Self-Reported Personal Hygiene Practice and Associated Factors among Prison Inmates in Gondar City, Northwest Ethiopia: An Institution-Based Cross-Sectional Study

ABSTRACT.

The growing prevalence of communicable diseases in prison is significantly attributed to poor hygiene practices and insufficient sanitary conditions. The aim of this study was to assess self-reported personal hygiene practice and its associated factors among prison inmates in Gondar, northwest Ethiopia. An institution-based cross-sectional study was conducted from December 1, 2018, to February 30, 2019. Data were gathered using a structured, interviewer-administered questionnaire and observational checklists. The mean age of the inmates was 36 years (±12.4) and the mean months spent in prison was 98.2 ± 15.4 months. The overall adherence to good personal hygiene practices among Gondar City Prison inmates was 54.3%, with a 95% CI of (49.4, 59.1). The number of prisoners per cell [adjusted odds ratio (AOR), 0.31; 95% CI, (0.16, 0.62)], daily water consumption [AOR, 6.78; 95% CI, (2.84, 16.15)], and good knowledge (AOR, 1.50; 95% CI, (1.23, 5.61)] were found to be significant predictors of personal hygiene practice among prison inmates. More than half of the study participants had good personal hygiene practices. Knowledge, daily water consumption, and the number of prisoners per cell were all found to be significantly associated with prisoners’ personal hygiene practices. Improving the availability of water would be the best alternative way to improve the personal hygiene practices of the prisoners. Furthermore, prison inmates should be educated on proper hygiene measures and personal cleanliness to prevent the transmission of communicable diseases.

INTRODUCTION

Personal hygiene is the practice of maintaining the cleanliness of one’s own body. Personal hygiene risks are directly related to some important daily activities implicated in worthy operational actions and obligatory responsibilities, such as washing hands before meals and after defecation with soap, brushing teeth at least twice a day, especially after breakfast and after meals, taking a bath with soap regularly, keeping nails short, and taking regular exercise.^1,2

Prisons include temporary immigration and juvenile detention facilities in addition to long-term correctional facilities.³ The health of those who are imprisoned suffers as a result of the sometimes subpar hygiene conditions in jails. Prisons were not conducive to health. In many prisons, unhealthy circumstances including overcrowding and poor cleanliness are common, and communicable diseases are regularly transmitted among prisoners.³ Ninety-five percent of inmates who reside in prisons frequently battle skin problems (dermatitis and other skin diseases), breathing illnesses (the common cold, COVID-19, and influenza), infectious diseases and diarrhea, cardiovascular problems, and sexually transmitted diseases (hepatitis and HIV),⁴ although prisoners are more likely to have parasite infections as a result of a variety of socioeconomic and behavioral factors, including “high exposure to pollutants, inadequate standards of personal cleanliness, hunger, mobility challenges, psychological illnesses, and stress.”^5,6

People who have been relocated or are in legal custody and require access to water, sanitation, and hygiene (WASH) services are largely ignored and underserved.³ Prisons are criminal facilities used all over the world to house, discipline, and reeducate people who have been ordered into custody by the law or who have been convicted of an offense.⁷

According to estimates, 10.74 million people are imprisoned worldwide, either as remanded (pretrial) inmates or as those who have been found convicted by a court with appropriate jurisdiction.^8,9 Since 2000, the number of people incarcerated worldwide has increased by 24%, roughly keeping pace with the projected growth in the global population.⁸ Although it is a basic human right for everyone to have access to safe water, sanitation, and hygiene facilities, many prisoners around the world are forced to live with a scarcity of WASH facilities.^2,3 Prison inmates are a group that is neglected by society, and providing convicts with the basic essentials of services is becoming a major global concern.^10,11 According to reports, there were more than 10.2 million inmates incarcerated in jails in 2013 (144 per every 100,000 people), whereas the global annual turnover is closer to 30 million.^11,12 United Nations Sustainable Development Goals (SDG) 6 call for equitable sanitation and hygiene for all by 2030¹³; as a result, SDG 6.2 will not be fully achieved if WASH services for people in prisons are not taken into consideration.³

