Mandatory handwashing in elementary schools reduces absenteeism due to infectious illness among pupils: a pilot intervention study

Impact of an educational intervention on water, sanitation and hygiene knowledge, attitudes, and practices in early childhood development centres in low-socio-economic areas in the Nelson Mandela Bay, South Africa

Good water, sanitation, and hygiene (WASH) enhance healthy living and safe environments for child development. The study aimed to evaluate the impact of an educational intervention on WASH status, knowledge, attitudes and practices in early child development (ECD) centres in low socio-economic areas in the Nelson Mandela Bay in 2021. This quasi-experimental, one group, pre-post-test study elicited responses from 51 ECD practitioners (1 per ECD centre). Telephonic structured knowledge, attitude and practices (KAP) questionnaires were used. KAP was good among participants. The educational intervention significantly improved mean knowledge (p<0.001, 95% CI: 0.58-1.11) attitudes (p<0.001, 95% CI: 0.39-0.67) and practices (p = 0.001, 95% CI: 0.20-0.74). WASH knowledge was significantly impacted by toilet facilities ventilation status (p = 0.083) while WASH attitudes scores were significantly impacted by ventilation where the potties are kept (p = 0.041). WASH practice scores were significantly impacted by across the bush/field (no facility) (p = 0.021) and plastic potties usage (p = 0.057). The educational intervention significantly improved WASH-related knowledge, attitudes, and practices among ECD practitioners. WASH conditions in the ECD centres in the study area require additional interventions targeted to sustainable strategies to enhance behavioural modifications for acceptability and sustainability of intervention strategies.

Making Germs Visible - Assessing the Impact of a School-Based, Low-Cost Intervention on Hand Hygiene Knowledge, Attitude and Practice of Children in Rural India

Handwashing with soap at critical moments is one of the most important factors in controlling the spread of germs and preventing the spread of infection. The objective of this study was to determine the effectiveness of a low-cost, school-based intervention that simulated germs and their spread on hand hygiene knowledge, attitude and practice of primary school children. Five hundred and sixty-two students from 28 rural schools were enrolled in this pre-posttest study. Endline data was collected 4 weeks after conducting the intervention at baseline. The mean scores for knowledge, attitude and practice improved significantly after the intervention (p < .05). Significant positive gains were also observed in children's understanding of germs, the associated illness threat and washing hands with soap as a prevention mechanism. The present study suggests that entertainment-education-based interventions have the potential to improve hygiene behavior among children while being low-cost.

A cluster-randomised controlled equivalence trial of the Surprise Soap handwashing intervention among older children living in a refugee settlement in Sudan

INTRODUCTION

Increasing handwashing with soap (HWWS) among older children in emergency settings can have a large public health impact, however, evidence on what works is limited. One promising approach is the 'Surprise Soap' intervention in which a novel soap with an embedded toy is delivered to children in a short, participatory household session that includes a glitter game and HWWS practice. Here, we evaluate this intervention against a standard intervention in a complex emergency setting.

METHODS

A cluster-randomised controlled equivalence trial was conducted in Naivasha refugee settlement, Sudan. Blinding was not possible. 203 randomly selected households, with at least one child aged 5-12, were randomised to receive the Surprise Soap intervention (n=101) or a standard intervention comprising a short household session with health messaging and plain soap distribution (n=102). The primary outcome was the proportion of prespecified potential HWWS events observed for children aged 5-12, accompanied by HWWS, at baseline, 4, 12 and 16 weeks post intervention delivery.

RESULTS

200 households were included in the analyses: 101 intervention and 99 control. No difference in intervention effectiveness was observed at any follow-up (4 weeks: adjusted rate ratio (RR) 1.2, 95% CI 0.8 to 1.7; 12 weeks: RR 0.8, 95% CI 0.5 to 1.1; 16 weeks: RR 1.1, 95% CI 0.8 to 1.5). However, we observed increased HWWS in both arms at 4 weeks (27 and 23 percentage point increase in the intervention and control arm, respectively) that was sustained at 16 weeks.

CONCLUSIONS

We find that the Surprise Soap intervention is no more effective at increasing older children's HWWS than a standard, household-level, health-based intervention in this complex humanitarian emergency. There appears to be no marginal benefit in terms of HWWS that would justify the additional cost of implementing the Surprise Soap intervention. Further trials that include a passive control arm are needed to determine the independent effects of each intervention and guide future intervention design.

Effect of a novel hygiene intervention on older children's handwashing in a humanitarian setting in Kahda district, Somalia: A cluster-randomised controlled equivalence trial

INTRODUCTION

Improving handwashing with soap (HWWS) among children in humanitarian emergencies has the potential to reduce the transmission of several important infectious diseases. However, there is limited evidence on which approaches are effective in increasing HWWS among children in humanitarian settings. One recent innovation - the "Surprise Soap" intervention - was shown to be successful in a small-scale efficacy trial in a humanitarian setting in Iraq. This intervention includes soap with embedded toys delivered through a short household session comprising a glitter game, instruction of how and when to wash hands, and HWWS practice. Whilst promising, this approach has not been evaluated at programmatic scale in a complex humanitarian setting.

METHODS

We conducted a cluster-randomised controlled equivalence trial of the Surprise Soap intervention in IDP camps in Kahda district, Somalia. Proportionate stratified random sampling was employed to recruit 200 households, with at least one child aged 5-12, across the camps. Eligible households were randomly allocated to receive the Surprise Soap intervention (n = 100) or an active comparator handwashing intervention in which plain soap was delivered in a short household session comprising standard health-based messaging and instruction of how and when to wash hands (n = 100). The primary outcome was the proportion of pre-specified occasions when HWWS was practiced by children aged 5-12 years, measured at baseline, 4-weeks, 12 weeks, and 16 weeks post invention delivery.

RESULTS

HWWS increased in both groups (by 48 percentage points in the intervention group and 51 percentage points in the control group, at the 4-week follow up), however, there was no evidence of a difference in HWWS between the groups at the 4-week (adjusted RR (aRR) = 1.0, 95% CI 0.9-1.1), 12-week (aRR = 1.1, 95% CI 0.9-1.3), or 16-week (aRR = 1.0, 95% CI 0.9-1.2) follow-up.

CONCLUSIONS

In this complex humanitarian setting, where soap availability and past exposure to handwashing promotion was low, it appears that well-designed, household-level targeted handwashing interventions that include soap provision can increase child HWWS and potentially reduce disease risk, but the Surprise Soap intervention offers no marginal benefit over a standard intervention that would justify the additional costs.

Nongovernmental Organization Practitioners' Perspectives on the Challenges and Solutions to Changing Handwashing Behavior in Older Children: A Qualitative Study

BACKGROUND

Increasing handwashing with soap (HWWS) among older children (aged 5-14 years) can achieve a substantial public health impact. However, HWWS interventions targeting older children have had mixed success. Recent research has attempted to quantitatively identify effective intervention techniques; however, success is likely also influenced by the wider context of implementation. We explore nongovernmental organization (NGO) practitioners' perspectives on the challenges and solutions to HWWS interventions targeting older children to enhance understanding of what is required, beyond intervention content, for them to be effective.

METHODS

We conducted in-depth, semistructured interviews in April-November 2020 with 25 practitioners employed across 11 NGOs and involved in HWWS interventions targeting older children in development and humanitarian settings. We used purposive and snowball sampling to recruit participants in roles at the global, national/regional, and local levels. Interviews were audio-recorded, transcribed, and thematically analyzed to identify challenges and solutions to HWWS interventions targeting older children. Results were organized according to program development cycle stages.

RESULTS

Twelve themes relating to perceived challenges emerged: (1) lack of prioritization, (2) funding inconsistency, (3) insufficient formative research, (4) demand on resources, (5) unengaging intervention content, (6) non-enabling physical environments, (7) availability of skilled implementers, (8) reaching out-of-school children, (9) community mistrust, (10) lack of coordination, (11) lack of evaluation rigor, and (12) failure to assign older children's HWWS as a primary outcome in evaluations of hygiene interventions. Recommended solutions were at the intervention, organization, and sector levels.

CONCLUSION

Intervention design and delivery are important for the success of HWWS interventions for older children, but contextual factors, such as the availability of human and material resources and the level of coordination within and beyond the NGO sector, should also be considered. NGOs need to prioritize HWWS promotion among older children and support programs accordingly.

Physical interventions to interrupt or reduce the spread of respiratory viruses

BACKGROUND

Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review last published in 2020. We include results from studies from the current COVID-19 pandemic.

OBJECTIVES

To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses.

SEARCH METHODS

We searched CENTRAL, PubMed, Embase, CINAHL, and two trials registers in October 2022, with backwards and forwards citation analysis on the new studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, glasses, and gargling) to prevent respiratory virus transmission.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures.

