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Mandatory handwashing in elementary schools reduces absenteeism due to infectious illness among pupils: A pilot intervention study
Abstract
The objective of this study was to determine the effect of mandatory, scheduled handwashing on actual absenteeism due to infectious illness in elementary school pupils in Denmark.
A 3-month pilot intervention study, randomized between 2 schools, was performed on 652 pupils age 5 to 15 years. The pupils at the intervention school (IS; n=290) were required to wash their hands before the first lesson, before lunch, and before going home. Those at the control school (CS; n=362) continued their usual handwashing practices. All absences due to illness were recorded, and data were analyzed statistically.
Multivariate analysis demonstrated a significantly reduced rate of absenteeism for the IS compared with the CS (P=.002). For girls, the rate was 1.05 periods (95% confidence interval [CI]=0.90 to 1.22) for the IS versus 1.35 (95% CI=1.26 to 1.44) for the CS. For boys, these rates were 0.87 (95% CI=0.72 to 1.05) and 1.12 (95% CI=0.92 to 1.36). An alternative approach demonstrated that the odds ratio for absence was 0.69 (95% CI=0.52 to 0.92) for the IS compared with the CS.
This study suggests that handwashing could be an effective tool to reduce absences due to infectious illness in elementary school pupils. A school policy regarding hand hygiene and teaching of hand hygiene is warranted.
... Two studies clustered by class (White et al. 2001) or 'teams' of classes (Sandora et al. 2008). All other studies clustered by school (Ladegaard and Stage 1999;Nandrup-Bus 2009;Prazuck et al. 2010;Stebbins et al. 2011;Azor-Martínez et al. 2014;Priest et al. 2015;Azor-Martinez et al. 2016;Alzaher et al. 2018). ...
... All studies included children across multiple ages or school years. The age range of four studies extended beyond the age range (White et al. 2001;Nandrup-Bus 2009;Azor-Martínez et al. 2014Alzaher et al. 2018). ...
... Eight of the studies were carried out in schools (White et al. 2001;Sandora et al. 2008;Nandrup-Bus 2009;Prazuck et al. 2010;Stebbins et al. 2011;Azor-Martínez et al. 2014;Priest et al. 2015;Azor-Martinez et al. 2016;Alzaher et al. 2018) and one took place in a day care centre (Ladegaard and Stage 1999). ...
Aim
Control of infection is important to prevent school absence. We aimed to review hand-hygiene interventions in high income countries aiming to reduce gastrointestinal and upper-respiratory tract infection-related absence in educational settings, and identify which intervention components are effective.
Subject and methods
A systematic review and meta-analysis. Interventions were coded according to Behaviour Change Techniques Taxonomy. We searched MEDLINE, Embase, CINAHL, Cochrane Library, Education Resource Information Centre, Science and Social Sciences Citation Index and the British Education Index from 1 September 2014 to 25 May 2022, papers included in a 2014 review by Willmott et al., and hand-searching reference lists of included studies. We also searched for, and coded, relevant international guidelines on hand-hygiene.
Results
We screened 1653 papers, including 11 papers from 9 studies. Meta-analysis showed that school-based interventions significantly reduced respiratory tract and gastrointestinal infection-related absence (relative rate ratio 0.754; 95% confidence interval 0.602 to 0.944). Evidence from subgroup analysis supports the use of more than seven behaviour change techniques, targeting both adults and children, and providing information on the risks of inadequate hand-hygiene as well as instruction. The effectiveness of individual behaviour change techniques could not be determined. We found no evidence to support the interventions currently recommended in a range of international guidelines.
Conclusion
School-based hand-hygiene interventions are effective in reducing infection-related absence. There is some evidence that the number and type of behaviour change techniques used in interventions is important in increasing intervention success.