Ethiopia had 111,050 officially recorded prisoners in 2015 (or 128 out of every 100,000 people).¹⁴ Prisoners in Ethiopia have limited access to housing and hygienic conditions, which include overcrowding, unsanitary surroundings, a lack of sanitary supplies, inadequate medical care, and insufficient food.¹⁵

The growing prevalence of communicable diseases in prison is significantly attributed to poor hygiene practices and insufficient sanitary conditions. It is crucial to study how inmates practice personal hygiene because it is a topic that requires more attention because of the challenging conditions that prisoners must deal with on a daily basis.² Poor hygiene behaviors, a lack of access to sanitation, and contaminated, unsafe drinking water are to blame for about 88% of diarrheal disease-related deaths in underdeveloped nations.¹⁶ By itself, improved sanitation might cut these illnesses by a third. Similar to this, poor sanitation and hygiene practices contribute to nearly 60% of the disease burden in Ethiopia.¹⁷

Numerous factors, including overcrowding, an increase in the danger of infectious diseases, sluggish disease detection, a lack of isolation rooms, and inadequate treatment, are thought to contribute to health problems in prisons.⁵ The medical personnel and facilities, on the other hand, do not have optimal possibilities (they don’t have training, routine checklist-based hygiene inspections, and lack of isolation rooms).

Despite the importance of personal hygiene and the challenges faced by prison inmates in maintaining personal hygiene, no study has explored hygiene-related self-care practices among prison inmates in Gondar City. Therefore, the goal of this study was to assess personal hygiene practices and associated factors among prison inmates in Gondar Prison, northwest Ethiopia.

MATERIALS AND METHODS

Study design, period, and area.

An institution-based cross-sectional study was conducted from December 1, 2018, to February 30, 2019.

The study was conducted in Gondar, northwest Ethiopia. The overall area of the city of Gondar is 209.27 km² (80.80 square miles). During the study period, there were more than 2,000 prisoners housed in one prison facility in Gondar City, and 64 of them were women.

According to WHO and national standards, the WASH requirements for prisons, particularly in Ethiopia, and in the study area are challenging to meet. There are worldwide minimum standards for monitoring and assessing the state of WASH in prisons of one tap per 100 inmates, one toilet per 25 detainees, and one hand-washing station per 50 detainees.¹⁸ The above minimum standards for the study area (Gondar Prison) were not met.

Source population and study population.

All prison inmates in Gondar Prison were the source population, whereas the randomly selected prison inmates were the study population.

Inclusion and exclusion criteria.

Inmates who had been incarcerated for at least 4 weeks were eligible to participate in the study, whereas those with critical illness and unable to communicate were not.

Sample size determination and sampling procedure.

Fisher’s method for a single proportion in cross-sectional studies was used to determine the 422 minimum samples (with 10% added for nonresponse)¹⁹:

$$n=\frac{{\left(Z\mathrm{\alpha }/2\right)}^2\times p(1-p)}{d^2} n={(1.96)}^2 \frac{\left[0.5(1-0.5)\right]}{{0.05}^2}=384.$$

The total sample size (N = 422) was obtained by adding a 10% contingency for nonresponse. Where Zα is the standard normal deviation of 1.96 at a 95% CI, p, the proportion of inmates with poor sanitation and hygiene in Gondar Prison, was assumed to be 50%, and d was the acceptable difference, using 5% (d = 0.05).

A simple random sampling technique was used to select study participants (inmates) at a prison during the study period.

Operational definitions and measurements.

Personal hygiene.

Personal hygiene refers to behaviors that support prison inmates’ physical, emotional, social, and spiritual health and well-being, as well as the cleanliness of a person’s body.^20,21

Knowledge.

Knowledge refers to the correct responses of prison inmates regarding personal hygiene as measured by a face-to-face interview with a structured questionnaire. Prison inmates who scored more than or equal to 70% on the overall knowledge-related questions on hygiene were considered to have “good knowledge,” whereas those with a score below 70% were considered to have “poor knowledge.”^20,22

Personal hygiene practice.