MAIN RESULTS

We included 11 new RCTs and cluster-RCTs (610,872 participants) in this update, bringing the total number of RCTs to 78. Six of the new trials were conducted during the COVID-19 pandemic; two from Mexico, and one each from Denmark, Bangladesh, England, and Norway. We identified four ongoing studies, of which one is completed, but unreported, evaluating masks concurrent with the COVID-19 pandemic. Many studies were conducted during non-epidemic influenza periods. Several were conducted during the 2009 H1N1 influenza pandemic, and others in epidemic influenza seasons up to 2016. Therefore, many studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID-19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high-income countries; crowded inner city settings in low-income countries; and an immigrant neighbourhood in a high-income country. Adherence with interventions was low in many studies. The risk of bias for the RCTs and cluster-RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included 12 trials (10 cluster-RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and 10 in the community). Wearing masks in the community probably makes little or no difference to the outcome of influenza-like illness (ILI)/COVID-19 like illness compared to not wearing masks (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.84 to 1.09; 9 trials, 276,917 participants; moderate-certainty evidence. Wearing masks in the community probably makes little or no difference to the outcome of laboratory-confirmed influenza/SARS-CoV-2 compared to not wearing masks (RR 1.01, 95% CI 0.72 to 1.42; 6 trials, 13,919 participants; moderate-certainty evidence). Harms were rarely measured and poorly reported (very low-certainty evidence). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). We are very uncertain on the effects of N95/P2 respirators compared with medical/surgical masks on the outcome of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; 3 trials, 7779 participants; very low-certainty evidence). N95/P2 respirators compared with medical/surgical masks may be effective for ILI (RR 0.82, 95% CI 0.66 to 1.03; 5 trials, 8407 participants; low-certainty evidence). Evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirators compared to medical/surgical masks probably makes little or no difference for the objective and more precise outcome of laboratory-confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; 5 trials, 8407 participants; moderate-certainty evidence). Restricting pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies (very low-certainty evidence).  One previously reported ongoing RCT has now been published and observed that medical/surgical masks were non-inferior to N95 respirators in a large study of 1009 healthcare workers in four countries providing direct care to COVID-19 patients.  Hand hygiene compared to control Nineteen trials compared hand hygiene interventions with controls with sufficient data to include in meta-analyses. Settings included schools, childcare centres and homes. Comparing hand hygiene interventions with controls (i.e. no intervention), there was a 14% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.86, 95% CI 0.81 to 0.90; 9 trials, 52,105 participants; moderate-certainty evidence), suggesting a probable benefit. In absolute terms this benefit would result in a reduction from 380 events per 1000 people to 327 per 1000 people (95% CI 308 to 342). When considering the more strictly defined outcomes of ILI and laboratory-confirmed influenza, the estimates of effect for ILI (RR 0.94, 95% CI 0.81 to 1.09; 11 trials, 34,503 participants; low-certainty evidence), and laboratory-confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials, 8332 participants; low-certainty evidence), suggest the intervention made little or no difference. We pooled 19 trials (71, 210 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. Pooled data showed that hand hygiene may be beneficial with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.83 to 0.94; low-certainty evidence), but with high heterogeneity. In absolute terms this benefit would result in a reduction from 200 events per 1000 people to 178 per 1000 people (95% CI 166 to 188). Few trials measured and reported harms (very low-certainty evidence). We found no RCTs on gowns and gloves, face shields, or screening at entry ports.

AUTHORS' CONCLUSIONS

The high risk of bias in the trials, variation in outcome measurement, and relatively low adherence with the interventions during the studies hampers drawing firm conclusions. There were additional RCTs during the pandemic related to physical interventions but a relative paucity given the importance of the question of masking and its relative effectiveness and the concomitant measures of mask adherence which would be highly relevant to the measurement of effectiveness, especially in the elderly and in young children. There is uncertainty about the effects of face masks. The low to moderate certainty of evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness, and although this effect was also present when ILI and laboratory-confirmed influenza were analysed separately, it was not found to be a significant difference for the latter two outcomes. Harms associated with physical interventions were under-investigated. There is a need for large, well-designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, as well as the impact of adherence on effectiveness, especially in those most at risk of ARIs.

Hand washing practice among public primary school children and associated factors in Harar town, eastern Ethiopia: An institution-based cross-sectional study

Background

Hand washing with soap and water reduces the risk of diarrheal episode by 28-48% and acute respiratory infection by 20-50%. However, there is limited evidence on hand washing practices among students in Eastern Ethiopia, particularly in Harari town. Therefore, this study aimed to determine hand washing practice among primary school students and associated factors in Harar town, Eastern Ethiopia.

Methods

An institution-based cross-sectional study was applied among 670 students in Harar town from June 1 to 30, 2021. A multi-stage sampling was employed; 6 out of 20 schools were selected through simple random sampling, while eligible children from each school was selected by probability proportional to size sampling method. Data were collected using a pre-tested questionnaire with a face-to-face interview technique and via observation. The data were analyzed using SPSS software version 23. Binary and mult-variable analysis were used to determine the association between factors and outcome variable. Finally, a p-value of < 0.05 was considered to declare a statistically significant association.

Results

A total of 670 participants were included in the study, of which 248 (37.0%) had washed their hands [95% CI: 33.3-40.06]. Being in grade 8 Adjusted Odd Ratio[AOR = 4.9; 95% Confidence Interval (CI): 2.28-10.52], living in an urban area [AOR = 3.49; 95% CI: 1.29-9.40], having role models (parents [AOR = 4.41; 95% CI: 1.79-10.86], teachers [AOR = 3.69; 95% CI: 1.39-8.81], and health professionals [AOR = 3.17, 95% CI: 1.17-8.63]), availability of hand washing facility [AOR = 3.62; 95% CI: 1.57-8.34], access to soap and water [AOR = 2.89; 95% CI: 1.39-5.98] and being membership of water sanitation and hygiene (WASH) club [AOR = 2.39; 95% CI: 1.41-4.03] were found to be significantly associated with hand washing practice.

Conclusions

The current study found that nearly a third of students practiced proper hand washing. Hand washing practice was influenced by students' grade level, residence, referents (role models for hand washing), presence of a hand washing facility, access to water and soap, and membership of WASH club. Therefore, the finding revealed that there is a need to improve hand-washing practices in schools by concerned agencies.

The school education, ritual customs, and reciprocity associated with self-regulating hand hygiene practices during COVID-19 in Japan

Background

The role of social ties, other-regarding preferences, and cultural traits in boosting community resilience and minimizing citizens’ vulnerability to crises such as COVID-19 is increasingly being recognized. However, little is presently known about the possible routes through which such personal preferences and cultural norms pertinent to social behaviors are formulated. Thus, in this paper, factors that can be potentially associated with individuals to self-regulate strict hand hygiene practices before the pandemic, during the state of emergency, and after the state of emergency was lifted in Japan are investigated. Focus is given to the handwashing education in primary school, a cultural practice originating from the old Shinto tradition, and individuals’ reciprocal inclinations. As people in Japan are known to be highly conscious of hygiene in all aspects of their daily life and are less likely to contract an infection, evidence obtained in this specific context could contribute to the better understanding of individuals’ health-related behaviors in general, and during crises in particular.

Methods

Using the data derived from a four-wave nationwide longitudinal online survey, we examined the extent to which elementary school education, childhood cultural experiences at shrines, and individual other-regarding preferences are associated with self-regulating hand hygiene practices prior to the pandemic and people’s efforts to comply with the government-imposed measures aimed at preventing the spread of COVID-19 infection during the state of emergency. We also investigated the long-term trends in the relationships among these factors (i.e., after the abolishment of the state of emergency) using panel data.

Results

Our findings reveal that childhood education and cultural experiences related to handwashing practices, as well as reciprocal inclinations, are significantly associated with Japanese attitudes toward personal hygiene (beyond handwashing practices) prior to, during, and after the state of emergency. In recognition of the possible effects of recall bias and measurement errors, several important attempts to mitigate these issues were made to strengthen the value of our findings.

Conclusions

The importance of school education received during childhood, as well as culture and other-regarding preferences, in the individual attitudes toward hand hygiene in adulthood highlighted in this study contributes to the better understanding of the role that these factors play in the variations in voluntary compliance with strict hand hygiene practices before and during an uncertain and prolonged crisis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14012-z.

Knowledge about Hand Hygiene and Related Infectious Disease Awareness among Primary School Children in Germany

Hand hygiene is a cornerstone of infection prevention. However, few data are available for school children on their knowledge of infectious diseases and their prevention. The aim of the study was to develop and apply a standardized questionnaire for children when visiting primary schools to survey their knowledge about infectious diseases, pathogen transmission and prevention measures. Enrolling thirteen German primary schools, 493 questionnaires for grade three primary school children were included for further analyses, comprising 257 (52.1%) girls and 236 (47.9%) boys with an age range of 8–11 years. Out of 489 children, 91.2% participants indicated that they knew about human-to-human transmissible diseases. Of these, 445 children responded in detail, most frequently mentioning respiratory and gastrointestinal diseases, followed by childhood diseases. Addressing putative hygiene awareness-influencing factors, it was worrisome that more than 40.0% of the children avoided visiting the sanitary facilities at school. Most of the children (82.9%) noted that they did not like to use the sanitary facilities at school because of their uncleanliness and the poor hygienic behavior of their classmates. In conclusion, basic infection awareness exists already in primary school age children. Ideas about the origin and prevention of infections are retrievable, however, this knowledge is not always accurate and adequately contextualized. Since the condition of sanitary facilities has a strong influence on usage behavior, the child’s perspective should be given more consideration in the design and maintenance of sanitary facilities.

School-based surveillance of acute infectious disease in children: a systematic review

BACKGROUND

Syndromic surveillance systems are an essential component of public health surveillance and can provide timely detection of infectious disease cases and outbreaks. Whilst surveillance systems are generally embedded within healthcare, there is increasing interest in novel data sources for monitoring trends in illness, such as over-the-counter purchases, internet-based health searches and worker absenteeism. This systematic review considers the utility of school attendance registers in the surveillance of infectious disease outbreaks and occurrences amongst children.

METHODS

We searched eight databases using key words related to school absence, infectious disease and syndromic surveillance. Studies were limited to those published after 1st January 1995. Studies based in nursery schools or higher education settings were excluded. Article screening was undertaken by two independent reviewers using agreed eligibility criteria. Data extraction was performed using a standardised data extraction form. Outcomes included estimates of absenteeism, correlation with existing surveillance systems and associated lead or lag times.

