Hand Hygiene Education Components Among First-Year Nursing Students: A Cluster Randomized Clinical Trial

Importance

Few studies have directly and objectively measured the individual and combined effects of multifaceted hand hygiene education programs.

Objective

To evaluate the individual and combined immediate effects of an instructional video and hand scan images on handwashing quality, decontamination, and knowledge improvement.

Design, Setting, and Participants

This cluster randomized clinical trial was conducted in June to July 2023 among first-year nursing students at a university in Hong Kong. The study used an intention-to-treat analysis.

Intervention

Hand hygiene education sessions featuring an instructional video, hand scan images, or both.

Main Outcomes and Measures

The primary outcome was the change in residue from fluorescent lotion remaining on participants' hands after handwashing before and after the intervention. The secondary outcomes included handwashing quality and knowledge of hand hygiene.

Results

A total of 270 of 280 students (mean [SD] age, 19 [1] years; 182 [67.4%] female) participated in the trial (96.4% participation rate). Participants were randomized to a control group (66 participants), hand scan image group (68 participants), instructional video group (67 participants), and hand scan image with instructional video group (69 participants). All intervention groups had greater reductions in residue after the intervention compared with the control group, although none reached statistical significance (hand scan image group: 3.9 [95% CI, 2.0-5.8] percentage points; instructional video group: 4.8 [95% CI, 2.9-6.7] percentage points; hand scan image with instructional video: 3.5 [95% CI, 1.6-5.4] percentage points; control group: 3.2 [95% CI, 1.3-5.2] percentage points). The instructional video group showed a significant improvement in their handwashing performance, with a higher percentage of participants correctly performing all 7 steps compared with the control group (22.4% [95% CI, 13.1% to 31.6%] vs 1.5% [-7.9% to 10.9%]; P < .001). Hand scan images revealed that wrists, fingertips, and finger webs were the most commonly ignored areas in handwashing.

Conclusions and Relevance

In this cluster randomized clinical trial of an education program for hand hygiene, a handwashing instructional video and hand scan images did not enhance the level of decontamination. The intervention group had improved handwashing techniques compared with the control group, a secondary outcome.

Trial Registration

ClinicalTrials.gov Identifier: NCT05872581.

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.

Playful activity with robot for hand hygiene of elementary school students: quasi-experimental study

OBJECTIVE

To evaluate the effectiveness of the hand hygiene process after elementary school students participated in an educational activity using an automated digital technology called Tutor Robot.

METHOD

Quasi-experimental study developed in 2019 with elementary school students (n=203). Hand hygiene was performed with a fluorescent solution before and after participating in an educational activity with a tutor robot. The images were recorded in a dark chamber and the data related to area of residence, grade, gender, hand position and laterality were analyzed by Anova and Holm-Sidak Post-Hoc (p≤0,05).

RESULTS

All conditions studied improved the hand hygiene process after activity with the tutor robot. There was no association between grade, gender, and dominant hand and the performance in the hand hygiene process, however, students from urban areas performed better than those from rural areas.

CONCLUSION

The activity with the tutor robot represented an important resource for conducting health education actions on hand hygiene and can also be tested in other settings and populations.

Duration or technique to improve the effectiveness of children' hand hygiene: A randomized controlled trial

BACKGROUND

How to wash hands is as important as when and how often to wash hands for acquiring proper hand hygiene habits.

METHODS

The study aimed to compare the effect of education based on technique or duration for developing children's handwashing skills. The double-blind randomized controlled study was conducted in a primary school between the 10th and 28th of December, 2018 with 155 children who were divided into Group-I, Group-II, and Control groups. One group was taught by a multi-stage technique, the other was by duration-based teaching, and the control group was provided with usual training. Handwashing efficacy was assessed by variance analysis on fluorescent residue after using glo-germ.

RESULTS

The students' mean age was 9.74 ± 0.69 years, 53.6% of them were girls. Effective handwashing was highest in the Group-I. There was a difference between Group-I and Group-II, and Group-I and Control group in terms of hand cleanness. The frequently missed areas when cleaning hands were palmar surface, dorsal metacarpal area, and fingertips.

CONCLUSIONS

Teaching hand hygiene to children by multi-step technique may increase the handwashing effectiveness. Conducting comparative studies with new techniques including fewer stages is recommended.

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.

Hand-washing promotion for preventing diarrhoea

BACKGROUND

Diarrhoea accounts for 1.8 million deaths in children in low- and middle-income countries (LMICs). One of the identified strategies to prevent diarrhoea is hand washing.

