A multilevel analysis of the determinants of handwashing behavior among households in Eswatini: a secondary analysis of the 2014 multiple indicator cluster survey

Introduction: Handwashing with soap has received considerable attention due to its importance in the prevention and inter- ruption of the transmission of diseases. Regardless of the positive effects of handwashing with soap, developing countries still have a low rate of handwashing. Objective: The study aimed to determine the individual, household and community-level factors associated with handwash- ing behavior among households in Eswatini. Methods: Using the Eswatini Multiple Indicator Cluster Survey conducted in 2014, a secondary analysis was done of the households surveyed. A total of 1,520 households nested in communities with complete data on handwashing practices were included in the analysis. Univariate, bivariate analysis and multivariate multilevel logistic regression were used to estab- lish the factors that were associated with handwashing behavior. Results: The prevalence of handwashing among households was 56% in 2014. Households whose heads were aged 35-54 and 55 years and older were more likely to practice handwashing (AOR=1.88, 95% CI:1.39, 2.54); and (AOR=1.77, 95% CI: 1.205, 2.62) compared to those aged 15-34 years. Households with a pit latrine or no toilet facility at all, were less likely to practice handwashing (AOR=0.24, 95% CI: 0.17, 0.35); (AOR=0.28, 95% CI: 0.11, 0.71) respectively compared to those with a flush toilet. Region of residence was a community-level variable associated with lower odds of handwashing, with those from the Hhohho (AOR=0.22, 95% CI: 0.14, 0.35) and Manzini region (AOR=0.42, 95% CI: 0.27, 0.67) compared to Lubombo region. Households from communities where access to mass media was high were more likely to practice handwashing (AOR =1.47, 95% CI: 1.05, 2.03) compared to those from communities where access to mass media was low. Conclusion: Households headed by young adults, with pit latrine or no toilet facility at all and lived in the Hhohho and Manzini regions and with low access to mass media, should be targeted for interventions aimed at improving handwashing practices. Keywords: Handwashing; factors; Eswatini; households; multilevel logistic regression.