Personal hygiene practice refers to the activities performed by prison inmates in relation to personal hygiene to promote hygiene behavior. Prison inmates who scored more than or equal to 70% on the overall practice-related questions on hygiene from the observational checklist were considered to have “good practice,” whereas those whose total score was below 70% were classified as having “poor practice.”^20,22

Prisoner.

Any individual who is involuntarily confined or held in a criminal facility is referred to as a prisoner. The phrase refers to those who have received a criminal or civil penalty and are being held pending arraignment, trial, or sentencing.²³

Personal hygiene characteristics.

Personal hygiene characteristics refers to keeping all parts of the external body (fingernails, face, hair, clothing, teeth, and feet) clean and healthy.²⁴

Data collection tools and procedure.

Data were collected from 403 prison inmates, and only one inmate from each cell was interviewed. Data were gathered by face-to-face interviews using a structured interviewer-administered questionnaire and observational checklists adopted and modified from the WHO^25,26 and other literature.²⁷ The questionnaire includes sociodemographic variables and individual factors (10 questions), the sanitary condition of the prison (27 questions), knowledge (11 questions), practice toward personal hygiene (eight questions), training-related information, and prison inmates’ personal condition.

The prison administration approved the study and gave the research team temporary access to a dormitory where they could interact with randomly chosen respondents. An interviewer administered the questionnaire. A simple random selection method was used to choose the respondents from the prisoner cells (free and solitary cells). To avoid response contamination among those still to be interviewed, the chosen inmates were interrogated sequentially while in the dormitory and then sent back to their cells. At the near end of the dormitory, the chosen inmates were interviewed one at a time. The inmates were individually asked for consent and those who accepted were interviewed, whereas those who objected were taken back to their cells. Additionally, the study included transect walks with designated prison authorities around the prison grounds, cells, related restrooms, open wastewater drains, and solid and liquid waste management facility.

Eleven close- and open-ended questions with two response alternatives, “yes” or “no,” as well as questions allowing free response were used to assess prison inmates’ knowledge of personal hygiene. The questions mainly addressed prison inmates’ personal cleanliness, protection from diarrhea, importance of hand washing with soap and water, critical times for hand washing, time to boil water and its importance, provision of health and hygiene measures, and education about WASH. One point was awarded for each successful answer, whereas zero points were awarded for incorrect answers or unsolved questions. The answers to these questions were then added together to give a knowledge score between 0 and 11.

During serving of meals, interviewing, and transect walk-throughs, an observation checklist was used to assess personal hygiene practices. Eleven close- and open-ended questions were used to assess the hygiene practices of prison inmates. The questions mainly address the critical hand-washing times, the frequency of changing clothes, washing clothes, and cleaning teeth, and the materials used for hand washing. These practices were graded similarly, with one point for each standard practice and zero points for each unsanitary practice.

Data quality assurance.

The data collectors were trained, and a pretest was conducted on 5% of the prison inmates identified in a nearby city (a place where the actual data collection did not take place), and the necessary modifications were made. In addition, the structured questionnaire was validated by pretesting before the start of the study. The Cronbach’s alpha values were acceptable for the adopted and the modified questions (i.e., they were acceptable). The Cronbach’s alpha value was 0.84 for prison inmates’ knowledge of personal hygiene. The measure of internal consistency (reliability) for the dependent variable, the practice of personal hygiene by prison inmates, was estimated, and we found an acceptable value (Cronbach’s alpha, 0.79). During data collection, the survey was closely monitored. The completeness and consistency of the data collected were checked daily. Incomplete or missing questionnaires were returned to the data collectors for correction. Anything that was inaccurate or misleading was corrected the following day of the survey. To ensure accuracy, the data collected were double entered.

Data management, processing, and analysis.

