Inexpensive and time-efficient hand hygiene interventions increase elementary school children's hand hygiene rates

Effectiveness of a continuous handwashing education program with multiple activities at a Japanese kindergarten school

Formation of proper handwashing techniques and habits from childhood is important for disease prevention. However, there are few studies that comprehensively and longitudinally evaluate the effectiveness of handwashing education for kindergarteners. This study aims to evaluate the effectiveness of continuous handwashing education using multiple activities to improve handwashing practices and skills among first- to third-grade students at a kindergarten in central Japan. A quasi-experimental one group pre- and post-test design was used. The education program consisted of three activities: (i) a 1-day teaching session by a researcher in January 2021, (ii) a 1-month follow-up activity led by kindergarten teachers and (iii) a 1-month follow-up activity led by parents at home, both occurring from late January to late February 2021. The study used questionnaires and handwashing skill experiments to investigate the kindergarteners' handwashing practices and comprehensive handwashing skills (handwashing steps, handwashing time, rinsing time and areas of the hands left unwashed) before and after Activities 1, 2 and 3. Data were obtained from 56 kindergarteners (64.4%). Second and third graders showed a significant improvement in their handwashing practices after coughing or sneezing. With the exception of rinsing time, handwashing skills significantly improved in all grades after the 1-day teaching session. After 1-month follow-up activities, the number of areas left unwashed by first graders significantly decreased, and the score for handwashing steps significantly improved. This study indicated that continuous handwashing education is partially effective at improving and maintaining handwashing practices and skills, except for rinsing time, among kindergarteners of all grades.

Determinants of handwashing behaviour among primary school teachers in a district of Ghana

Background: Hand hygiene practise is an effective school-based measure for infectious disease prevention, especially in developing countries. School children model their behaviour through the observation of significant others, including teachers. However, little is known about the handwashing behaviour and factors influencing the handwashing practises of teachers at the primary school level in Ghana. Methods: A quantitative cross-sectional study was conducted among 214 primary school teachers, recruited by convenience sampling. Data were collected using a structured questionnaire which were designed based on selected constructs in the Theory of Planned Behaviour and the Health Belief Model. Data analyses was done with the aid of STATA software, version 14.0. To identify determinants of hand washing with soap (HWWS) among participants, correlation and multiple linear regression analysis were used. Results: The participants' mean SD age was 34.7 7.6 years, ranging from 20 to 51 years. The majority were males (87.9%). The majority (84.0% and 86.0%) of the teachers, respectively, reported HWWS practises after using the toilet and before eating with bare hands. A correlation was found between reported HWWS practise and toilet use (r = 0.64; p = 0.001) and eating with bare hands (r = 0.84; p = 0.001). A multiple linear regression analysis found that knowledge (p = 0.001), attitude toward HWWS (p = 0.002), and teachers' perception of the severity of diarrhoea (p = 0.009) were determinants of teachers' reported HWWS behaviours. Conclusion: Teachers' perceptions of their susceptibility to and severity of diarrhoea, and their knowledge and attitude towards HWWS at critical times should be focus areas for handwashing programmes to achieve the desired outcomes.

Handwashing Practice among Elementary Schoolchildren in Urban Setting, Mongolia: A School-Based Cross-Sectional Survey

Objectives

Handwashing with soap is the simplest, most affordable, and cost-effective preventative intervention for reducing the burden of communicable diseases, including the COVID-19. This study was aimed at investigating elementary schoolchildren's handwashing practice at two critical moments, namely, before eating and after using the toilet and its associated factors.

Methods

The cross-sectional study was conducted at ten public secondary schools in Ulaanbaatar, Mongolia, between February and March 2019. Data were collected from all fifth-grade children's parents at the selected schools by using a self-reported questionnaire. Descriptive and multiple regression analyses were conducted using STATA/MP version 13.0.