RESULTS

Fifteen studies met the inclusion criteria, all of which were concerned with the surveillance of influenza. The specificity of absence data varied between all-cause absence, illness absence and syndrome-specific absence. Systems differed in terms of the frequency of data submissions from schools and the level of aggregation of the data. Baseline rates of illness absence varied between 2.3-3.7%, with peak absences ranging between 4.1-9.8%. Syndrome-specific absenteeism had the strongest correlation with other surveillance systems (r = 0.92), with illness absenteeism generating mixed results and all-cause absenteeism performing the least well. A similar pattern of results emerged in terms of lead and lag times, with influenza-like illness (ILI)-specific absence providing a 1-2 week lead time, compared to lag times reported for all-cause absence data and inconsistent results for illness absence data.

CONCLUSION

Syndrome-specific school absences have potential utility in the syndromic surveillance of influenza, demonstrating good correlation with healthcare surveillance data and a lead time of 1-2 weeks ahead of existing surveillance measures. Further research should consider the utility of school attendance registers for conditions other than influenza, to broaden our understanding of the potential application of this data for infectious disease surveillance in children.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2019 CRD42019119737.

Interventions to increase personal protective behaviours to limit the spread of respiratory viruses: A rapid evidence review and meta-analysis

PURPOSE

Increasing personal protective behaviours is critical for stopping the spread of respiratory viruses, including SARS-CoV-2: We need evidence to inform how to achieve this. We aimed to synthesize evidence on interventions to increase six personal protective behaviours (e.g., hand hygiene, face mask use, maintaining physical distancing) to limit the spread of respiratory viruses.

METHODS

We used best practice for rapid evidence reviews. We searched Ovid MEDLINE and Scopus. Studies conducted in adults or children with active or passive comparators were included. We extracted data on study design, intervention content, mode of delivery, population, setting, mechanism(s) of action, acceptability, practicability, effectiveness, affordability, spill-over effects, and equity impact. Study quality was assessed with Cochrane's risk-of-bias tool. A narrative synthesis and random-effects meta-analyses were conducted.

RESULTS

We identified 39 studies conducted across 15 countries. Interventions targeted hand hygiene (n = 30) and/or face mask use (n = 12) and used two- or three-arm study designs with passive comparators. Interventions were typically delivered face-to-face and included a median of three behaviour change techniques. The quality of included studies was low. Interventions to increase hand hygiene (k = 6) had a medium, positive effect (d = .62, 95% CI = 0.43-0.80, p < .001, I²  = 81.2%). Interventions targeting face mask use (k = 4) had mixed results, with an imprecise pooled estimate (OR = 4.14, 95% CI = 1.24-13.79, p < .001, I²  = 89.67%). Between-study heterogeneity was high.

CONCLUSIONS

We found low-quality evidence for positive effects of interventions targeting hand hygiene, with unclear results for interventions targeting face mask use. There was a lack of evidence for most behaviours of interest within this review.

Effectiveness of behaviour change techniques used in hand hygiene interventions targeting older children - A systematic review

BACKGROUND

Promoting good hand hygiene in older children is an important measure to reduce the burden of common diseases such as diarrhoea and acute respiratory infections. The evidence around what works to change this behaviour, however, is unclear.

OBJECTIVES

To aid future intervention design and effective use of resources, this review aims to identify the individual components used in hand hygiene interventions and assesses their contribution to intended behavioural change.

METHODS

We systematically searched seven databases for experimental studies evaluating hand hygiene interventions targeting children (age 5-12) and quantitively reporting hand hygiene behaviour. Interventions in each study were categorised as 'promising', or 'non-promising' according to whether they led to a positive change in the targeted behaviour. Behaviour change techniques (BCTs) were identified across interventions using a standard taxonomy and a novel promise ratio calculated for each (the ratio of promising to non-promising interventions featuring the BCT). 'Promising' BCTs were those with a promise ratio of ≥2. BCTs were ranked from most to least promising.

RESULTS

Our final analysis included 19 studies reporting 22 interventions across which 32 unique BCTs were identified. The most frequently used were 'demonstration of the behaviour', 'instruction on how to perform the behaviour' and 'adding objects to the environment'. Eight BCTs had a promise ratio of ≥2 and the five most promising were 'demonstration of the behaviour', 'information about social and environmental consequences', 'salience of consequences', 'adding objects to the environment', and 'instruction on how to perform the behaviour'.

CONCLUSIONS

Our findings suggest that hand hygiene interventions targeting older children should employ a combination of promising BCTs that ensure children understand the behaviour and the consequences of their hand hygiene habits, appropriate hardware is available, and social support is provided. Researchers are encouraged to consistently and transparently describe evaluated interventions to allow promising components to be identified and replicated.

Evaluating children's handwashing in schools: an integrative review of indicative measures and measurement tools

Children are a key target of handwashing interventions as washing hands reduces the spread of disease and reliance on antibiotics. While there is guidance for evaluating handwashing with adults in other settings, this is lacking for children in schools. An integrative review of 65 studies where handwashing was measured in schools was conducted to establish which indicative measures (what is measured to evaluate the processes and/or impacts of, handwashing) and measurement tools (data collection instruments) have been applied to evaluate handwashing in schools, and under what circumstances. Further analysis highlighted different challenges when seeking to apply such measures and tools in schools, as opposed to other settings. It was concluded that indicative measures, and measurement tools need to be appropriate to the organizational setting, the study participants, and research objectives. A summative analysis of relevant considerations is presented.

Changes in demand for emergency ambulances during a nationwide lockdown that resulted in elimination of COVID-19: an observational study from New Zealand

OBJECTIVE

To examine the impact of a 5-week national lockdown on ambulance service demand during the COVID-19 pandemic in New Zealand.

DESIGN

A descriptive cross-sectional, observational study.

SETTING

High-quality data from ambulance electronic clinical records, New Zealand.

PARTICIPANTS

Ambulance records were obtained from 588 690 attendances during pre-lockdown (prior to 17 February 2020) and from 36 238 records during the lockdown period (23 March to 26 April 2020).

MAIN OUTCOME MEASURES

Ambulance service utilisation during lockdown was compared with pre-lockdown: (a) descriptive analyses of ambulance events and proportions of event types for each period, (b) absolute rates of ambulance attendance (event types/week) for each period.

RESULTS

During lockdown, ambulance patients were more likely to be attended at home and less likely to be aged between 16 and 25 years. There was a significant increase in the proportion of lower acuity patients (Status 3 and Status 4) attended (p<0.001) and a corresponding increase in patients not transported from scene (p<0.001). Road traffic crashes (p<0.001) and alcohol-related incidents (p<0.001) significantly decreased. There was a decrease in the absolute number of weekly ambulance attendances (ratio (95% CI), 0.89 (0.87 to 0.91), p<0.001), attendances to respiratory conditions (0.74 (0.61 to 0.86), p=0.01), and trauma (0.81 (0.77 to 0.85), p<0.001). However, there was a significant increase in ambulance attendances for mental health conditions (1.37 (1.22 to 1.51), p=0.005).

CONCLUSIONS

Despite the relative absence of COVID-19 in the community during the 5-week nationwide lockdown, there were significant differences in ambulance utilisation during this period. The lockdown was associated with an increase in ambulance attendances for mental health conditions and is of concern. In considering future lockdowns, the potential implications on a population's mental well-being will need to be seriously considered against the benefits of elimination of virus transmission.

Physical interventions to interrupt or reduce the spread of respiratory viruses

BACKGROUND

Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review published in 2007, 2009, 2010, and 2011. The evidence summarised in this review does not include results from studies from the current COVID-19 pandemic.

OBJECTIVES

To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses.

SEARCH METHODS

We searched CENTRAL, PubMed, Embase, CINAHL on 1 April 2020. We searched ClinicalTrials.gov, and the WHO ICTRP on 16 March 2020. We conducted a backwards and forwards citation analysis on the newly included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs of trials investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, and gargling) to prevent respiratory virus transmission. In previous versions of this review we also included observational studies. However, for this update, there were sufficient RCTs to address our study aims.   DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. Three pairs of review authors independently extracted data using a standard template applied in previous versions of this review, but which was revised to reflect our focus on RCTs and cluster-RCTs for this update. We did not contact trialists for missing data due to the urgency in completing the review. We extracted data on adverse events (harms) associated with the interventions.