After double-checking for accuracy and consistency, the data were entered into Epi Info version 7.2.1.0. For further analysis, they were transferred to SPSS version 26 software. Variables that were statistically significant in the univariate analysis, biologically plausible, and relevant to the main interest of the study were included in the multivariable logistic regression analysis. Results were presented in tables and prose, using descriptive statistics such as mean, standard deviation, and percentage to characterize the study population in relation to key variables. Multivariable logistic regressions were used to examine the independent characteristics related to personal hygiene. An odds ratio (OR) with a 95% CI was used to calculate the degree of relationship between the independent variables and the dependent variable. The assumption of multicollinearity was tested using a variance inflation factor (VIF), and all variables had values of less than 5, indicating that there is no evidence of multicollinearity. The final regression model included all variables with a P value of less than 0.2 in the bivariable logistic regression analysis. Variables with a P value of less than 0.05 were used in the multivariable logistic regression analysis to determine a statistically significant relationship. The final model was tested for goodness of fit using the Hosmer–Lemeshow test. The result declared a good fit (P = 0.89).²⁸

RESULTS

Sociodemographic characteristics.

Our analysis showed that the mean age was 36 years (±12.4), and 368 (91.3%) of the prisoners were males. More than half (206; 51.1%) of the prisoners were married, and only 3.2% had a diploma or higher education. The majority of prison inmates (350; 86.8%) got < 20 L of water per day. However, the majority of them reside in fewer cells than the average prison has, 97 (24%) live in a single cell of 66–152 inmates. Furthermore, 178 (44.2%) of the prisoners were farmers prior to incarceration; the mean number of months spent in prison by inmates was 98.2 ± 15.4 months, with 205 (50.8%) having spent more than 1 year in prison (Table 1).

Table 1.

Demographic characteristics of prison inmates in Gondar City, northwest Ethiopia, 2019 (N = 403)

Variables		Number	Percent
Sex	Male	368	91.3
	Female	35	8.7
Age (years)	17–28	105	26.1
	29–36	108	26.8
	37–42	93	23.1
	43–70	97	24
Marital status	Single	140	34.7
	Married	206	51.1
	Widowed	22	5.5
	Divorced	35	8.7
Educational status	Not able to read and write	94	23.3
	Able to read and write without formal school	147	36.5
	Primary	103	25.6
	Secondary	46	11.4
	Diploma or above	13	3.2
Duration of imprisonment (months)	3–8	124	30.8
	9–12	97	24
	13–36	95	23.6
	37–144	87	21.6
Average net income	100–700	127	31.5
	701–1,000	154	38.2
	1,001–1,500	83	20.6
	1,501–2,500	39	9.7
Occupation before imprisonment	Civil servant	48	11.9
	Farmer	178	44.2
	Private worker	123	30.5
	Student	39	9.7
	Other	15	3.7
Water consumption per day (L)	< 20	350	86.8
	> 20	53	13.2
Number of prisoners per cell	17–52	120	30
	53–60	112	27.7
	61–65	74	18.3
	66–152	97	24

Knowledge of prison inmates.

Half [205; 50.8%; 95% CI, (46.8, 54.2)] of the inmates knew about personal hygiene. Thirty-eight percent of inmates received personal hygiene information from health care staff; 346 (85.8%) knew the importance of boiling water to reduce the risk of diarrhea; and 211 (52.3%) knew the importance of disposing of human waste and not disposing of it in nature (because it contains pathogenic microorganisms). Almost all prison inmates (398; 98.7%) knew the importance of washing their hands (before, during, and after food preparation), followed by before and after caring for a person in prison who is ill with vomiting or diarrhea (385; 95.5%) (Table 2).

Table 2.

Knowledge of prison inmates about personal hygiene in Gondar City Prison, northwest Ethiopia, 2019 (N = 403)