Results

A total of 1507 parents/guardians of 5^th-grade school children participated. Reported schoolchildren's handwashing practice for both critical moments was 50.1%. It was significantly associated with female gender (adjusted odds ratio [AOR] = 0.56 (95%CI = 0.45, 0.70)), number of siblings (AOR = 0.72 (95%CI = 0.61, 0.80)), and availability of handwashing amenity at school (AOR = 1.1595%CI = 0.86, 1.42)). Only 34% of children wash their hands with soap at school, and the most common reasons for skipping handwashing were an absence of soap (23.9%), lack of sink (14.5%), and the use of hand sanitizer (19.7%).

Conclusions

The school children's handwashing practice at two critical moments is considerably low. The main disabling factors of regular handwashing at school included insufficient handwashing facility and soap. Therefore, promoting HW facilities and innovative and participatory education for elementary schoolchildren should be prioritized.

Effects of Micro Architectural Environmental Interventions on Handwashing Compliance of Adolescents: A School-Based Intervention Trial

PURPOSE

Aimed to explore more practical interventions for handwashing compliance (HWC) and protect the minor' health with the pandemic background, this study tested whether micro architectural interventions would promote HWC of adolescents through active experience.

BACKGROUND

Despite the well-documented benefits of handwashing (HW), low compliance is common among adolescents. HW space in schools has always been treated as attached spaces of little matter, which is unfavorable to public health. According to environment behavior perspective, personal motivation of HWC may be motivated by active environment.

METHOD

A school-based investigation and a 30-week environmental behavior experiment were conducted when students returned to school after the COVID-19 pandemic closure in 2020 in China to evaluate the effects of active environment interventions selected by previous survey on promoting adolescents' HW rate. Digital infrared counters were used to unobtrusively document their behavior.

RESULTS

Results in summer revealed a positive effect on all intervention groups. The effects of combined interventions were higher than the effect of any single intervention. However, HW rates of all groups declined sharply in the coldest month and the between-group differences decreased. Significant correlations were found between HW rates and satisfaction with the intervention schemes.

CONCLUSIONS

Findings suggest that architectural environmental intervention may potentially be a positive, friendly, and one-time investment mean to expand the HWC intervention scope from passive policies to positive experience, and HW space design for adolescents should be treated as a public health strategy.

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.

Deployment of a Smart Handwashing Station in a School Setting During the COVID-19 Pandemic: Field Study

Background

Hand hygiene is one of the most effective ways to remove germs, prevent the spread of infectious pathogens, and avoid getting sick. Since the COVID-19 pandemic began, health authorities have been advocating good hand hygiene practices.

Objective

The primary aim of this study is to field test a prototype smart handwashing station deployed in a school setting during the COVID-19 pandemic.

Methods

We deployed a smart handwashing station and examined key technological considerations including connectivity, security, and data management systems, as well as the health and safety of users.

Results

The smart handwashing station was deployed for 10 days in a school setting in Australia during the COVID-19 pandemic. The smart handwashing station’s electrical components remained operational during field testing and underwent robust cleaning protocols each day. The handwashing station was used 1138 times during the field test and there was no COVID-19 transmission at the school during the testing.

Conclusions

This study demonstrates that a personalized feedback approach using technology can successfully be implemented at a school and can provide a platform to improve hand hygiene among school-aged children.

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.

A study of handwashing training effects on awareness, attitude, and handwashing skills of third grade elementary school students

Background and Aims:

Hands are the first way of which many infectious diseases are transmitted. Hand hygiene is a means of infection control in schools. Close consideration of handwashing in educational units is important to control and prevent infection transmission. The present study aimed to determine the effect of handwashing education on awareness, attitude and handwashing skills of third-grade elementary school students in Tehran.

Methods:

In this study, 76 third grade students of elementary schools located at district 1 of Tehran with the mean age of 9 years were randomly divided into intervention and control groups using pre-test and post-test. Data collection for intervention and control groups was done using a researcher-made awareness- and attitude-gauging questionnaire, along with a checklist of handwashing performance which was completed in cooperation with the health instructor.