MAIN RESULTS

We included 44 new RCTs and cluster-RCTs in this update, bringing the total number of randomised trials to 67. There were no included studies conducted during the COVID-19 pandemic. Six ongoing studies were identified, of which three evaluating masks are being conducted concurrent with the COVID pandemic, and one is completed. Many studies were conducted during non-epidemic influenza periods, but several studies were conducted during the global H1N1 influenza pandemic in 2009, and others in epidemic influenza seasons up to 2016. Thus, studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID-19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high-income countries; crowded inner city settings in low-income countries; and an immigrant neighbourhood in a high-income country. Compliance with interventions was low in many studies. The risk of bias for the RCTs and cluster-RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included nine trials (of which eight were cluster-RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and seven in the community). There is low certainty evidence from nine trials (3507 participants) that wearing a mask may make little or no difference to the outcome of influenza-like illness (ILI) compared to not wearing a mask (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.82 to 1.18. There is moderate certainty evidence that wearing a mask probably makes little or no difference to the outcome of laboratory-confirmed influenza compared to not wearing a mask (RR 0.91, 95% CI 0.66 to 1.26; 6 trials; 3005 participants). Harms were rarely measured and poorly reported. Two studies during COVID-19 plan to recruit a total of 72,000 people. One evaluates medical/surgical masks (N = 6000) (published Annals of Internal Medicine, 18 Nov 2020), and one evaluates cloth masks (N = 66,000). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). There is uncertainty over the effects of N95/P2 respirators when compared with medical/surgical masks on the outcomes of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; very low-certainty evidence; 3 trials; 7779 participants) and ILI (RR 0.82, 95% CI 0.66 to 1.03; low-certainty evidence; 5 trials; 8407 participants). The evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirator compared to a medical/surgical mask probably makes little or no difference for the objective and more precise outcome of laboratory-confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; moderate-certainty evidence; 5 trials; 8407 participants). Restricting the pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies. One ongoing study recruiting 576 people compares N95/P2 respirators with medical surgical masks for healthcare workers during COVID-19. Hand hygiene compared to control Settings included schools, childcare centres, homes, and offices. In a comparison of hand hygiene interventions with control (no intervention), there was a 16% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.84, 95% CI 0.82 to 0.86; 7 trials; 44,129 participants; moderate-certainty evidence), suggesting a probable benefit. When considering the more strictly defined outcomes of ILI and laboratory-confirmed influenza, the estimates of effect for ILI (RR 0.98, 95% CI 0.85 to 1.13; 10 trials; 32,641 participants; low-certainty evidence) and laboratory-confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials; 8332 participants; low-certainty evidence) suggest the intervention made little or no difference. We pooled all 16 trials (61,372 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. The pooled data showed that hand hygiene may offer a benefit with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.84 to 0.95; low-certainty evidence), but with high heterogeneity. Few trials measured and reported harms. There are two ongoing studies of handwashing interventions in 395 children outside of COVID-19. We identified one RCT on quarantine/physical distancing. Company employees in Japan were asked to stay at home if household members had ILI symptoms. Overall fewer people in the intervention group contracted influenza compared with workers in the control group (2.75% versus 3.18%; hazard ratio 0.80, 95% CI 0.66 to 0.97). However, those who stayed at home with their infected family members were 2.17 times more likely to be infected. We found no RCTs on eye protection, gowns and gloves, or screening at entry ports.

AUTHORS' CONCLUSIONS

The high risk of bias in the trials, variation in outcome measurement, and relatively low compliance with the interventions during the studies hamper drawing firm conclusions and generalising the findings to the current COVID-19 pandemic. There is uncertainty about the effects of face masks. The low-moderate certainty of the evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of randomised trials did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks during seasonal influenza. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness. Harms associated with physical interventions were under-investigated. There is a need for large, well-designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, especially in those most at risk of ARIs.

Effect of caste on health, independent of economic disparity: evidence from school children of two rural districts of India

Caste, a stratifying axis of the Indian society, is associated with wealth and health. However, to what extent caste-based health inequality is explained by wealth disparities, is not clear. Therefore, we aimed to examine the caste-based differences in anaemia (haemoglobin < 11 gm/dl) and self-reported sickness absenteeism in schoolchildren and the mediating role of economic disparity. Students (n = 1764) were surveyed from 54 government schools of Dhenkanal and Angul, Odisha state. Socioeconomic data, anaemia and absenteeism were recorded. The relative risks of anaemia among Scheduled Tribe (least advantaged) and Scheduled Caste (second least advantaged) students were 1.19 (95% CI: 1.08, 1.26) and 1.13 (1.03, 1.20), respectively, as compared to students of the most advantaged caste and that for sickness absenteeism were 2.78 (2.03, 3.82) and 2.84 (2.13, 3.78); p < 0.05, with marginal attenuation when controlled for inter-caste economic disparities. Caste had an independent effect on anaemia and sickness absenteeism in school children, unexplained by inter-caste economic disparities.

Rinse-free hand wash for reducing absenteeism among preschool and school children

BACKGROUND

Illness-related absenteeism is an important problem among preschool and school children for low-, middle- and high- income countries. Appropriate hand hygiene is one commonly investigated and implemented strategy to reduce the spread of illness and subsequently the number of days spent absent. Most hand hygiene strategies involve washing hands with soap and water, however this is associated with a number of factors that act as a barrier to its use, such as requiring running water, and the need to dry hands after cleaning. An alternative method involves washing hands using rinse-free hand wash. This technique has a number of benefits over traditional hand hygiene strategies and may prove to be beneficial in reducing illness-related absenteeism in preschool and school children.

OBJECTIVES

1. To assess the effectiveness of rinse-free hand washing for reducing absenteeism due to illness in preschool and school children compared to no hand washing, conventional hand washing with soap and water or other hand hygiene strategies. 2. To determine which rinse-free hand washing products are the most effective (if head-to-head comparisons exist), and what effect additional strategies in combination with rinse-free hand washing have on the outcomes of interest.

SEARCH METHODS

In February 2020 we searched CENTRAL, MEDLINE, Embase, CINAHL, 12 other databases and three clinical trial registries. We also reviewed the reference lists of included studies and made direct contact with lead authors of studies to collect additional information as required. No date or language restrictions were applied.

SELECTION CRITERIA

Randomized controlled trials (RCTs), irrespective of publication status, comparing rinse-free hand wash in any form (hand rub, hand sanitizer, gel, foam etc.) with conventional hand washing using soap and water, other hand hygiene programs (such as education alone), or no intervention. The population of interest was children aged between two and 18 years attending preschool (childcare, day care, kindergarten, etc.) or school (primary, secondary, elementary, etc.). Primary outcomes included child or student absenteeism for any reason, absenteeism due to any illness and adverse skin reactions.

DATA COLLECTION AND ANALYSIS

Following standard Cochrane methods, two review authors (out of ZM, CT, CL, CS, TB), independently selected studies for inclusion, assessed risk of bias and extracted relevant data. Absences were extracted as the number of student days absent out of total days. This was sometimes reported with the raw numbers and other times as an incidence rate ratio (IRR), which we also extracted. For adverse event data, we calculated effect sizes as risk ratios (RRs) and present these with 95% confidence intervals (CIs). We used standard methodological procedures expected by Cochrane for data analysis and followed the GRADE approach to establish certainty in the findings.

MAIN RESULTS

This review includes 19 studies with 30,747 participants. Most studies were conducted in the USA (eight studies), two were conducted in Spain, and one each in China, Colombia, Finland, France, Kenya, Bangladesh, New Zealand, Sweden, and Thailand. Six studies were conducted in preschools or day-care centres (children aged from birth to < five years), with the remaining 13 conducted in elementary or primary schools (children aged five to 14 years). The included studies were judged to be at high risk of bias in several domains, most-notably across the domains of performance and detection bias due to the difficulty to blind those delivering the intervention or those assessing the outcome. Additionally, every outcome of interest was graded as low or very low certainty of evidence, primarily due to high risk of bias, as well as imprecision of the effect estimates and inconsistency between pooled data. For the outcome of absenteeism for any reason, the pooled estimate for rinse-free hand washing was an IRR of 0.91 (95% CI 0.82 to 1.01; 2 studies; very low-certainty evidence), which indicates there may be little to no difference between groups. For absenteeism for any illness, the pooled IRR was 0.82 (95% CI 0.69 to 0.97; 6 studies; very low-certainty evidence), which indicates that rinse-free hand washing may reduce absenteeism (13 days absent per 1000) compared to those in the 'no rinse-free' group (16 days absent per 1000). For the outcome of absenteeism for acute respiratory illness, the pooled IRR was 0.79 (95% CI 0.68 to 0.92; 6 studies; very low-certainty evidence), which indicates that rinse-free hand washing may reduce absenteeism (33 days absent per 1000) compared to those in the 'no rinse-free' group (42 days absent per 1000). When evaluating absenteeism for acute gastrointestinal illness, the pooled estimate found an IRR of 0.79 (95% CI 0.73 to 0.85; 4 studies; low-certainty evidence), which indicates rinse-free hand washing may reduce absenteeism (six days absent per 1000) compared to those in the 'no rinse-free' group (eight days absent per 1000). There may be little to no difference between rinse-free hand washing and 'no rinse-free' group regarding adverse skin reactions with a RR of 1.03 (95% CI 0.8 to 1.32; 3 studies, 4365 participants; very low-certainty evidence). Broadly, compliance with the intervention appeared to range from moderate to high compliance (9 studies, 10,749 participants; very-low certainty evidence); narrativley, no authors reported substantial issues with compliance. Overall, most studies that included data on perception reported that teachers and students perceived rinse-free hand wash positively and were willing to continue its use (3 studies, 1229 participants; very-low certainty evidence).

AUTHORS' CONCLUSIONS

The findings of this review may have identified a small yet potentially beneficial effect of rinse-free hand washing regimes on illness-related absenteeism. However, the certainty of the evidence that contributed to this conclusion was low or very low according to the GRADE approach and is therefore uncertain. Further research is required at all levels of schooling to evaluate rinse-free hand washing regimens in order to provide more conclusive, higher-certainty evidence regarding its impact. When considering the use of a rinse-free hand washing program in a local setting, there needs to be consideration of the current rates of illness-related absenteeism and whether the small beneficial effects seen here will translate into a meaningful reduction across their settings.

Child handwashing in an internally displaced persons camp in Northern Iraq: A qualitative multi-method exploration of motivational drivers and other handwashing determinants

BACKGROUND

Children in humanitarian situations are particularly vulnerable to diseases such as diarrhoea. Handwashing with soap can greatly reduce transmission but handwashing rates are often low and traditional interventions ineffective. To aid future intervention design, this study aims to understand the determinants of child handwashing and the key motivational drivers of children's behaviour within a specific humanitarian setting.