... To what extent … Acceptability …is the intervention judged to be acceptable by all key stakeholders Practicability …can the intervention be delivered as intended at the scale intended and in the context intended Effectiveness …will the intervention deliver the desired outcome in the target population Affordability …can the intervention be afforded within an acceptable budget Spill-over effects …is the intervention likely to have additional negative or positive consequences Equity …is the intervention likely to increase or decrease inequalities in society Studies were conducted in the United States (13/39; 33%) (Aiello et al., 2010a(Aiello et al., , 2012Arbogast et al., 2016a;Azman et al., 2013;Koep et al., 2016;Larson et al., 2009Larson et al., , 2010Mott et al., 2007;Sandora et al., 2005a;Stebbins et al., 2010;Stedman-Smith et al., 2015a;Updegraff et al., 2011;White et al., 2003), China (5/39; 13%) (Chan et al., 2007;B J Cowling et al., 2009; Benjamin J. Cowling et al., 2008;Liu et al., 2019;Or et al., 2020), Germany (3/39; 13%) (Hübner et al., 2010a;T Suess et al., 2011;Thorsten Suess et al., 2012), Thailand (3/39; 13%) (Apisarnthanarak et al., 2009;Kaewchana et al., 2012;Simmerman et al., 2011b), Australia (2/39; 5%) (MacIntyre et al., 2009;Roberts et al., 2000a), Denmark (2/39; 5%) (Bundgaard et al., 2020;Nandrup-Bus, 2009a), Spain (2/39; 5%) (Azor-Martinez et al., 2016a, 2018a, the United Kingdom (2/39; 5%) (Little et al., 2014;Yardley et al., 2011), with one study each in Australia/Saudi Arabia (Barasheed et al., 2014a), Bangladesh (Ram et al., 2015), Costa Rica (Reyes Fernández et al., 2015a), Finland (Savolainen-Kopra et al., 2012a), France (Canini et al., 2010), the Netherlands (Zomer et al., 2016), and Turkey (Öncü et al., 2019) (see Table 2). ...
... Fourteen studies reported on the acceptability of interventions. Indicators assessed included mask comfort (Aiello et al., 2012;Barasheed et al., 2014a;Canini et al., 2010;MacIntyre et al., 2009;T Suess et al., 2011;Thorsten Suess et al., 2012), skin problems/irritation (Azor-Martinez et al., 2016a, 2018aLittle et al., 2014;Nandrup-Bus, 2009a;Sandora et al., 2005a), adverse events (Benjamin J. Cowling et al., 2008), liking/positive impressions (Arbogast et al., 2016a) and ease of understanding (Updegraff et al., 2011), with a small number of participants experiencing discomfort or irritation in the majority of studies that reported these outcomes (see Table 4). ...
... Overall, the 30 studies pertaining to hand hygiene behaviours (including hand washing and/or hand sanitizer/soap use) had positive results, with 19 studies reporting positive effects (Aiello et al., 2010b(Aiello et al., , 2012Apisarnthanarak et al., 2009;Arbogast et al., 2016a;Chan et al., 2007;Benjamin J. Cowling et al., 2008;Kaewchana et al., 2012;Larson et al., 2009;Liu et al., 2019;Mott et al., 2007;Öncü et al., 2019;Or et al., 2020;Simmerman et al., 2011b;Stebbins et al., 2010;T Suess et al., 2011;Updegraff et al., 2011;White et al., 2003;Yardley et al., 2011;Zomer et al., 2016), three studies reporting negative effects (Aiello et al., 2010b;Larson et al., 2009;Mott et al., 2007), six studies reporting no difference (Aiello et al., 2012;B J Cowling et al., 2009;Koep et al., 2016;Larson et al., 2010;Reyes Fernández et al., 2015a;Stedman-Smith et al., 2015a) and six studies with indeterminate results (Hübner et al., 2010a;Nandrup-Bus, 2009a;Ram et al., 2015;Roberts et al., 2000a;Sandora et al., 2005a;Savolainen-Kopra et al., 2012a) (see Figure 4). It should be noted that some studies reported more than one hand hygiene outcome (e.g. ...