Results:

The results of this study showed that there was a significant difference between the awareness of 3^rd-grade students in intervention (69.79 ± 1.61) and control (49.03 ± 1.18) groups (P < 0.05). Moreover, students’ attitude toward handwashing improved as a result of education, and the intervention group (62.37 ± 0.65) had a more positive attitude toward hygiene and handwashing compared to the control group (48.45 ± 0.73) (P < 0.05). In the case of handwashing performance, the intervention group (56.76 ± 1.33) had better health performance compared to the control group (40.08 ± 0.67) (P < 0.05).

Conclusion:

Practical training, preparation of educational posters and videos can enhance awareness, attitude and handwashing performance.

School-based, blacklight handwashing program can improve handwashing quality and knowledge among pre-school aged children

In the United States, lack of proper handwashing is associated with respiratory and gastrointestinal illnesses. Interventions to improve handwashing practices have led to an increase in handwashing knowledge and behavior, and decreases in gastrointestinal illnesses. Most studies have evaluated their interventions in the context of reported handwashing rates by observation, reduction of illnesses, as well as reduced absences, however none of these studies examined handwashing quality or knowledge as outcome measures. The objective of this paper is to present the results from a handwashing program with a special focus on the evaluation methods. A pre-post design was used to evaluate a handwashing program that took place in two pre-schools the northeast of the United States. The program utilized a black light technology to demonstrate to children the importance of good quality. The evaluation consisted of assessing knowledge and quality of handwashing using a linear puzzle and individual handwashing observation, respectively. Students from both schools improved on both knowledge and quality over time (p-values 0.071 and <0.001, respectively). The present study demonstrates that the use of black light technology as an educational tool may help to improve handwashing quality among pre-school aged children, even after only one instructional session.

Improving children's and their visitors' hand hygiene compliance

Background

Numerous interventions have tried to improve healthcare workers' hand hygiene compliance. However, little attention has been paid to children's and their visitors' compliance.

Aim

To test whether interactive educational interventions increase children's and visitors' compliance with hand hygiene.

Methods

This was a cluster randomised study of hand hygiene compliance before and after the introduction of educational interventions. Observations were compared for different moments of hygiene and times of the day. Qualitative data in the form of questionnaire-based structured interviews were obtained.

Findings

Hand hygiene compliance increased by 24.4% (P < 0.001) following the educational interventions, with children's compliance reaching 40.8% and visitors' being 50.8%. Compliance varied depending on which of the five moments of hygiene was observed (P < 0.001), with the highest compliance being 'after body fluid exposure' (72.7%). Responses from questionnaires showed educational interventions raised awareness of the importance of hand hygiene (69%, 57%) compared to those who had not experienced the educational intervention (50%).

Conclusion

Educational interventions may result in a significant increase in children's and visitors' hand hygiene (P < 0.001).

Visibility and transmission: complexities around promoting hand hygiene in young children - a qualitative study

Background

Effective hand hygiene practice can reduce transmission of diseases such as respiratory tract infections (RTIs) and gastrointestinal infections, especially in young children. While hand hygiene has been widely promoted within Australia, primary care providers’ (PCPs) and parents’ understanding of hand hygiene importance, and their views on hand hygiene in reducing transmission of diseases in the community are unclear. Therefore, the aim of this study was to explore the views of PCPs and parents of young children on their knowledge and practice of hand hygiene in disease transmission.

Methods

Using a cross-sectional qualitative research design, we conducted 30 in-depth interviews with PCPs and five focus groups with parents (n = 50) between June 2014 and July 2015 in Melbourne, Australia. Data were thematically analysed.

Results

Participants agreed that hand hygiene practice was important in reducing disease transmissions. However, barriers such as variations of hand hygiene habits, relating visibility to transmission; concerns around young children being obsessed with washing hands; children already being ‘too clean’ and the need to build their immunity through exposure to dirt; and scepticism that hand hygiene practice was achievable in young children, all hindered participants’ motivation to develop good hand hygiene behaviour in young children.

