{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T03:00:58Z","timestamp":1777950058961,"version":"3.51.4"},"reference-count":83,"publisher":"BMJ","issue":"4","license":[{"start":{"date-parts":[[2026,4,30]],"date-time":"2026-04-30T00:00:00Z","timestamp":1777507200000},"content-version":"unspecified","delay-in-days":29,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100009131","name":"Direktion f\u00fcr Entwicklung und Zusammenarbeit","doi-asserted-by":"publisher","award":["Hands4Health project (7F-l 0345.03.01)"],"award-info":[{"award-number":["Hands4Health project (7F-l 0345.03.01)"]}],"id":[{"id":"10.13039\/100009131","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,3,26]]},"published-print":{"date-parts":[[2026,4]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>\n                      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 (\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"clintrialgov\" xlink:href=\"NCT05964478\">NCT05964478<\/jats:ext-link>\n                      ), and this manuscript reports pre-results baseline findings alongside additional cross-sectional household survey data.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>Public primary schools in rural and semiurban areas of the Hebron governorate, Palestine, February\u2013March 2023.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Primary and secondary outcome measures<\/jats:title>\n                    <jats:p>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\u2019s health and handwashing knowledge; guardian\u2019s 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Observation and survey data were available for 931 child\u2013guardian 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\u2019s self-reported handwashing behaviour was associated with a lower likelihood of children\u2019s observed handwashing at school (adjusted OR (OR\n                      <jats:sub>adj<\/jats:sub>\n                      ): 0.68; 95% CI 0.47 to 0.99), particularly when the guardian was the mother (OR\n                      <jats:sub>adj<\/jats:sub>\n                      : 0.55; 95%\u2009CI 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\n                      <jats:sub>adj<\/jats:sub>\n                      : 0.41; 95%\u2009CI 0.20 to 0.90).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  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State of Palestine"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Safa","family":"Sultan","sequence":"additional","affiliation":[{"name":"Palestine Polytechnic University, Hebron, State of Palestine"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Maryna","family":"Peter","sequence":"additional","affiliation":[{"name":"FHNW University of Applied Sciences and Arts Northwestern Switzerland, Muttenz, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mirko S","family":"Winkler","sequence":"additional","affiliation":[{"name":"Swiss Tropical and Public Health Institute, Allschwil, Switzerland"},{"name":"University of Basel, Basel, Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nicole","family":"Probst-Hensch","sequence":"additional","affiliation":[{"name":"Swiss Tropical and Public Health Institute, Allschwil, Switzerland"},{"name":"University of Basel, Basel, 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