Characteristics		Number	Percent
Heard about WASH practice	Yes	278	69
	No	125	31
Source of information	TV and radio	89	22.2
	Health care workers	156	38.7
	Prison administration	120	29.7
	Colleagues/friends	38	9.4
Provision of health and hygiene education in the prison	Yes	299	74.2
	No	104	25.8
Personnel provide health education regarding personal hygiene activities	Educational staff (teacher)	56	13.8
	Health extension workers	114	28.2
	Health care professionals	203	50.6
	Prison-trained staff	30	7.4
How frequently is health education regarding personal hygiene activities conducted?	Every day	32	8
	Once or twice per week	42	10.4
	Once or twice per month	157	38.9
	Once or twice per a quarter	98	24.3
	Once per year	46	11.4
	Do not know	28	7
What is the importance of boiling water?	Kills germs	293	72.7
	Makes water safe to drink	168	41.6
	Reduces the chances of getting diarrhea	346	85.8
	Gives water a better taste	189	46.8
Why human feces should be disposed of in a proper way (latrine) rather than be left in the open field	Contain pathogenic microorganisms	211	52.3
	Avoid contaminating water sources, air, and soils	304	75.4
	Have smell	399	99
	Fly breeding	204	50.6
	Act as a means of disease transmission	198	49
What are the critical times to wash your hands?	Before, during, and after preparing food	398	98.7
	Before and after a meal	303	75
	Before and after caring for someone at the prison who is sick with vomiting or diarrhea	385	95.5
	Before and after treating a cut or wound	267	66
	After using the toilet	299	74
	After blowing your nose, coughing, or sneezing	347	86
	After touching an animal, animal feed, or animal wastes	244	60.5
	After touching waste	367	91
Why is it important to wash your hands using water and soap?	Reduces the chances of getting diarrhea	378	93.7
	Reduces the chances of getting other diseases/infections	201	49.8
	Keeps hands clean	381	94.5
	Reduces communicable disease (fecal–oral)	367	91
	Religious beliefs	379	94
How can you protect yourself against diarrhea?	Eat properly washed fruits and vegetables	356	88
	Eat noncontaminated and unspoiled food	303	75
	Use clean toilet	351	87
	Drink clean/boiled water	374	92.8
	Use clean water	389	96.5
	Wash hands at critical times	379	94
Overall knowledge status	Good	205	50.8
	Poor	156	49.2

WASH = water, sanitation, and hygiene.

Self-reported personal hygiene practices of the inmates.

Two hundred and nineteen (54.3%) prisoners, with a 95% CI of (49.4, 59.1), practiced good personal hygiene. More than half of the respondents (218; 54.1%) always washed their hands before eating, and 165 (40.9%) washed their hands after going to the toilet. Two hundred and fifteen (53.3%) of the prisoners used water and soap, nine (2.3%) of the prisoners used water with ash, and 179 (44.4%) of the prisoners used only water to wash their hands. Nearly half of the prison inmates (196; 48.6%) always washed their hands after sneezing, coughing, or blowing their nose, whereas 104 (25.8%) usually brushed their teeth (Table 3).

Table 3.

Self-reported personal hygiene practice among prison inmates in Gondar City Prison, northwest Ethiopia, 2019 (N = 403)

Characteristics		Number	Percent
Washing hands before a meal	Always	218	54.1
	Usually	127	31.5
	Sometimes	45	11.2
	Never	13	3.2
Washing hands after blowing your nose, coughing, or sneezing	Always	196	48.6
	Usually	96	23.8
	Sometimes	103	25.6
	Never	8	2.0
Washing hands after going to the toilet	Always	165	40.9
	Usually	96	23.8
	Sometimes	133	33.0
	Never	9	2.3
Materials for hand washing	Soap and water	215	53.3
	Water only	179	44.4
	Water and ash	9	2.3
Frequency of taking a shower	Always	42	10.4
	Usually	191	47.4
	Sometimes	168	41.7
	Never	2	0.5
Frequency of changing clothes	Always	34	8.4
	Usually	194	48.1
	Sometimes	171	42.4
	Never	3	0.7
Frequency of washing clothes	Always	32	7.9
	Usually	179	44.4
	Sometimes	189	46.9
	Never	3	0.7
Frequency of cleaning teeth	Always	73	18.1
	Usually	104	25.8
	Sometimes	197	48.9
	Never	29	7.2

Objectively observed personal hygiene characteristics of the inmates.

In this study, more than 241 (59.8%) of the prisoners’ personal hygiene characteristics were rated as moderate by the objective observers. About 266 (66%) of the prisoners had clean clothes, 236 (58.6%) had clean fingernails, and 326 (80.9%) had a clean face. Thirty-one (7.7%) detainees reported having diarrhea in the previous 2 weeks, and seven (1.7%) reported having vomited in the previous 2 weeks. Fifty-two (13%) of the inmates had a lice infestation (Table 4).