Conclusion

Despite the established benefits of hand hygiene, sustained efforts are needed to ensure its uptake in routine care. To overcome the barriers identified in this study a multifaceted intervention is needed that includes teaching young children good hand hygiene habits, PCPs prompting parents and young children to practice hand hygiene when coming for an RTI consultation, reassuring parents that effective hand hygiene practice will not lead to abnormal psychological behaviour in their children, and community health promotion education campaigns.

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.

The Effect of Therapeutic Clowning on Handwashing Technique and Microbial Colonization in Preschool Children

PURPOSE

This study aimed to determine the effect of therapeutic clowning on handwashing technique and microbial colonization in preschool children.

DESIGN

This randomized controlled trial was conducted using pre-test and post-test experimental and control groups.

METHODS

The study was conducted between March and June 2016 in two kindergartens in eastern Turkey. The study was completed with a total of 195 students, including 90 students in the experimental group and 105 students in the control group. A questionnaire was used for data collection. This questionnaire included sections about the subjects' descriptive characteristics and the results of the bacterial cultures of their hand swabs. For the collection of these swabs, the subjects were informed in advance, and samples were collected at predetermined times. The swabs were analyzed to determine the bacterial colonization of the subjects' hands. Clowns and video activities were used as intervention tools in the study.

FINDINGS

In the post-test, the microbial growth was ≤10³ in 68.9% and >10³ in 31.1% of the subjects in the experimental group. In contrast, the growth was ≤10³ in 34.3% and >10³ in 65.7% of the control group subjects. The difference in the post-test microbial growths of the two groups was statistically significant (p < .000).

CONCLUSIONS

The hygienic handwashing technique taught in the therapeutic clowning and videos reduced the bacterial colonization on the preschool children's hands by 50%. Moreover, this method was effective in reducing the growth rate of coliform bacteria that indicate undesirable, poor hygiene of the hands.

CLINICAL RELEVANCE

Considering these results, we recommend that pediatric healthcare professionals use entertaining methods such as those involving clowns to teach and guide children regarding hygienic handwashing techniques.

A framework for designing hand hygiene educational interventions in schools

OBJECTIVES

Hygiene education appears to be the commonest school-based intervention for preventing infectious diseases, especially in the developing world. Nevertheless, there remains a gap in literature regarding a school-specific theory-based framework for designing a hand hygiene educational intervention in schools. We sought to suggest a framework underpinned by psychosocial theories towards bridging this knowledge gap. Furthermore, we sought to propound a more comprehensive definition of hand hygiene which could guide the conceptualisation of hand hygiene interventions in varied settings.

METHODS

Literature search was guided by a standardized tool and literature was retrieved on the basis of a predetermined inclusion criteria. Databases consulted include PubMed, ERIC, and EBSCO host (Medline, CINAHL, PsycINFO, etc.). Evidence bordering on a theoretical framework to aid the design of school-based hand hygiene educational interventions is summarized narratively.

RESULTS

School-based hand hygiene educational interventions seeking to positively influence behavioural outcomes could consider enhancing psychosocial variables including behavioural capacity, attitudes and subjective norms (normative beliefs and motivation to comply).

CONCLUSIONS

A framework underpinned by formalized psychosocial theories has relevance and could enhance the design of hand hygiene educational interventions, especially in schools.

Learning through Teaching: A Microbiology Service-Learning Experience

Service learning is defined as a strategy in which students apply what they have learned in the classroom to a community service project. Many educators would agree that students often learn best through teaching others. This premise was the motivation for a new service-learning project in which undergraduate microbiology students developed and taught hands-on microbiology lessons to local elementary school children. The lessons included teaching basic information about microbes, disease transmission, antibiotics, vaccines, and methods of disease prevention. This service-learning project benefitted the college students by enforcing their knowledge of microbiology and provided them an opportunity to reach out to children within their community. This project also benefitted the local schools by teaching the younger students about microbes, infections, and handwashing. In this paper, I discuss the development and implementation of this new microbiology service-learning project, as well as the observed impact it had on everyone involved.

