses were conducted to explore heterogeneity. Ten primary studies involving 5,693 primary school children were included. The national pooled prevalence of proper handwashing practices was 39.24% (95% CI: 30.23%–48.25%), with significant heterogeneity (I² = 97.32%, p < 0.001). Subgroup analysis indicated the highest pooled prevalence in the combined urban/northern cluster (Addis Ababa, Harar, Amhara, Tigray: 47.87%; 95% CI: 34.42%–61.31%) and the lowest in Southern Ethiopia (27.41%; 95% CI: 23.79%–31.02%). Multivariable meta-analysis revealed that good hygiene knowledge (AOR = 3.09; 95% CI: 1.67–4.50), urban school location (AOR = 2.54; 95% CI: 1.42–3.67), and active participation in school WASH clubs (AOR = 2.32; 95% CI: 1.27–3.37) were significantly associated with proper handwashing practices. More than 60% of primary school children in Ethiopia do not practice proper handwashing. Closing this hygiene gap requires integrating infrastructure investments, such as ensuring reliable access to water and soap, with targeted, peer-led behavioral interventions, including school WASH clubs. This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42026143662 .