Association between receiving the Aksi Bergizi Social Behavioral Change Communication (SBCC) intervention and hygiene behaviors among secondary school students in Padang, Indonesia

Introduction

Among adolescents, hygienic behaviours play a critical role in maintaining overall health and preventing the spread of infectious diseases (Jatrana et al., 2021; Singh et al., 2023). Hygiene refers to the practice of maintaining the cleanliness of body parts. The most common type of hygiene studied in public health is hand hygiene, which includes hand washing with soap and water as well as the use of hand rubs (e.g., hand sanitizers) (UNICEF, 2022). Hand hygiene is universally recognized as a fundamental practice for preventing gastrointestinal and respiratory infections (Aiello et al., 2008). Oral hygiene refers to the practices that maintain the cleanliness and health of the mouth, teeth, and gums. This includes regular brushing and flossing of teeth, using mouthwash, and visiting the dentist for check-ups and cleanings (NIDCR, 2024). Poor oral hygiene after meals can lead to dental caries, gum diseases, and other health issues (Duangthip & Chu, 2020; Santhosh et al., 2023). Nail hygiene refers to the practices and behaviors that keep the fingernails and toenails clean, healthy, and free from harmful microorganisms (CDC, 2024). This includes regularly trimming nails, cleaning under them, and avoiding habits like biting nails or using unclean tools that can introduce germs or cause damage (CDC, 2024; Wu & Lipner, 2020). However, despite their importance, oral and nail hygiene practices are often overlooked as components of hygiene (Wu & Lipner, 2020), even among adolescents (Su et al., 2024). To promote hygiene and other health behaviors, various actors in health have applied Social Behavioral Change Communication (SBCC) tools. SBCC refers to the “systematic application of theory-based, research-driven communication strategies” (USAID, 2019) to influence social conditions and modify individual behaviors (McKee, Becker-Benton & Bockh, 2014).

Indonesia is a middle-income country in Southeast Asia where eating with hands is a common cultural practice, making hand hygiene promotion essential for reducing the risk of infectious diseases (Han et al., 2020). Health promotion programs in Indonesia that focus on adolescent nutrition may also include hygiene promotion. Despite this inclusion, hygiene behaviors are not as thoroughly described in the evaluation of these programs as dietary behaviors (Loveday et al., 2014). The Indonesian government, in collaboration with UNICEF, has implemented the Aksi Bergizi (“Nutrition Action”) program in 2022 in selected secondary schools nationwide. The program aimed to promote proper nutrition among adolescents based on SBCC principles (Ministry of Health of Indonesia, 2019b; Ministry of Health of Indonesia, 2019a; UNICEF, 2019), but also included hand, oral, and nail hygiene promotion activities. Information regarding hand, oral, and nail hygienes among students in schools that did and did not receive the Aksi Bergizi program can provide basic information and empirical evidence for stakeholders in adolescent health and infectious diseases. Therefore, the objective of this study is to assess the association between exposure to the Aksi Bergizi nutrition promotion program and hand, oral, nail hygiene behaviors among secondary school students in Padang, Indonesia.

Materials & Methods

Results

A total of 253 students from the Aksi Bergizi target schools and 253 students from the Aksi Bergizi non-target schools participated in our study (response rate = 100%). There were significant socio-demographic differences between participants target and non-target schools regarding age distribution, the education level of the participants’ father, and household monthly income (Table 1). Students in target schools self-reported higher adherence to hand hygiene at key moments for hand hygiene (before eating, after using the toilet or latrine) than students at non-target schools (Table 2). Students from target schools were also significantly more likely to report adherences to oral hygiene and nail hygiene than students from non-target schools.

Students at Aksi Bergizi target schools were significantly more likely than students at the non-target schools to self-reported handwashing with soap at all times vs. the otherwise before eating (75% vs. 21%; Adjusted OR = 6.03; 95% CI [3.96–9.19]) (Table 3) and after using the toilet (74% vs. 21%; Adjusted OR = 5.74, 95% CI [3.78–8.72]). However, there was no statistically significant association between school group and clipping nails.

Discussion

In this school-based cross-sectional study, we compared self-reported hygiene behaviors among students from schools that received the Aksi Bergizi nutrition promotion program with hygiene-related activities vs. students from schools that did not receive the program. We found universal compliance to oral hygiene. We also found significant differences regarding the probability of handwashing with soap before eating and after toilet use, but no statistically significant difference regarding nail hygiene behaviour.

The findings of our study regarding hand hygiene align with these previous studies (Jatrana et al., 2021; Rahman Zuthi et al., 2022). The additional contribution of our study findings may be the data pertaining to oral hygiene and nail hygiene behaviors, which were less commonly studied. In that regard, all of the students in our study, regardless of school type, reported brushing teeth at least twice per day. Although the participants self-administered the questionnaire, they might have feared being overseen by their peers and thus were less likely to self-report socially undesirable behaviors, and social desirability is common in self-reporting oral hygiene practices (AlGhamdi et al., 2020; Sanzone et al., 2013). Future studies should consider alternative ways to measure oral hygiene that may be less prone to social desirability, such as asking participants to click on the link for the questionnaire when they are home and safe from being overseen by peers.

While the study highlighted significant disparities in hygiene behaviors, several important aspects remained unknown or understudied. Firstly, previous studies have found gaps btween self-reported vs. observed hygiene behaviors (Hagiya et al., 2022; Seyed Nematian et al., 2017). Future studies should consider including a structured observation of hand hygiene behavior, similar to that in a previous study (Wichaidit et al., 2019). Furthermore, hygiene is influenced by disgust and social norms (Nizame et al., 2013; Wichaidit et al., 2019). We did not include measurement questions for these behavioral drivers in our study. Future studies should consider developing a theory of behavior change for the intervention, and collect data on potential drivers of hygiene behaviors and make pathway analyses according to the developed theory to achieve a more complete understanding of the observed differences.

The strength of our study was the high level of voluntary participation, which reduced selection bias from non-response. However, a number of limitations should be considered in the interpretation of the study findings. Firstly, the intervention was not randomized, and the cross-sectional design of the study precludes the ability to make inferences regarding program effectiveness. Secondly, hygiene behavior is deemed in many regions, including the study area, to be socially desirable. Thus, the influence of social desirability may be non-negligible in our study findings. Lastly, we conducted our study only among schools in Padang, West Sumatera. The findings of the study may not be generalizable to students and schools in other regions.

Conclusions

We found that students in schools that received the Aksi Bergizi nutritional promotion program were more likely to self-report handwashing with soap before eating and after toilet use, but there was no significant difference regarding frequency of nail-clipping. Considering the role of hygiene in improving nutrition, the findings of this study may be relevant to stakeholders in both adolescent infectious diseases and adolescent nutrition. However, limitations regarding the cross-sectional design, social desirability, and limited generalizability should be considered in the interpretation of the study findings.

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