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.

The effect of grade on compliance using nonpharmaceutical interventions to reduce influenza in an urban elementary school setting

OBJECTIVES

The Pittsburgh Influenza Prevention Project (PIPP) has previously shown that school-aged children in grades K-5 can learn hygiene-based, nonpharmaceutical interventions (NPIs) and persist in these behaviors over the duration of an influenza season. The purpose of this study was to determine whether age (as estimated by grade) plays any role in this ability.

METHODS

The Pittsburgh Influenza Prevention Project is a prospective, controlled, randomized trial of the effectiveness of a suite of NPIs in 10 elementary schools. The project measured adoption of NPIs by students through surveys of intervention homeroom teachers before, during, and after the influenza season and control home-room teachers after influenza season.

RESULTS

There were large, statistically significant improvements and persistence over time across all grade levels, in students' concern about influenza and their daily practice of NPIs that promote health behaviors-"wash or sanitize your hands often" and "cover your coughs and sneezes." Nonpharmaceutical interventions characterized as extinguishing unhealthy behaviors, such as "avoid touching your eyes, nose, and mouth" or "home is where you stay when you are sick," showed no reliable improvement.

CONCLUSIONS

The study provides evidence that elementary school-aged children, across all grades, can understand and implement protective NPIs and maintain these activities throughout influenza season and beyond. Improvements were most prominent when teaching students to engage in health-promoting behaviors. Habitual behaviors (unconscious touching) and changing family behaviors (staying home) seem less susceptible to intervention. These results will be useful to public health policy makers and health care practitioners considering methods of infectious disease prevention in school-based settings.

What is the role and authority of gatekeepers in cluster randomized trials in health research?

This article is part of a series of papers examining ethical issues in cluster randomized trials (CRTs) in health research. In the introductory paper in this series, we set out six areas of inquiry that must be addressed if the CRT is to be set on a firm ethical foundation. This paper addresses the sixth of the questions posed, namely, what is the role and authority of gatekeepers in CRTs in health research? ‘Gatekeepers’ are individuals or bodies that represent the interests of cluster members, clusters, or organizations. The need for gatekeepers arose in response to the difficulties in obtaining informed consent because of cluster randomization, cluster-level interventions, and cluster size. In this paper, we call for a more restrictive understanding of the role and authority of gatekeepers.

Previous papers in this series have provided solutions to the challenges posed by informed consent in CRTs without the need to invoke gatekeepers. We considered that consent to randomization is not required when cluster members are approached for consent at the earliest opportunity and before any study interventions or data-collection procedures have started. Further, when cluster-level interventions or cluster size means that obtaining informed consent is not possible, a waiver of consent may be appropriate. In this paper, we suggest that the role of gatekeepers in protecting individual interests in CRTs should be limited. Generally, gatekeepers do not have the authority to provide proxy consent for cluster members. When a municipality or other community has a legitimate political authority that is empowered to make such decisions, cluster permission may be appropriate; however, gatekeepers may usefully protect cluster interests in other ways. Cluster consultation may ensure that the CRT addresses local health needs, and is conducted in accord with local values and customs. Gatekeepers may also play an important role in protecting the interests of organizations, such as hospitals, nursing homes, general practices, and schools. In these settings, permission to access the organization relies on resource implications and adherence to institutional policies.

Compliance with a multilayered nonpharmaceutical intervention in an urban elementary school setting

OBJECTIVES

The purpose of this study was to determine to what extent school-aged children can learn hygiene-based nonpharmaceutical interventions (NPIs) and persist in these behavioral changes over the duration of an influenza season. If this can be done successfully, it may be a preferable pandemic mitigation strategy to much more disruptive strategies such as whole-scale school closure.