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 synthesise evidence on interventions to increase six personal protective behaviours (e.g. hand hygiene, face mask use) 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 from published intervention descriptions on study design, intervention content, delivery mode, 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_=0.62, 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 hand hygiene interventions, with unclear results for face mask use interventions. There was a lack of evidence for interventions targeting most behaviours of interest within this review.
... Fourteen studies reported on the acceptability of interventions. Indicators assessed included mask comfort (Aiello et al., 2012;Barasheed et al., 2014;Canini et al., 2010;MacIntyre et al., 2009;Suess et al., 2011Suess et al., , 2012, skin problems/irritation (Azor-Martinez et al., 2016, 2018Little et al., 2015;Nandrup-Bus, 2009;Sandora et al., 2005), adverse events (Cowling et al., 2008), liking/positive impressions (Arbogast et al., 2016), and ease of understanding (Updegraff et al., 2011), with a small number of participants experiencing discomfort or irritation in the majority of studies that reported these outcomes (see Table 4). ...
... Overall, the 30 studies pertaining to hand hygiene behaviours (including hand washing and/or hand sanitizer/soap use) had positive results, with 19 studies reporting positive effects (Aiello et al., 2010(Aiello et al., , 2012Apisarnthanarak et al., 2009;Arbogast et al., 2016;Chan et al., 2007;Cowling et al., 2008;Kaewchana et al., 2012;Larson et al., 2009;Liu et al., 2019;Mott et al., 2007;€ Onc€ u et al., 2019;Simmerman et al., 2011;Stebbins et al., 2010;Suess et al., 2011;Updegraff et al., 2011;White et al., 2003;Yardley et al., 2011;Zomer et al., 2016), three studies reporting negative effects (Aiello et al., 2010;Larson et al., 2009;Mott et al., 2007), six studies reporting no difference (Aiello et al., 2012;;Cowling et al., 2009;Koep et al., 2016;Larson et al., 2010;Reyes Fern andez et al., 2015;Stedman-Smith et al., 2015), and six studies with indeterminate results (H€ ubner et al., 2010;Nandrup-Bus, 2009;Ram et al., 2015;Roberts et al., 2000;Sandora et al., 2005;Savolainen-Kopra et al., 2012) (see Figure 4). It should be noted that some studies reported more than one hand hygiene outcome (e.g., hand washing and hand sanitizer use). ...
... Studies were conducted in the United States (13/39; 33%) (Aiello et al., 2010(Aiello et al., , 2012Arbogast et al., 2016;Azman et al., 2013; Koep et al., 2016;Larson, Ferng, McLoughlin, Wang, & Morse, 2009;Larson et al., 2010;Mott et al., 2007;Sandora et al., 2005;Stebbins, Stark, & Vukotich, 2010;Stedman-Smith et al., 2015;Updegraff, Emanuel, Gallagher, & Steinman, 2011;White, Kolble, Carlson, Lipson, & Dolan, 2003), China (5/39; 13%) (Chan, So, Wong, Lee, & Tiwari, 2007; Cowling et al., 2008 Cowling et al., , 2009 Liu et al., 2019;Or, Ching, & Chung, 2020), Germany (3/39; 13%) (H€ ubner, H€ ubner, Wodny, Kampf, & Kramer, 2010;Suess et al., 2011Suess et al., , 2012, Thailand (3/39; 13%) (Apisarnthanarak, Apisarnthanarak, Cheevakumjorn, & Mundy, 2009;Kaewchana et al., 2012; Simmerman et al., 2011), Australia (2/39; 5%) (MacIntyre et al., 2009;Roberts et al., 2000), Denmark (2/39; 5%) (Bundgaard et al., 2020;Nandrup-Bus, 2009), Spain (2/39; 5%) (Azor-Martinez et al., 2016, 2018, and the United Kingdom (2/39; 5%) (Little et al., 2015;Yardley, Miller, Schlotz, & Little, 2011), with one study each in Australia/Saudi Arabia (Barasheed et al., 2014), Bangladesh (Ram et al., 2015), ...
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.