METHODS

In an internally displaced persons camp in Northern Iraq we conducted a series of 36 friendship-paired interviews with children aged 7-12 years, six semi-structured caregiver interviews, and three semi-structured hygiene promoter interviews. Perceived determinants of child handwashing were explored qualitatively, and motivational drivers were explored quantitatively with children in a rating exercise. Qualitative data were analysed thematically, using an inductive approach, and logistic regression analyses of motive rating data were performed to determine the predicted probabilities of motives being rated as important.

RESULTS

Access to soap and water was perceived to be high across all participant groups. Children, caregivers and hygiene promoters all perceive the determinants of child handwashing to be associated with familial role, environmental factors pertaining to location and quality of handwashing materials and facilities, and level of exposure to hygiene promotion, and children also attribute their handwashing to social norms. We find that children in this context are motived most by play and nurture.

CONCLUSIONS

Provision of soap and water alone is not sufficient to encourage children to practice handwashing with soap in a humanitarian context. Our findings suggest that equal consideration should be given to the quality and location of handwashing materials and facilities and social norms could be leveraged to promote and enhance child handwashing. Motive-based interventions targeting play or nurture may be a promising approach and are likely most effective when used in conjunction, along with other motivational drivers such as affiliation and love.

Patients' capability, opportunity, motivation, and perception of inpatient hand hygiene

BACKGROUND

Studies that examine the perceptions and behaviors of patients regarding patient hand hygiene rarely examine the viewpoint of patients about their hand hygiene behavior relative to current resources provided in the hospital.

METHODS

Voluntary interviews that employed a 16-item survey tool were used among patients (N = 107) in outpatient clinics at post-admission visits. The survey was created using the Behavior Change Wheel, Capability, Opportunity, Motivation Behavior model. Patients were asked whether they brought hand sanitizer to the hospital, used hospital resources to clean their hands, and their perspective on patient hand hygiene importance compared with hospital staff, as well as their satisfaction or lack of satisfaction with hand hygiene independence.

RESULTS

Most of the participants (65, 60.7%) reported that prior to being admitted to the hospital, they were able to maintain cleaning their hands with little or no difficulty. During their admission, only 21 (19.6%) of the participants reported needing little or no assistance. More than one-half of the participants, 34 (31.8%) and 23 (21.5%), respectively, reported, mostly or completely agreeing that the hand hygiene of the health care staff was more important than their own. Close to one-half of the participants (50, 46.7%) reported not being satisfied at all with their ability to maintain their hand hygiene in the hospital, whereas only 10 (9.3%) were very satisfied with their ability to maintain hand hygiene.

CONCLUSIONS

Findings from this study will enhance our understanding of how to incorporate inpatient hand hygiene into existing infection control programs in inpatient settings.

Comparison of Interactive Education Versus Fluorescent Concretization on Hand Hygiene Compliance Among Primary School Students: A Randomized Controlled Trial

Hand hygiene for children is crucial to keep them healthy. The purpose of the study was to evaluate the effects of two educational initiatives on “handwashing effectiveness (HWE).” A randomized controlled trial was carried out during April/June 2016, and 96 primary school students were randomly assigned to Group I receiving education with fluorescent gel; Group II receiving interactive education or control group continuing its normal education. Evaluation was made by scoring the fluorescent areas on the hands with photographs. There were significant differences in handwashing scores between preprogram and postprogram for all areas in only Group II ( p < .05). HWE increased from 17.9% to 18.4% in Group I, from 15.4% to 37.7% in Group II, and from 35.5% to 35.8% in control group. Only concretization with fluorescent gel is not a sufficiently strong motivator for increasing HWE. New techniques should be integrated into the training programs for children.

Importance of implementation level when evaluating the effect of the Hi Five Intervention on infectious illness and illness-related absenteeism

BACKGROUND

There is limited research on the importance of implementation when evaluating the effect of hand hygiene interventions in school settings in developed countries. The aim of this study was to examine the association between an implementation index and the effect of the intervention. The Hi Five Intervention was evaluated in a 3-armed cluster randomized controlled trial involving 43 randomly selected Danish schools.

METHODS

Analyses investigating the association between implementation of the Hi Five Intervention and infectious illness days, infectious illness episodes, illness-related absenteeism, and hand hygiene were carried out in a multilevel model (school, class, and child).

RESULTS

The level of implementation was associated with hand hygiene and potentially associated with number of infectious illness days and infectious illness episodes among children. This association was not found for illness-related absenteeism.

CONCLUSIONS

Classes that succeeded in achieving a high level of implementation of the Hi Five Intervention had a lower number of infectious illness days and infectious illness episodes, suggesting that the Hi Five Intervention, if implemented adequately, may be relevant as a tool to decrease infectious illness in a Danish school setting.

Effect Evaluation of a Randomized Trial to Reduce Infectious Illness and Illness-related Absenteeism Among Schoolchildren: The Hi Five Study

BACKGROUND

Previous school-based hand hygiene interventions have reported to successfully reduce infectious illness among schoolchildren. But few studies have tested the effect in large populations with adequate statistical power and analyses. The aim of this study was to evaluate whether a school-based multicomponent intervention to improve handwashing among schoolchildren, the Hi Five study, succeeded in reducing infectious illness and illness-related absenteeism in schools.

METHODS

The Hi Five study was a three-armed cluster-randomized controlled trial involving 43 randomly selected Danish schools; two intervention arms involving 14 schools each, and 15 control schools. Infectious illness days, infectious illness episodes and illness-related absenteeism were estimated in multilevel regressions, based on available cases of text messages answered by parents and based on questionnaire data reported by schoolchildren, respectively.

RESULTS

At follow-up, children in the intervention schools did not differ from the control schools in number of illness days [odds ratio (OR)I-arm I: 0.91 (0.77-1.07) and ORI-arm II: 0.94 (0.79-1.12)] and illness episodes [ORI-arm I: 0.95 (0.81-1.11) and ORI-arm II: 0.98 (0.84-1.16)] or in reporting illness-related absenteeism [ORI-arm I: 1.09 (0.83-1.43) & ORI-arm II: 1.06 (0.81-1.40)].

CONCLUSIONS

The multicomponent Hi Five intervention achieved no difference in the number of illness days, illness episodes or illness-related absenteeism among children in intervention schools compared with control schools. It is noteworthy that one of the main components in the intervention, a mandatory daily handwashing before lunch, was only implemented by 1 of 3 of teachers in intervention schools.

The effect of hand-hygiene interventions on infectious disease-associated absenteeism in elementary schools: A systematic literature review

BACKGROUND

Hand-hygiene interventions are widely used in schools but their effect on reducing absenteeism is not well known.

METHODS

The aim of our literature review was to determine whether implementation of a hand-hygiene intervention reduced infectious disease-associated absenteeism in elementary schools. The eligible studies (N = 19), published between 1996 and 2014, were summarized and the methodologic quality of each was assessed.

RESULTS

Our review indicated evidence is available to show hand-hygiene interventions had an effect on reducing acute gastrointestinal illness-associated absenteeism but inadequate evidence is available to show an effect on respiratory illness-associated absenteeism.

CONCLUSIONS

The methodologic quality assessment of eligible studies revealed common design flaws, such as lack of randomization, blinding, and attrition, which must be addressed in future studies to strengthen the evidence base on the effect of hand-hygiene interventions on school absenteeism.

Improving water, sanitation, and hygiene in schools in Indonesia: A cross-sectional assessment on sustaining infrastructural and behavioral interventions

Water, sanitation, and hygiene (WASH) in schools are important for child health, development, and educational performance; yet coverage in Indonesian schools remains low. To address this deficiency, UNICEF and partners conducted a WASH intervention in 450 schools across three provinces in Indonesia. A survey evaluating the sustainability of infrastructure and behavioral interventions in comparison to control districts was conducted one year after completion of the intervention. The survey data were also compared with national government data to assess the suitability of government data to report progress on the Sustainable Development Goals (SDGs). Logistic regression was used to explore associations between WASH conditions and behaviors. Intervention schools were more likely to have handwashing stations with soap and water. In multivariable analyses, schools with a toilet operation and maintenance fund were more likely to have functional toilets. Students who learn hygiene skills from their teachers were less likely to defecate openly, more likely to share hygiene knowledge with their parents, and more likely to wash their hands. Survey data were comparable with government data, suggesting that Indonesian government monitoring may be a reliable source of data to measure progress on the SDGs. This research generates important policy and practice findings for scaling up and sustaining WASH in schools and may help improve WASH in schools programs in other low-resource contexts.

Hand Hygiene Program Decreases School Absenteeism Due to Upper Respiratory Infections

BACKGROUND

We assessed the effectiveness of a handwashing program using hand sanitizer to prevent school absenteeism due to upper respiratory infections (URIs).

METHODS

This was a randomized, controlled, and open study on a sample of 1341 children 4-12 years old, attending 5 state schools in Almería (Spain), with an 8-month follow-up. The experimental group (EG) washed their hands with soap and water, together with using hand sanitizer, and the control group followed their usual handwashing procedures. Absenteeism rates due to URIs were compared between the 2 groups through a multivariate Poisson regression analysis. The percent of days missed in both groups were compared with a z test.

RESULTS

Overall, 1271 cases of school absenteeism due to URIs were registered. Schoolchildren from the EG had a 38% lower risk of absenteeism due to URIs, incidence rate ratio: 0.62, 95% confidence interval: 0.55-0.70, and a decrease in absenteeism of 0.45 episodes/child/academic year, p < .001. Pupils missed 2734 school days due to URIs and the percentage of days absent was significantly lower in the EG, p < .001.