METHODS

The Pittsburgh Influenza Prevention Project (PIPP) is a prospective, controlled, randomized trial of the effectiveness of a suite of hygiene-based NPIs in controlling influenza and related illnesses in elementary schools in the City of Pittsburgh. During the 2007-08 school year, the project measured adoption of NPIs by students in five elementary schools through surveys of home-room teachers before, during, and after influenza season.

RESULTS

Results showed highly statistically significant improvement in students' daily practice of nearly all of the NPIs, including hand washing and sanitizer use and covering coughs and sneezes.

CONCLUSIONS

The study provides evidence that children can learn, implement, and persist in the behaviors of a multilayered suite of NPIs over a typical flu season. These results will be useful to public health policy makers and practitioners considering methods of infectious disease prevention in school-based settings.

An observational study of hand hygiene compliance in paediatric wards

AIMS AND OBJECTIVES

To measure healthcare workers', children's and visitors' hand hygiene compliance in a paediatric oncology ward and a paediatric respiratory ward in an English hospital.

BACKGROUND

Children are especially vulnerable to healthcare-associated infections, yet few studies have reported on hand hygiene compliance in paediatric clinical areas.

DESIGN

This was an observational study.

METHOD

We measured hand hygiene compliance over an eight-hour period in two hospital wards using the 'five moments of hand hygiene' observation tool. We monitored a total of 407 hand hygiene opportunities.

RESULTS

Overall opportunities for compliance were 74% for healthcare workers (n = 315) and children and visitors 23% (n = 92). Compliance was 84% for allied health professionals, 81% for doctors, 75% for nurses and 73% for ancillary and other staff. Hand hygiene compliance varied depending on which of the five moments of hygiene healthcare workers were undertaking (p < 0·001), with compliance before child contact 90% (140/155); after child contact 78% (89/114); after body fluid exposure 75% (3/4); and after surroundings contact 36% (15/42). For healthcare workers and visitors, there was no evidence of an association between time of day and their hand hygiene compliance, and for visitors to the oncology ward, hand hygiene compliance was higher (p < 0·05).

CONCLUSION

Owing to the nature of the clinical environments, we are unable to draw conclusions about children's hand hygiene compliance; however, visitors' compliance was low. Among healthcare workers, levels of compliance were higher compared with previous reported estimates.

RELEVANCE TO CLINICAL PRACTICE

Visitors had the lowest level of compliance yet owing to the nature of the clinical environments, nearly a quarter of care is delivered by them rather than healthcare workers, and so, this offers opportunities for specific future interventions aimed at families and carers.

Glow gel hand washing in the waiting room: a novel approach to improving hand hygiene education

OBJECTIVES

To characterize handwashing behaviors of children and assess the efficacy of a waiting room-based hand hygiene intervention at improving handwashing ability.

DESIGN

Prospective randomized pilot study.

SETTING

Emergency department waiting room at a freestanding urban pediatric hospital.

PARTICIPANTS

Children (8-18 years) and their parent.

INTERVENTION

Participants were randomized to glow gel hand washing without hand hygiene education or glow gel hand washing with hand hygiene education. After participants washed with glow gel, "dirty areas" were illuminated using a black light, and hands were scored. A questionnaire about handwashing behavior was administered. All subjects returned 2-4 weeks after intervention to repeat glow gel hand washing and the questionnaire.

RESULTS

Sixty pediatric patients and 57 parents were recruited, with 77% of patients returning for follow up. Patients were 50% male, 58% Latino, 28% African American, and 8% Caucasian. At the initial visit, 91% of children reported hand washing after using the bathroom and 78% reported hand washing before dinner. On the basis of objective scoring, all children improved handwashing ability when compared with the initial visit (P = .02) and were more likely to use warm water at follow up (P = .01). Parents did not significantly improve in handwashing ability (P = .73).