... Several hand hygiene interventions have said to reduce the number of infectious illnesses among schoolchildren in school settings of developed countries, but none of these studies are adequately sized or designed for firm scientific conclusions to be made. [8][9][10][11][12][13][14][15][16][17][18][19] We are aware of only one large randomized controlled trial (RCT) involving 68 primary schools in New Zealand. 20 The study found no effect of hand sanitizer in reducing the incidence rate of absence episodes due to any illnesses in schoolchildren, dur- ing the winter season. ...
... Our results are also contradicting previous school-based hand hygiene interventions in high-income countries reporting to reduce infectious illness among schoolchildren. [8][9][10][11][12][13][14][15][16][17][18][19] These studies are smaller (fewer participants), comprise fewer schools (7 stud- ies involved 1 or 2 schools, 3 studies involved 3-5 schools and 2 studies involved up to 16 schools) and conduct analyses at the individual level-that is, not using multilevel modeling in the anal- ysis. Seven of the 12 studies used sanitizers or complemented hand wash with sanitizers rather than promoting hand wash with soap and water. ...
... 8,9,11,13,[15][16][17][18] The Hi Five intervention was inspired by these studies, especially the Danish study by Nandrup-Bus. 14 However, when expanding interventions from 1 school to 28 schools, imple- mentation processes increase in complexity. 29 We carefully consid- ered barriers and promoters identified by other studies. ...
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 multi-component intervention to improve hand washing 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 (ORI-arm I: 0.91 (0.77-1.07) & ORI-arm II: 0.94 (0.79-1.12)) and illness episodes (ORI-arm I: 0.95 (0.81-1.11) & ORI-arm II: 0.98 (0.84-1.16)) or in reporting illness-related absenteeism(OR I-arm I : 1.09 (0.83-1.43) & ORI-arm II: 1.06 (0.81-1.40)).
Conclusions:
The multi component 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 hand washing before lunch, was only implemented by 1/3 of teachers in intervention schools.
... Of the 19 eligible studies (all published between 1996 and 2014), 12 were conducted in the United States [19][20][21][22][23][24][25][26][27][28][29][30] and the remaining 7 were conducted in Denmark (n = 2), 31,32 China (n = 1), 33 Egypt (n = 1), 34 New Zealand (n = 1), 35 Spain (n = 1), 36 or Thailand (n = 1). 37 Ten studies were cluster-randomized controlled trials [19][20][21]26,[32][33][34][35][36][37] ; 7 used a nonrandomized design, 22,25,27-31 and 2 used a crossover design. 23,24 The range of study sample sizes was wide-199-44,451 students and 1-87 elementary schools. ...
... One study included younger students (ages 2-6 years) 37 and 3 included older students (ages 6 through 14 years and ages 5-15 years). 19,31,32 Quality assessment Because Downs and Black 17 do not report a method to classify good from poor studies, we used the method suggested by Gorber et al. 38 These authors used the median of the quality scores generated using the Downs and Black checklist to classify studies as "higher" or "lower" quality. The median quality score of studies in our sample was 18 (range, 10-20) of a possible high score of 28 ( Table 2). ...
... The median quality score of studies in our sample was 18 (range, 10-20) of a possible high score of 28 ( Table 2). As expected, the 10 cluster randomized-controlled studies had higher quality scores (score, 17-25) [19][20][21]26,[32][33][34][35][36][37] than those that did not use randomization (score, 10-18). [22][23][24][25][27][28][29][30][31] All studies had weaknesses in the reported study design, with 5 weaknesses common across most studies. ...
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.
... The attitude of the child's parents is of great importance in achieving risk factor changes (Guzmán-Armstrong, 2005). Teachers' and principals' acting as role models could have a significant impact especially for these children who have observed incorrect attitudes from their parents (Nandrup-Bus, 2009). Girls had a better level of knowledge both at pre-and post-test, and the training did not alter this gender difference. ...