Table 4.

Observed personal hygiene characteristics among prison inmates in Gondar City Prison, northwest Ethiopia, 2019 (N = 403)

Characteristics		Number	Percent
Clothing	Clean	266	66.0
	Not clean	137	34.0
Hair	Clean	282	70.0
	Not clean	120	29.8
Face	Clean	333	82.6
	Not clean	70	17.4
Fingernails	Clean	236	58.6
	Not clean	167	41.4
Lice	Yes	52	12.9
	No	351	87.1
Teeth	Clean	244	60.5
	Not clean	159	39.5
Scabies	Yes	7	1.7
	No	396	98.3
Feet	Clean	252	62.5
	Not clean	151	37.5
Diarrhea over the past 2 weeks	Yes	31	7.7
	No	372	92.3
Vomiting over the past 2 weeks	Yes	7	1.7
	No	396	98.3

Description of the hygienic conditions in the prison.

The location of the prison is out of sight from the edge of the town, which is far from the residential area, has its own land, has a relatively good lighting system, and is free from noise hazards. The cells (free and solitary cells) are constructed of concrete and have adequate natural ventilation systems, but the rooms lack cross- and artificial ventilation because of the positioning and orientation of the windows. Both flowing liquid waste and solid waste are present within the prison compound. Solid waste segregation and disposal, however, also pose challenges. Additionally, the female free cells were fenced within the premises and separated from their male counterparts.

In the prison, each vacant cell has two flush toilet compartments for 6–38 inmates, whereas inmates in single cells use a common traditional pit latrine at the end of the block.

The study found that 310 (77.0%) inmates had access to a pit latrine, whereas only 16 (3.9%) used a flush toilet. The majority of the inmates 232 (57.6%) always had access to a toilet, with about two-thirds of them always queuing before they could use the toilet and one-third of them queuing between 3 and 7 minutes before they could access it. The study also found filled septic tanks in one-third of the toilets. Maintenance of prison facilities and services, including toilets, is routinely performed by the inmates on a rotational schedule. Toilets were cleaned with soap and water in more than half of the facilities (216; 52.5%). Graywater from prison bathrooms and other water-intensive activities stagnates in partially covered drains.

The least satisfactory part of the prison was the availability of water; this is a point about which almost all prisoners complained. The drinking water supply and hand-washing facilities were better, and the water source was piped. The prison obtains water from a safe source (a tap or sanitary well) and stores it (in a corrugated steel tank, plastic water storage container, 5-gallon water jugs, or aboveground cisterns or tanks). It keeps the storage container covered, stores the water on a ground-level platform, and uses narrow-necked containers. However, the availability and sustainability of water were the most important things lacking in the prison.

Latrine provision is somewhat more satisfactory. It has octant quadrants, separate for men and women, is functional for inmates, is easy to clean and wash, is relatively safe to use, and has a water connection. The latrine is a pit latrine and flushes with a concrete floor and superstructure. Inmates are tasked with cleaning their latrines, and there is a functional hand-washing facility and shower near the latrine.

There is a waste receptacle both on the prison grounds and in each cell, and the solid waste is collected by municipal waste trucks for final disposal. There is no solid waste pit for burial, and the prison does not have its own incinerator. Open burning is also practiced within the compound.

Factor analysis associated with personal hygiene practices.

A binary logistic regression analysis was conducted to determine the factors associated with personal hygiene practices. On bivariable analyses, sex, income, occupation before imprisonment, residence before imprisonment, number of prisoners per cell, frequency of cleaning, daily water consumption, and level of knowledge were significantly associated with a P value of 0.2, and were candidates for multivariable logistic regression.

In multivariable logistic regression analysis (Table 5), the number of prisoners per cell (who live in a prison cell with 66–152 inmates) [adjusted OR (AOR), 0.31; 95% CI, (0.16, 0.62)], daily water consumption (who consume ≥ 20 L/day) [AOR, 6.78; 95% CI, (2.84, 16.15)], and knowledge [AOR, 1.50; 95% CI, (1.23, 5.61)] were found to be significant factors for personal hygiene practice among prison inmates.