CONCLUSIONS

Use of hand sanitizer plus handwashing with soap accompanied by educational support is an effective measure to reduce absenteeism due to URIs.

Promotion of Preventive Measures in Public Nursery Schools: Lessons From the H1N1 Pandemic

Nursery schools serve as reservoirs of transmission of infectious diseases, and teachers should be able to implement and monitor hygiene measures to prevent them. The aim of the present study was to assess the compliance of nursery school teachers on promoting preventive interventions and to identify associated factors, during the novel H1N1 influenza pandemic. A secondary objective was to evaluate their knowledge and vaccination status regarding the novel virus. A cross-sectional study was performed, with the use of a predesigned anonymous, questionnaire, and distributed to all public nursery teachers of Athens, Greece. General etiquette practices were highly acceptable to over 92% of teachers. Those with longer teaching experience promoted simple preventive measures, such as hand washing and use of hand sanitizer, more often while older children were more likely to familiarize with them. However, teachers presented inadequate knowledge concerning the novel virus and their vaccination rates with the pandemic vaccine were unacceptably low (1.1%). Our study showed that promotion of simple preventive measures is feasible and may contribute to the prevention of outbreaks in nursery schools, although knowledge gaps and fear concerning the pandemic vaccine highlight communication issues.

Adoption of Preventive Measures and Attitudes Toward the H1N1 Influenza Pandemic in Schools

BACKGROUND

This study describes the perceived impact of H1N1 influenza and the adoption of the recommended measures to address the pandemic in schools.

METHODS

A cross-sectional self-reported survey was conducted in 433 schools in Barcelona addressed to the school principal or the H1N1 influenza designated person. A descriptive analysis was performed, stratifying by educational level and type of school. A logistic regression analysis also was conducted.

RESULTS

Around 70% of the respondents reported that there had been H1N1 influenza cases among students, being this percentage significantly higher among those schools offering primary education (74.4%) (p < .05). The main measures (single-use paper towels, availability of sanitizer solutions and 15 minutes ventilation per day of enclosed spaces) were implemented in most of the centers. However, the correct adoption of the main measures took place in around 30% of the schools, being the percentage lower in those offering only secondary education (Odds ratio [OR]: 0.518; 95% confidence interval [CI]:0.272-0.986) and those located in medium (OR: 0.438, 95% CI: 0.234-0.811) or low socioeconomic status (SES) districts (OR: 0.321, 95% CI: 0.159-0.649).

CONCLUSIONS

Despite the climate of social alarm, the perceived impact of H1N1 influenza in most schools was moderate. In future potential threats, the educational level and the SES of the school should be considered, especially when measures requiring purchasing any product are recommended but not provided.

Process evaluation of a multi-component intervention to reduce infectious diseases and improve hygiene and well-being among school children: the Hi Five study

The Hi Five study was a three-armed cluster randomized controlled trial designed to reduce infections and improve hygiene and well-being among pupils. Participating schools (n = 43) were randomized into either control (n = 15) or one of two intervention groups (n = 28). The intervention consisted of three components: (i) a curriculum (ii) mandatory daily hand washing before lunch (iii) extra cleaning of school toilets. The aim of this study was to evaluate the implementation and to identify challenges to program implementation. Several data sources were used, including observations of school toilets, semi-structured interviews with school coordinators (n = 4), focus groups with pupils (n = 6) and teachers (n = 5), and questionnaires among pupils (n = 5440), teachers (n = 387) and school coordinators (n = 28). This study indicates that the curriculum was successfully implemented at most schools, and that teachers and pupils reacted positively to this part of the intervention. However, daily hand washing before lunch seems to be difficult to implement. Overall, the implementation process was affected by several factors such as poor sanitary facilities, lack of time and prioritization and objections against the increasing tendency to place the responsibility for child-rearing tasks on schools. This study reveals the strong and weak parts of the Hi Five study and can guide program improvement.

Improving hand hygiene behaviour among adolescents by a planning intervention

To improve regular hand hygiene in adolescents, educational messages based on medical information have not been very successful. Therefore, a theory-guided self-regulatory intervention has been designed with a particular focus on planning strategies. A randomised controlled trial with 307 adolescents, aged 12-18 years, was conducted in high schools. The control group received educational hand hygiene leaflets, whereas the experimental group received a self-regulatory treatment which required them to generate specific action plans and coping plans. Three times during one month, both groups received verbal reminder messages about planning to wash their hands properly. At one-month follow-up, hand hygiene behaviour as well as planning to practise hand hygiene were higher in the self-regulation than in the education group (p < .01). Moreover, changes in planning levels operated as a mediator between experimental conditions and changes in behavioural outcomes. Teaching self-regulatory planning strategies may constitute a superior approach than educational messages to improve regular hand hygiene practice in adolescents.

The Hi Five study: design of a school-based randomized trial to reduce infections and improve hygiene and well-being among 6-15 year olds in Denmark

BACKGROUND

Infectious illnesses such as influenza and diarrhea are leading causes of absenteeism among Danish school children. Interventions in school settings addressing hand hygiene have shown to reduce the number of infectious illnesses. However, most of these studies include small populations and almost none of them are conducted as randomized controlled trials. The overall aim of the Hi Five study was to develop, implement and evaluate a multi-component school-based intervention to improve hand hygiene and well-being and to reduce the prevalence of infections among school children in intervention schools by 20% compared to control schools. This paper describes the development and the evaluation design of Hi Five.

METHODS/DESIGN

The Hi Five study was designed as a tree-armed cluster-randomized controlled trial. A national random sample of schools (n = 44) was randomized to one of two intervention groups (n = 29) or to a control group with no intervention (n = 15). A total of 8,438 six to fifteen-year-old school children were enrolled in the study. The Hi Five intervention consisted of three components: 1) a curriculum component 2) mandatory daily hand washing before lunch 3) extra cleaning of school toilets during the school day. Baseline data was collected from December 2011 to April 2012. The intervention period was August 2012 to June 2013. The follow-up data was collected from December 2012 to April 2013.

DISCUSSION

The Hi Five study fills a gap in international research. This large randomized multi-component school-based hand hygiene intervention is the first to include education on healthy and appropriate toilet behavior as part of the curriculum. No previous studies have involved supplementary cleaning at the school toilets as an intervention component. The study will have the added value of providing new knowledge about usability of short message service (SMS, text message) for collecting data on infectious illness and absenteeism in large study populations.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN19287682 , 21 December 2012.

Effect of cleaning and disinfection of toys on infectious diseases and micro-organisms in daycare nurseries

Background

The rising number of children in daycare nurseries increases opportunities for the transmission of infectious diseases. Pathogens may be transmitted directly from child to child via sneezing, coughing and touching, or indirectly via the environment. Toys are among the fomites with the highest pathogen load, but their role in disease transmission is unknown.

Aim

To determine if washing and disinfection of toys can reduce sickness absence and microbial pathogen load in the nursery environment.

Methods

Twelve nurseries (caring for 587 children) were randomized to intervention and control groups. The intervention consisted of washing and disinfection of toys and linen every two weeks for three months by a commercial cleaning company. The extent and causes of sickness absence among the children were recorded in both groups before and after introduction of the intervention. Ten sampling points in each nursery were examined for bacteria and respiratory viruses.

Results

The presence of respiratory virus DNA/RNA was widespread, but very few pathogenic bacteria were found in the environment. The intervention reduced the presence of adenovirus [odds ratio (OR) 2.4, 95% confidence interval (CI) 1.1–5.0], rhinovirus (OR 5.3, 95% CI 2.3–12.4) and respiratory syncytial virus (OR 4.1, 95% CI 1.5–11.2) compared with the control group, but the intervention had no effect on sickness absence or disease patterns in the nurseries.

Conclusion

Although cleaning and disinfection of toys every two weeks can decrease the microbial load in nurseries, it does not appear to reduce sickness absence among nursery children.

Assessment of factors influencing hygiene behaviour among school children in Mereb-Leke District, Northern Ethiopia: a cross-sectional study

BACKGROUND

Poor school sanitation and hygiene is a major problem in developing countries and remains high risk behaviour among primary school going children. Many outbreaks of gastrointestinal infections have been associated with primary schools. This research paper was designed to assess the factors influencing hygiene behaviour among school children.

METHODS

A cross sectional study was conducted in Mereb-Leke District, Tigray National Regional State among school children. The study population consisted of those who are in the second cycle as they are more mature and most senior in primary schools. A multi-stage probability sampling procedure with three stages was used to select participated schools. A total of 528 school children were randomly selected from students networking list of selected schools. Structured questionnaire and observational checklist at home and school setting were used to collect data. Statistical analysis was done using SPSS Version 17.0 after the data has been entered using Epi-Info version 3.5.3. Primarily variables that had p-value <0.2 at bivariate analysis were used to develop logistic model to identify factors influencing hygiene behaviour via crude and adjusted odds ratio.

RESULTS

Children were grouped according to whether positive or negative hygiene behaviour outcome which permitted identifying factor affecting hygiene behaviour. Out of these, 326 (61.7%) had positive hygiene behaviour. The study found that knowledge s on water handling (AOR, 2.24; 95% CI 1.54, 3.26), hand washing (AOR, 1.70; 95% CI 1.12, 2.57) and awareness on water handling matters (AOR, 2.0; 95% CI 1.37, 2.90), hand washing practice (AOR, 2.36; 95% CI 1.62, 3.45) were significantly associated to hygiene behaviour status. Being a member of hygiene and sanitation club (COR 0.42; 95% CI 0.26, 0.68), parent's health package status (COR 0.62; 95% CI 0.43, 0.90), training on hygiene and sanitation and experience of visiting model school (COR 1.99; 95% CI 1.37, 2.88) had significance difference in hygiene behaviour.

