Hand hygiene, including handwashing by children, has been reported to contribute to the prevention of various infectious conditions. This study aims to explore the correlates of handwashing behavior among 1690 fourth to sixth grade primary school students in 19 Tibetan primary schools (Golog, Qinghai, China). The theory of reasoned action (TRA) was applied. Data was collected by questionnaire. Structural equation modeling (SEM) analysis showed that students' attitude (β = 0.22, 95% CI 0.13-0.31) and subjective norms in terms of compliance to teachers', parents' and peers' suggestions to wash hands (β = 0.09, 95% CI 0.01-0.18) were directly associated with students' handwashing behavior. Students' knowledge (β = 0.04, 95% CI 0.03-0.07) had an indirect association with handwashing behavior, mediated by students' attitudes and subjective norms. Subjective norms (β = 0.12, 95% CI 0.07-0.17) were also indirectly correlated with handwashing through students' attitudes. Therefore, our study supported the theory of reasoned action through our findings that students' attitude and knowledge, and also attitudes from teachers, parents and peers were correlated with student handwashing behavior. Students reported higher level of compliance to teachers than to their parents and classmates. Based on this information, we recommend teacher-involved participatory hygiene education to promote students' handwashing behaviors in areas at high risk for infectious diseases that can be prevented by handwashing.
Keywords: handwashing behavior; rural areas; school children; structural equation model; the Tibetan nationality; theory of reasoned action.