CONCLUSION

Glow gel hand washing is an effective method to improve children's handwashing ability. This short-term intervention was effective even in the absence of specific hand hygiene education. This intervention could serve as a valuable public health measure to teach hand washing in healthcare settings.

A review of gastrointestinal outbreaks in schools: effective infection control interventions

BACKGROUND

The purpose of this study was to review documented outbreaks of gastrointestinal illness in schools, published in the last 10 years, to identify etiology, mode of transmission, the number of children affected, morbidity and mortality patterns, and interventions for control and prevention.

METHODS

Searches of electronic databases, public health publications, and federal, state, and provincial public health Web sites were completed.

RESULTS

Of the 121 outbreaks that met the inclusion criteria, 51% were bacterial, 40% viral, 7% were from Cryptosporidium, and 2% from multiple organisms. Transmission routes recorded in 101 reports included foodborne (45%), person-to-person (16%), waterborne (12%), and animal contact (11%). Actions to control outbreaks included alerting medical and public health authorities or the community to the outbreak (13%), treating cases (12%), enhancing hand washing (11%), and increased vigilance during food preparation (8%). Recommendations to prevent future outbreaks were compared with previously published studies that demonstrated effectiveness.

CONCLUSIONS

The risk of foodborne illness was reduced when food handlers practiced effective hand washing technique and received food safety training and certification. Student training programs on hand hygiene, enhanced cleaning and disinfection of the school, and hepatitis A vaccination were found effective. Children should be supervised on farm visits, hand washing strictly enforced, and food eaten in an area separated from the animals. Staff and students should have a positive, continuous communication with public health authorities including educational sessions and immediate reporting of possible outbreaks.

Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 11. Use of antiseptics and sanitizers in community settings and issues of hand hygiene compliance in health care and food industries

Hand washing with soap is a practice that has long been recognized as a major barrier to the spread of disease in food production, preparation, and service and in health care settings, including hospitals, child care centers, and elder care facilities. Many of these settings present multiple opportunities for spread of pathogens within at-risk populations, and extra vigilance must be applied. Unfortunately, hand hygiene is not always carried out effectively, and both enteric and respiratory diseases are easily spread in these environments. Where water is limited or frequent hand hygiene is required on a daily basis, such as for many patients in hospitals and astronauts in space travel, instant sanitizers or sanitary wipes are thought to be an effective way of preventing contamination and spread of organisms among coworkers and others. Most concerns regarding compliance are associated with the health care field, but the food industry also must be considered. Specific reasons for not washing hands at appropriate times are laziness, time pressure, inadequate facilities and supplies, lack of accountability, and lack of involvement by companies, managers, and workers in supporting proper hand washing. To facilitate improvements in hand hygiene, measurement of compliant and noncompliant actions is necessary before implementing any procedural changes. Training alone is not sufficient for long-lasting improvement. Multiactivity strategies also must include modification of the organization culture to encourage safe hygienic practices, motivation of employees willing to use peer pressure on noncompliant coworkers, a reward and/or penalty system, and an operational design that facilitates regular hand hygiene.

Teachers' risk perception and needs in addressing infectious disease outbreak

The outbreak of the Influenza A (H1N1) virus has led to numerous precautionary school closures in several countries. No research is available on the school teachers' perceptions as a health protective resource in controlling communicable disease outbreaks. The purposes of this study were to examine the risk perception, the perceived understanding of preventive measures and contingency plans, and the needs of school teachers before the imminent outbreak of H1N1. This survey was conducted with 1,169 Hong Kong school teachers before school closures due to the H1N1 outbreak. The results showed that the teachers were well aware of H1N1 but were still worried about the spread of H1N1 infection. The teachers' worries depended on their psychological reaction, the adequacy of the control measures, government support in providing infectious disease knowledge, perceived understanding of preventive measures and contingency plans, students and parents' awareness, and the need for support from health professionals.