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Background: Face washing is important to interrupt the transmission of trachoma, the leading infectious cause of blindness worldwide. We aimed to assess the household and personal factors that affected water use and face washing practices in Kongwa, Tanzania. Methods: We conducted a household water use survey in 173 households (329 children) in January, 2010. Self reported data on water use practices, observed water in the household, and observed clean faces in children were collected. Contingency table analyses and logistic regression analyses were used to measure associations between unclean faces and risk factors. Results: We found that women are recognized as primary decision makers on water use in a household, and respondents who reported laziness as a reason that others do not wash children's faces were significantly more likely to have children with clean faces. Washing was reported as a priority for water use in most households. Sixty four percent (95% Confidence Interval = 59%-70%) of children had clean faces. Conclusions: Attitudes toward face washing and household water use appear to have changed dramatically from 20 years ago when clean faces were rare and men made decisions on water use in households. The sources of these attitudinal changes are not clear, but are positive changes that will assist the trachoma control program in strengthening its hygiene efforts. [ABSTRACT FROM AUTHOR]