... As in other studies evaluating absenteeism as an outcome (Meadows and Le Saux, 2004;Nandrup-Bus, 2009). This study found a significant reduction in students' absenteeism. ...
z Giriş: Hijyen enfeksiyonların gelişimini önlemede önemli bir unsurdur. Amaç: Bu araştırma, Bayraklı, İzmir'de ilköğretim okullarında verilen kapsamlı bir hijyen eğitiminin öğrencilerin bilgi düzeyine ve okul devamsızlığına etkisini değerlendirmek amacıyla yapılmıştır. Yöntem: Tek grup ön test-son test deseninde bir eğitim müdahalesi çalışmasıdır. Yapılan eğitimin bilgi düzeyine ve devamsızlığa etkisi incelenmiştir. Eğitim öncesi uygulanan ve 20 bilgi sorusu içeren ön-testin ardından, araştırmacılar Sağlık Bakanlığı tarafından hazırlanan hijyen eğitimi materyalini kullanarak 2010 bahar yarıyılında öğrencilere eğitim yapmışlardır. Üç ay sonra 584 öğrenciye son-test uygulanmış ve ön-testle karşılaştırılmıştır. Ayrıca öğrencilerin 2009 ve 2010 güz yarıyılı devamsızlıkları karşılaştırılmıştır. Verilerin analizinde ki-kare, McNemar ve bağımlı gruplarda t testleri kullanılmıştır. Bulgular: Öğrencilerin ortalama bilgi puanları anlamlı olarak yükselmiştir (pre-test: 7.59 ± 2.57, post-test: 12.36 ± 2.38, p =.000, her iki test de 20 üzerinden değerlendirilmiştir). Devamsızlık oranı 2009 güz yarıyılında %3.18 günden (%95 GA 3.03-3.34) 2010 güz yarıyılında %2.83 güne (%95 CI 2.69-2.98) düşmüştür ve %11 azalmıştır. Eğitim öncesinde ortalama bilgi puanları, öğrencilerin yaş, sosyal güvence ve aile tipine göre anlamlı farklılık gösterirken eğitim sonrası puanlar, bu etmenlerden bağımsızdır ve eğitimin öğrenciler arasındaki bilgi eşitsizliklerini azalttığını göstermektedir. Sonuç: Eğitimin öğrencilerin bilgi düzeyleri ve devamsızlıkları üzerinde önemli etkisi olmuştur. Bu değişimler, yapılandırılmış bir eğitim müdahalesinin, okul ortamında bulaşıcı hastalıkları kontrol etmeye yönelik etkili bir ilk adım olabileceğini düşündürmektedir. Anahtar Sözcükler: Okul Sağlığı, Eğitim, Öğrenci, Devamsızlık, Enfeksiyon Kontrolü. Abtract The Impact of Hygiene Training on Students' Level of Knowledge and School Absenteeism Background: Hygiene is a key element in preventing the development of infections. Objectives: This study aimed to evaluate the effects of a comprehensive hygiene training program on students' level of knowledge and absenteeism among primary schools in Bayraklı, Izmir. Methods: This study involves an educational intervention in the form of a one-group pretest-posttest design. The impact of the training was evaluated by comparing level of knowledge and absenteeism. Following a pre-test including 20 knowledge questions on hygiene, researchers conducted hygiene instruction using an education toolkit prepared by the Ministry of Health. A post-test was given to 584 students three months post-instruction. Chi-square, McNemar's and dependent samples t tests were used to analyse the data. Results: Students' mean knowledge scores significantly increased (pre-test: 7.59 ± 2.57, post-test: 12.36 ± 2.38, p =.001). Absenteeism rate per 100 student-days decreased significantly from 3.18 (95% CI 3.03-3.34) in the Fall 2009 semester to 2.83 (95% CI 2.69-2.98) in the Fall 2010 semester and this decrease corresponded to a 11.0% reduction in absenteeism. Before the training, students' mean scores on hygiene significantly differed according to their age, social security and family type, while post-test scores were independent of these determinants. Conclusion: The training had a significant impact on students' level of knowledge and absenteeism. These changes suggest that a structured educational intervention can be an effective first step in a controlling communicable disease in the school setting.