Table 5.

Binary logistic regression analysis and factors associated with personal hygiene practice among prison inmates, Gondar City Prison, northwest Ethiopia, 2019 (N = 403)

Characteristics	Personal hygiene practice
	Good	Poor	COR (95% CI)	AOR (95% CI)
Sex
Male	196	172	1	1
Female	23	12	2.18 (0.81, 3.48)	1.23 (0.87, 2.36)
Income
100–700	52	58	1	1
701–1,000	102	65	1.40 (0.93, 2.80)	1.10 (0.97, 3.12)
1,001–1,500	47	36	1.78 (0.82, 2.58)	0.87 (0.56, 1.90)
1,501–2,500	18	21	1.11 (0.46, 1.99)	0.90 (0.35, 2.84)
Occupation before imprisonment
Civil servant	30	18	1	1
Farmer	91	87	1.74 (0.33, 2.21)	0.42 (0.12, 1.30)
Private worker	70	53	1.38 (0.40, 1.97)	0.31 (0.10, 2.20)
Other	28	26	1.42 (0.29, 3.43)	1.30 (0.31, 4.70)
Residence before imprisonment
Rural	114	113	1	1
Urban	105	71	1.49 (0.98, 2.18)	1.50 (0.97, 2.33)
Number of prisoners per cell
17–52	72	48	1	1
53–60	55	57	1.44 (1.03, 5.60)	0.52 (0.29, 1.32)
61–65	31	43	0.69 (0.23, 0.87)	0.31 (0.16, 2.62)
66–152	61	36	1.22 (1.02, 3.77)	0.31 (0.16, 0.62)*
Frequency of cell cleaning
Once per week	84	84	1	1
Twice per week	73	46	1.59 (0.98, 2.56)	1.23 (0.86, 3.21)
Three times per week	62	47	2.09 (0.63, 3.72)	0.78 (0.58, 1.40)
Daily water consumption (L)
< 20	174	176	1	1
≥ 20	45	8	5.62 (2.61, 12.42)	6.78 (2.84, 16.15)*
Knowledge
Good	121	84	1.46 (1.99, 3.18)	1.50 (1.23, 5.61)*
Poor	98	100	1	1

AOR = adjusted odds ratio; COR = crude odds ratio.

“1” = reference group. Other = daily laborer or student. Hosmer–Lemeshow goodness of fit (0.89).

^*Significant at P < 0.05.

DISCUSSION

Good personal hygiene involves keeping all parts of the external body clean and healthy. It is important for maintaining both physical and mental health. People with poor personal hygiene provide an ideal environment for germs to grow, making them susceptible to infection. On a social level, people may avoid a person with poor personal hygiene, which may result in isolation and loneliness. This study was designed to assess personal hygiene practices among prison inmates in Gondar City. In this study, overall good personal hygiene practice was found to be 54.3%, with a 95% CI of (49.4, 59.1). This finding is higher than a study conducted in England (39.9%).²⁹ However, it is lower than a Mali prison sanitation and hygiene research project.³⁰ One possible reason was the difference between the study participants (who could potentially benefit from some form of social care), the study area, and the different prison conditions. Another possible reason was differences in knowledge, income, and communication about personal hygiene behavior changes among prisoners. In this study, prisoners had different opportunities to earn income from prison (weaving, handicrafts, artisan work, and business) and access to hygiene protection measures.