CONCLUSION

This study has shown that knowledge, awareness, training on hygiene and sanitation, being a member of hygiene and sanitation club, experience of visiting model school, and parent's health package status were factors influenced hygiene behaviour.

Hand sanitiser provision for reducing illness absences in primary school children: a cluster randomised trial

BACKGROUND

The potential for transmission of infectious diseases offered by the school environment are likely to be an important contributor to the rates of infectious disease experienced by children. This study aimed to test whether the addition of hand sanitiser in primary school classrooms compared with usual hand hygiene would reduce illness absences in primary school children in New Zealand.

METHODS AND FINDINGS

This parallel-group cluster randomised trial took place in 68 primary schools, where schools were allocated using restricted randomisation (1:1 ratio) to the intervention or control group. All children (aged 5 to 11 y) in attendance at participating schools received an in-class hand hygiene education session. Schools in the intervention group were provided with alcohol-based hand sanitiser dispensers in classrooms for the winter school terms (27 April to 25 September 2009). Control schools received only the hand hygiene education session. The primary outcome was the number of absence episodes due to any illness among 2,443 follow-up children whose caregivers were telephoned after each absence from school. Secondary outcomes measured among follow-up children were the number of absence episodes due to specific illness (respiratory or gastrointestinal), length of illness and illness absence episodes, and number of episodes where at least one other member of the household became ill subsequently (child or adult). We also examined whether provision of sanitiser was associated with experience of a skin reaction. The number of absences for any reason and the length of the absence episode were measured in all primary school children enrolled at the schools. Children, school administrative staff, and the school liaison research assistants were not blind to group allocation. Outcome assessors of follow-up children were blind to group allocation. Of the 1,301 and 1,142 follow-up children in the hand sanitiser and control groups, respectively, the rate of absence episodes due to illness per 100 child-days was similar (1.21 and 1.16, respectively, incidence rate ratio 1.06, 95% CI 0.94 to 1.18). The provision of an alcohol-based hand sanitiser dispenser in classrooms was not effective in reducing rates of absence episodes due to respiratory or gastrointestinal illness, the length of illness or illness absence episodes, or the rate of subsequent infection for other members of the household in these children. The percentage of children experiencing a skin reaction was similar (10.4% hand sanitiser versus 10.3% control, risk ratio 1.01, 95% CI 0.78 to 1.30). The rate or length of absence episodes for any reason measured for all children also did not differ between groups. Limitations of the study include that the study was conducted during an influenza pandemic, with associated public health messaging about hand hygiene, which may have increased hand hygiene among all children and thereby reduced any additional effectiveness of sanitiser provision. We did not quite achieve the planned sample size of 1,350 follow-up children per group, although we still obtained precise estimates of the intervention effects. Also, it is possible that follow-up children were healthier than non-participating eligible children, with therefore less to gain from improved hand hygiene. However, lack of effectiveness of hand sanitiser provision on the rate of absences among all children suggests that this may not be the explanation.

CONCLUSIONS

The provision of hand sanitiser in addition to usual hand hygiene in primary schools in New Zealand did not prevent disease of severity sufficient to cause school absence.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12609000478213. Please see later in the article for the Editors' Summary.

The impact of common infections on school absenteeism during an academic year

BACKGROUND

School absenteeism because of infections is one of the most important problems facing both public and private primary schools. The aim of the study was to assess the impact of infections on school absenteeism and their reduction with a handwashing program using hand sanitizer.

METHODS

The study was an 8-month-long, randomized, controlled open study (N = 1,609 children, aged 4-12 years old) at 5 state schools in Almeria (Spain). The experimental group (EG) washed their hands with soap and water, complemented with the use of hand sanitizer, and the control group (CG) followed the usual handwashing procedure. The total number of episodes and days missed as well as those because of upper respiratory infections and gastrointestinal infections were compared in both groups with a Z-test.

RESULTS

The students were absent 12,386 days in 7,945 episodes. The incidence of total absent episodes and percent of missed days, including those because of upper respiratory infections and gastrointestinal infections, were significantly lower in the EG than the CG (P < .001), and this was maintained through the flu pandemic period.

CONCLUSION

School absenteeism because of infections in schools is reduced when a hand hygiene program utilizing sanitizing gels is properly carried out, especially during the flu season.

Effectiveness of a multifactorial handwashing program to reduce school absenteeism due to acute gastroenteritis

BACKGROUND

Acute gastroenteritis (AGE) is one of the most common diseases among children and an important cause of school absenteeism. The aim of this study was to assess the effectiveness of a handwashing program using hand sanitizers for the prevention of school absenteeism due to AGE.

METHODS

A randomized, controlled and open study of a sample of 1341 children between 4 and 12 years of age, attending 5 state schools in Almería (Spain), with an 8-month follow up (academic year). The experimental group (EG) washed their hands with soap and water, complementing this with the use of a hand sanitizer, and the control group (CG) followed the usual handwashing procedure. Absenteeism rates due GI were compared between the 2 groups through the multivariate Poisson regression analysis. Percent days absent in both groups were compared with a Z-test.

RESULTS

446 cases of school absenteeism due to AGE were registered. The school children from the EG had a 36% lower risk of absenteeism due to AGE (IRR: 0.64, 95% confidence interval: 0.52-0.78) and a decrease in absenteeism of 0.13 episodes/child/academic year (0.27 of EG vs 0.40 CG/episodes/child/academic year, P < 0.001). Pupils missed 725 school days due to AGE and absent days was significantly lower in the EG (EG: 0.31%, 95% confidence interval: 0.28-0.35 vs. CG: 0.44%, 95% confidence interval: 0.40-0.48, P < 0.001).

CONCLUSIONS

The use of hand sanitizer as a complement to handwashing with soap is an efficient measure to reduce absent days and the number of school absenteeism cases due to AGE.

Hand hygiene and risk of influenza virus infections in the community: a systematic review and meta-analysis

Community-based prevention strategies for seasonal and pandemic influenza are essential to minimize their potential threat to public health. Our aim was to evaluate the efficacy of hand hygiene interventions in reducing influenza transmission in the community and to investigate the possible modifying effects of latitude, temperature and humidity on hand hygiene efficacy. We identified 979 articles in the initial search and 10 randomized controlled trials met our inclusion criteria. The combination of hand hygiene with facemasks was found to have statistically significant efficacy against laboratory-confirmed influenza while hand hygiene alone did not. Our meta-regression model did not identify statistically significant effects of latitude, temperature or humidity on the efficacy of hand hygiene. Our findings highlight the potential importance of interventions that protect against multiple modes of influenza transmission, and the modest efficacy of hand hygiene suggests that additional measures besides hand hygiene may also be important to control influenza.

Impact of water, sanitation, and hygiene interventions on improving health outcomes among school children

PURPOSE

This review was done to explore the impact of water treatment, hygiene, and sanitary interventions on improving child health outcomes such as absenteeism, infections, knowledge, attitudes, and practices and adoption of point-of-use water treatment.

METHODS

A literature search was conducted using the databases PubMed and Google scholar for studies published between 2009 and 2012 and focusing on the effects of access to safe water, hand washing facilities, and hygiene education among school-age children. Studies included were those that documented the provision of water and sanitation in schools for children less than 18 years of age, interventions which assessed WASH practices, and English-language, full-text peer reviewed papers.

RESULTS

Fifteen studies were included in the final analysis. 73% (n = 11) of the studies were conducted in developing countries and were rural based (53%, n = 8). The child's age, gender, grade level, socioeconomic index, access to hygiene and sanitary facilities, and prior knowledge of hygiene practices were significantly associated with the outcomes. Nutrition practices which are key factors associated with the outcomes were rarely assessed.

CONCLUSION

Further research is required to assess the long-term impact of such interventions in different settings.

The impact of school water, sanitation, and hygiene interventions on the health of younger siblings of pupils: a cluster-randomized trial in Kenya

OBJECTIVES

We examined the impact of school water, sanitation, and hygiene (WASH) interventions on diarrhea-related outcomes among younger siblings of school-going children.

METHODS

We conducted a cluster-randomized trial among 185 schools in Kenya from 2007 to 2009. We assigned schools to 1 of 2 study groups according to water availability. Multilevel logistic regression models, adjusted for baseline measures, assessed differences between intervention and control arms in 1-week period prevalence of diarrhea and 2-week period prevalence of clinic visits among children younger than 5 years with at least 1 sibling attending a program school.

RESULTS

Among water-scarce schools, comprehensive WASH improvements were associated with decreased odds of diarrhea (odds ratio [OR] = 0.44; 95% confidence interval [CI] = 0.27, 0.73) and visiting a clinic (OR = 0.36; 95% CI = 0.19, 0.68), relative to control schools. In our separate study group of schools with greater water availability, school hygiene promotion and water treatment interventions and school sanitation improvements were not associated with differences in diarrhea prevalence between intervention and control schools.

CONCLUSIONS

In water-scarce areas, school WASH interventions that include robust water supply improvements can reduce diarrheal diseases among young children.

Impact of regular soap provision to primary schools on hand washing and E. coli hand contamination among pupils in Nyanza Province, Kenya: a cluster-randomized trial

We assessed whether supplying soap to primary schools on a regular basis increased pupil hand washing and decreased Escherichia coli hand contamination. Multiple rounds of structured observations of hand washing events after latrine use were conducted in 60 Kenyan schools, and hand rinse samples were collected one time in a subset of schools. The proportion of pupils observed practicing hand washing with soap (HWWS) events was significantly higher in schools that received a soap provision intervention (32%) and schools that received soap and latrine cleaning materials (38%) compared with controls (3%). Girls and boys had similar hand washing rates. There were non-significant reductions in E. coli contamination among intervention school pupils compared with controls. Removing the barrier of soap procurement can significantly increase availability of soap and hand washing among pupils; however, we discuss limitations in the enabling policy and institutional environment that may have prevented reaching desired levels of HWWS.