OBJECTIVES

To assess the effects of hand-washing promotion interventions on diarrhoeal episodes in children and adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, nine other databases, the World Health Organization (WHO) International Clinical Trial Registry Platform (ICTRP), and metaRegister of Controlled Trials (mRCT) on 8 January 2020, together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

Individually-randomized controlled trials (RCTs) and cluster-RCTs that compared the effects of hand-washing interventions on diarrhoea episodes in children and adults with no intervention.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial eligibility, extracted data, and assessed risks of bias. We stratified the analyses for child day-care centres or schools, community, and hospital-based settings. Where appropriate, we pooled incidence rate ratios (IRRs) using the generic inverse variance method and a random-effects model with a 95% confidence interval (CI). We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 29 RCTs: 13 trials from child day-care centres or schools in mainly high-income countries (54,471 participants), 15 community-based trials in LMICs (29,347 participants), and one hospital-based trial among people with AIDS in a high-income country (148 participants). All the trials and follow-up assessments were of short-term duration. Hand-washing promotion (education activities, sometimes with provision of soap) at child day-care facilities or schools prevent around one-third of diarrhoea episodes in high-income countries (incidence rate ratio (IRR) 0.70, 95% CI 0.58 to 0.85; 9 trials, 4664 participants, high-certainty evidence) and may prevent a similar proportion in LMICs, but only two trials from urban Egypt and Kenya have evaluated this (IRR 0.66, 95% CI 0.43 to 0.99; 2 trials, 45,380 participants; low-certainty evidence). Only four trials reported measures of behaviour change, and the methods of data collection were susceptible to bias. In one trial from the USA hand-washing behaviour was reported to improve; and in the trial from Kenya that provided free soap, hand washing did not increase, but soap use did (data not pooled; 3 trials, 1845 participants; low-certainty evidence). Hand-washing promotion among communities in LMICs probably prevents around one-quarter of diarrhoea episodes (IRR 0.71, 95% CI 0.62 to 0.81; 9 trials, 15,950 participants; moderate-certainty evidence). However, six of these nine trials were from Asian settings, with only one trial from South America and two trials from sub-Saharan Africa. In seven trials, soap was provided free alongside hand-washing education, and the overall average effect size was larger than in the two trials which did not provide soap (soap provided: RR 0.66, 95% CI 0.58 to 0.75; 7 trials, 12,646 participants; education only: RR 0.84, 95% CI 0.67 to 1.05; 2 trials, 3304 participants). There was increased hand washing at major prompts (before eating or cooking, after visiting the toilet, or cleaning the baby's bottom) and increased compliance with hand-hygiene procedure (behavioural outcome) in the intervention groups compared with the control in community trials (data not pooled: 4 trials, 3591 participants; high-certainty evidence). Hand-washing promotion for the one trial conducted in a hospital among a high-risk population showed significant reduction in mean episodes of diarrhoea (1.68 fewer) in the intervention group (mean difference -1.68, 95% CI -1.93 to -1.43; 1 trial, 148 participants; moderate-certainty evidence). Hand-washing frequency increased to seven times a day in the intervention group versus three times a day in the control arm in this hospital trial (1 trial, 148 participants; moderate-certainty evidence). We found no trials evaluating the effects of hand-washing promotions on diarrhoea-related deaths or cost effectiveness.

AUTHORS' CONCLUSIONS

Hand-washing promotion probably reduces diarrhoea episodes in both child day-care centres in high-income countries and among communities living in LMICs by about 30%. The included trials do not provide evidence about the long-term impact of the interventions.

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.

Hand Hygiene Practices Among Adults with Diabetes Living in Communities: The 2015 Korea Community Health Survey

Hand hygiene is the most effective strategy to prevent infectious diseases. This study investigated and compared the hand hygiene practices of adults with diabetes and an age- and gender-matched comparison group. Adults with diabetes (n = 22,920) who participated in the 2015 Korea Community Health Survey and an appropriate comparison group (n = 22,920) were selected. Descriptive analyses, chi-square tests, and multiple logistic regression analyses were used. Greater than 98% of participants with diabetes recognized that hand hygiene helps prevent infectious diseases. Among participants with diabetes, 84.3%, 82.4%, 72.5%, and 64.1% washed their hands frequently before eating, after using the restroom, after returning from the outdoors, and with soap or hand sanitizer, respectively, but these values were significantly lower than those of the comparison group. After performing multiple regression analyses, treatments for diabetes, being educated about diabetes management and handwashing, and awareness of hemoglobin A1c levels were significantly associated with hand hygiene practices in participants with diabetes. Almost all people with diabetes were aware of the efficacy of hand hygiene, but handwashing rates were significantly lower in people with diabetes than in the comparison group. Considering treatments for diabetes, educational campaigns regarding handwashing, and increasing awareness of handwashing efficacy will help improve hand hygiene in people with diabetes.