In the current study, the number of prisoners in prison cells was directly associated with personal hygiene practice. About 69% of prisoners in prison cells with 66–152 inmates per cell had poor personal hygiene practices as compared with those who lived in prison cells with 17–52 inmates [AOR, 0.31; 95% CI, (0.16, 0.62)]. This is consistent with studies conducted in Bekasi,³¹ southwest Nigeria,³² Mojokerto,³³ and Oyo State, southwest Nigeria.³⁴ This is because of the fact that overcrowded inmates may share more clothes, beds, and utensils for daily living than those less crowded. Prison overcrowding, exacerbated by contaminated, uncleaned, suffocated, and uncirculated air, poses a significant risk for inmates to contract infectious diseases. Because of overcrowding in the maximum-security prison, prisoners’ access to beds and other items they need for warmth and health is restricted. Some prisoners complained about being forced to sleep on the floor or on cardboard boxes without receiving additional bedding.³⁵ According to minimum criteria, each prisoner should have their own mattress, blanket, pillow, and sheet.² Body sweat and other organic matter that is absorbed by beds and bedding will stay on the sheets unless they are routinely changed or ventilated. Inmates are at risk for contracting numerous skin diseases (like scabies and lice manifestations [Pediculosis capitis, or head lice])³⁶ as well as other health problems (including influenza, measles, mumps, and sexually transmitted infections)³⁷ as a result of the dampness in the bedding, which over time turns into a breeding environment for organisms.³⁸ Numerous infectious agents—bacteria, fungi, viruses, and protozoa—can threaten the health of inmates and also affect the health of prison staff, visitors to the facility, and ultimately the general public.³⁹

The water consumption of prisoners (liters per person per day, not only for drinking and cooking purposes but also for personal hygiene) was another significant factor associated with the personal hygiene practice of prison inmates. Prisoners who consumed greater than 20 L/day had 6.78× better personal hygiene practices than those who used less than 20 L/day [AOR, 6.78; 95% CI, (2.84, 16.15)]. The reality is that sanitation and access to water are fundamental human rights.⁴⁰ This right, which guarantees adequate, acceptable, physically accessible, and reasonably priced water for domestic and personal use as well as accessible sanitary facilities, is recognized by international legal instruments. This is also supported by the WHO,² consistent with national standards as well as in Africa.^15,41 A sufficient supply of clean water is required for drinking, cooking, and personal requirements, in addition to preventing and lowering the risk of water-related diseases.⁴² Even though meeting the minimum water requirements in a prison is highly important for the inmates to wash their bodies, hands, and genitalia, prevent body odor, handle food securely, and prevent bad breath in their everyday lives, conjunctivitis, scabies, trachoma, and diseases such as diarrhea, intestinal parasites, and chronic intestinal inflammation were frequent among prisoners who lacked access to clean water, making it difficult for them to maintain their personal hygiene.

Furthermore, knowledge was directly associated with personal hygiene practice in this study. The odds of performing good personal hygiene practices among prison inmates who had good knowledge were 1.5× higher than those who had poor knowledge regarding personal hygiene [AOR, 1.50; 95% CI, (1.23, 5.61)]. This is consistent with the findings of a study on hygiene practices in Oyo State, southwest Nigeria.³⁴ The current study, however, contrasts with findings from maximum-security correctional facilities in Nigeria³² and Mojokerto.³³ This is because of the difference in study area and population (the study population is a vulnerable and high-risk group) and the difference in the method of assessment used in Oyo State, Nigeria. Another possible reason was the difference in sampling technique (purposive sampling technique) used and the difference in the analysis in the Mojokerto study, partial least squares structural equation modeling (with three stages of analysis).³³ Attitude is essential for influencing prison inmates’ personal hygiene practices. In this study, prison inmates’ attitude was not substantially associated with their personal hygiene practices. This is also in line with the Southwest Nigeria Correctional Facility.³² However, this is in contrast with Mojokerto,³³ Oyo State, southwest Nigeria,³⁴ and the WHO.² The possible reasons for this discrepancy may be the difference in the method of analysis, the cut of points used, and the mixed-method approach used in data collection in the Southwest Nigeria Correctional Facility.

Limitations.

Certain factors, such as environmental, personal, and institutional factors that affect hand-washing procedures and methods and detailed sanitary practices in the prison, were not taken into account. Furthermore, intestinal parasitosis and other enteric pathogens were not addressed in this study. A qualitative type of study is preferable to address these factors.

CONCLUSION

In this study, the adherence to personal hygiene practices among prison inmates in Gondar City Prison was moderate. Greater consideration should be given to understanding wider environmental, personal, and organizational factors to prevent the transmission of communicable diseases. Knowledge, the water consumption of prisoners (greater than 20 L/day), and the number of prisoners in prison cells (with 66–152 inmates per cell) were significant predictors of personal hygiene practice.