The impact of a school-based water supply and treatment, hygiene, and sanitation programme on pupil diarrhoea: a cluster-randomized trial

The impact of improved water, sanitation, and hygiene (WASH) access on mitigating illness is well documented, although impact of school-based WASH on school-aged children has not been rigorously explored. We conducted a cluster-randomized trial in Nyanza Province, Kenya to assess the impact of a school-based WASH intervention on diarrhoeal disease in primary-school pupils. Two study populations were used: schools with a nearby dry season water source and those without. Pupils attending 'water-available' schools that received hygiene promotion and water treatment (HP&WT) and sanitation improvements showed no difference in period prevalence or duration of illness compared to pupils attending control schools. Those pupils in schools that received only the HP&WT showed similar results. Pupils in 'water-scarce' schools that received a water-supply improvement, HP&WT and sanitation showed a reduction in diarrhoea incidence and days of illness. Our study revealed mixed results on the impact of improvements to school WASH improvements on pupil diarrhoea.

Teaching handwashing with soap for schoolchildren in a multi-ethnic population in northern rural Vietnam

Background

In Vietnam, initiatives have been started aimed at increasing the practice of handwashing with soap (HWWS) among primary schoolchildren. However, compliance remains low.

Objective

This study aims to investigate responses to a teacher-centred participatory HWWS intervention in a multi-ethnic population of primary schoolchildren in northern rural Vietnam.

Design

This study was implemented in two phases: a formative research project over 5 months (July–November 2008) and an action research project with a school-based HWWS intervention study in two rural communes during 5 months (May, September–December 2010). Based upon knowledge from the formative research in 2008, schoolteachers from four selected schools in the study communes actively participated in designing and implementing a HWWS intervention. Qualitative data was collected during the intervention to evaluate the responses and reaction to the intervention of teachers, children and parents. This included semi-structured interviews with children (15), and their parents (15), focus group discussions (FGDs) with schoolchildren (32) and school staff (20) and observations during 15 HWWS involving children.

Results

Observations and interview data from children demonstrated that children were visibly excited and pleased with HWWS sessions where teachers applied active teaching methods including rewards, games and HWWS demonstrations. All children, schoolteachers and parents also viewed the HWWS intervention as positive and feasible, irrespective of ethnicity, gender of schoolchildren and background of schoolteachers. However, some important barriers were indicated for sustaining and transferring the HWWS practice to the home setting including limited emphasis on hygiene in the standard curriculum of schools, low priority and lack of time given to practical teaching methods and lack of guidance and reminding HWWS on a regular basis at home, in particular by highland parents, who spend most of their time working away from home in the fields. Access to soap and water at the household level did not seem a barrier for the uptake of HWWS but continuous access to these might be a challenge at schools.

Conclusions

This study demonstrated that it is feasible to engage teachers and implement active teaching methods for behaviour change of HWWS in a group of multi-ethnic primary schoolchildren without the need for major investments in water and hygiene infrastructures. However, in those areas there was limited transfer of practice from school promotion to home. Continuous access to soaps at schools needs to be invested.

Handwashing among schoolchildren in an ethnically diverse population in northern rural Vietnam

Background

Handwashing with soap (HWWS) is a simple and effective measure to prevent transmission of fecal–oral disease and other infectious diseases in school-age children. To promote the behavior, we need to understand their HWWS compliance. The aim of this article is to describe handwashing behavior and HWWS compliance and to identify associated factors among schoolchildren in the multiethnic rural area of northern Vietnam.

Methods

The study was conducted in six primary and secondary schools and in the homes of four ethnic villages in northern Vietnam. Quantitative methods included face-to-face interviews with, and demonstration of handwashing protocol to, 319 schoolchildren in first, fourth, and seventh grades. Qualitative methods included structured observations at six schools and 20 homes comprising 24 children. The dependent variable was the self-reported HWWS behavior (yes/no). The independent variables included grade, school type, gender, ethnicity group, owning home latrine, and household assets. Logistic regression modelling was performed to examine associations between HWWS behavior and demographic factors.

Results

Among the 319 schoolchildren interviewed, 66% reported HWWS. Through the demonstration protocol, only 10 out of 319 schoolchildren, performed HWWS satisfactorily. The percentage of students who washed their hands at recommended times (30–60 sec) was 58%. This proportion increased by grade (from 34% among grade 1 to 67% among grade 7; p<0.05). Correlates of self-reported HWWS were more common in higher grades [grade 4 vs. grade 1: odds ratio (OR)=4.14 (2.00–8.56), grade 7 vs. grade 1: OR=7.76 (3.67–16.4)] and less common in ethnic minority groups [Xa Phó vs. Kinh-Tay: OR=0.28 (0.11–0.70)]. All 20 homes of schoolchildren visited had soap and water but none of the six schools had soap for handwashing.

Conclusions

This article describes poor compliance of schoolchildren with HWWS in a multiethnic population in Vietnam. Education on handwashing needs to be prioritized among multiethnic children at school.

Impact of a school-based hygiene promotion and sanitation intervention on pupil hand contamination in Western Kenya: a cluster randomized trial

Handwashing with soap effectively reduces exposure to diarrhea-causing pathogens. Interventions to improve hygiene and sanitation conditions in schools within low-income countries have gained increased attention; however, their impact on schoolchildren's exposure to fecal pathogens has not been established. Our trial examined whether a school-based water, sanitation, and hygiene intervention reduced Escherichia coli contamination on pupils' hands in western Kenya. A hygiene promotion and water treatment intervention did not reduce risk of E. coli presence (relative risk [RR] = 0.92, 95% confidence interval [CI] = 0.54–1.56); the addition of new latrines to intervention schools significantly increased risk among girls (RR = 2.63, 95% CI = 1.29–5.34), with a non-significant increase among boys (RR = 1.36, 95% CI = 0.74–2.49). Efforts to increase usage of school latrines by constructing new facilities may pose a risk to children in the absence of sufficient hygiene behavior change, daily provision of soap and water, and anal cleansing materials.

Hand hygiene instruction decreases illness-related absenteeism in elementary schools: a prospective cohort study

Background

Illness-related absences have been shown to lead to negative educational and economic outcomes. Both hand washing and hand sanitizer interventions have been shown to be effective in reducing illness-related absences. However, while the importance of hand hygiene in schools is clear, the role of instruction in use is less obvious. The purpose of this study was to compare absenteeism rates among elementary students given access to hand hygiene facilities versus students given both access and short repetitive instruction in use, particularly during influenza season when illness-related absences are at a peak.

Methods

A hand hygiene intervention was implemented from October to May during the 2009/2010 academic year, including peak flu season, in two Chicago Public Elementary Schools among students grades pre-kindergarten to eighth grade (ages 4–14). Classrooms were systematically assigned to an intervention or control group by grade (cluster design). Hand hygiene facilities (sanitizer and soap) were made available to all students. Students in the intervention group also received short repetitive instruction in hand hygiene every 2 months. Only absences as a result of respiratory or gastrointestinal illness were used to establish illness-related absenteeism rates. Percent absent days were calculated and bivariate analyses were performed to compare percent absent days among students given access to hand hygiene facilities versus students given both access and instruction. Prior to the intervention, teachers’ perceptions of students’ hand hygiene were also evaluated. Teacher perceptions were analysed to describe attitudes and beliefs.

Results

Data were collected and analysed for 773 students reporting 1,886 absences during the study period (1.73% of total school days). Both the percent total absent days and percent illness-related absent days were significantly lower in the group receiving short instruction during flu season (P = 0.002, P < 0.001, respectively). This difference peaked during the influenza season (when intervention began) and declined in the following months. Teachers (n = 23) agreed that hand hygiene is not performed properly among students and reported time constraints as a barrier to frequent hand washing.

Conclusions

Adding hand hygiene instruction to existing hand hygiene practices improved attendance at public elementary schools during the flu season. Standardized and brief repetitive instruction in hand hygiene holds potential to significantly reduce absenteeism.

Assessing the impact of a school-based water treatment, hygiene and sanitation programme on pupil absence in Nyanza Province, Kenya: a cluster-randomized trial

OBJECTIVES

There has been increased attention to access to water, sanitation and hygiene (WASH) at schools in developing countries, but a dearth of empirical studies on the impact. We conducted a cluster-randomized trial of school-based WASH on pupil absence in Nyanza Province, Kenya, from 2007 to 2008.

METHODS

Public primary schools nested in three geographical strata were randomly assigned and allocated to one of three study arms [water treatment and hygiene promotion (WT & HP), additional sanitation improvement, or control] to assess the effects on pupil absence at 2-year follow-up.

RESULTS

We found no overall effect of the intervention on absence. However, among schools in two of the geographical areas not affected by post-election violence, those that received WT and HP showed a 58% reduction in the odds of absence for girls (OR 0.42, CI 0.21-0.85). In the same strata, sanitation improvement in combination with WT and HP resulted in a comparable drop in absence, although results were marginally significant (OR 0.47, 0.21-1.05). Boys were not impacted by the intervention.

CONCLUSION

School WASH improvements can improve school attendance for girls, and mechanisms for gendered impacts should be explored. Incomplete intervention compliance highlights the challenges of achieving consistent results across all settings.