... Hand washing with soap is the most cost-effective intervention and when applied at critical times such as before meal preparation and eating, and after toilet use, reduces diarrhoea rates [20]. Hand washing with soap can reduce incidences of acute respiratory infections and pneumonia, control of pandemic respiratory infection outbreaks [21], and reduce absenteeism among primary school children [22]. ...
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.
... HWWS interventions that reduce the transmission of diarrhoeal disease and ARIs among older children not only leads to lower rates of morbidity and mortality but also to non-health benefits such as reductions in rates of school absence, [8][9][10][11][12] and consequently to higher academic attainment, 13 14 and associated economic and health benefits later in life. 15 After receiving HWWS interventions, older children may also act as agents of change, spreading these messages to their family members and the broader community. ...
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.
... Nearly 80% of the world's communicable diseases are transmitted by a mere touch of unhygienic hands [6]. Globally about 400 million children are infected with worms which causes malnutrition and impaired learning capacity [7]. In Ethiopia, more than 250,000 children die annually from sanitation and hygienerelated diseases. ...
... 8 Improving HWWS among older children has significant public health potential. Not only does HWWS reduce disease transmission, but it is also associated with reduced rates of school absenteeism, [9][10][11][12][13] which may lead to improved academic attainment 14,15 and associated economic and health benefits later in life. 16 Keeping children in school is also important for access to vaccination and nutrition programs, access to mental health and psychosocial support services, and child protection risks. ...
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.
... Therefore, to protect the health and well-being of children, it is important to prevent infectious diseases such as diarrhea, pneumonia, and other communicable diseases (13,14). However, about 400 million children are infected with worms as a result of poor hand washing practices (15). ...
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.
... Furthermore, our results suggest that hygiene education could be more beneficial when it is used in conjunction with other intervention components, such as strengthening teachers' engagement in hygiene-related initiatives both within and outside classroom, and developing interactive teaching methods that promote personal hygiene (e.g., handmade soap-making class, exercises involving dining table etiquette). We posit that these and similar school programs [38][39][40] 8 would increase the likelihood that students would develop beneficial attitudes toward hand hygiene, and would gain greater appreciation of its role in personal and community health [12]. ...
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.
... The importance of handwashing as a basic infection control practice is made evident during the COVID19 pandemic given the possible contact transmission of microorganisms (Edmonds-Wilson et al., 2015). Effective handwashing practices can reduce the spread of antibiotic resistant infections within hospitals (Larson et al., 2000), decrease community risk to diarrhea (Curtis & Cairncross, 2003), and reduce absenteeism rates due to infectious illness in elementary schools (Nandrup-Bus, 2009). In times of infectious disease outbreak, handwashing is an individual's first line of defense against contagions (CDC, 2020), and is especially important for healthcare workers (Alzyood et al., 2020). ...
Handwashing is a basic infection control practice that needs to be performed correctly to be effective. In the ongoing COVID-19 pandemic, its correct practice is emphasized by public health institutions. However, turning a practice into a habit requires acceptance for adoption of the twenty-second proper procedure to which difficulty remains. To promote and convince the average user, we developed the “APD Handwash app” as a home-use demonstration/education tool to the pitfalls and need of proper handwashing practices through the detection of assigned clean or dirty areas on the hand in a quantitative manner to provide a gauge to the effectiveness of washing when used before and after washing.
... School attendance registers offer a novel dataset which could be used to provide more timely information regarding infectious disease and outbreaks amongst children [22]. Children are commonly affected by gastrointestinal illness and respiratory illness, both of which are key causes of illness absence from school [23][24][25][26]. Children are recognised as important transmitters of infection, [27][28][29][30] and schools are principal settings in the spread of infections between children [29,31]. ...
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.
... Nell'ambito della diffusione delle malattie infettive, in particolare, interventi di educazione al corretto lavaggio delle mani. Studi hanno dimostrato, infatti, che il lavaggio delle mani nel setting scolastico, riduce le malattie infettive, in particolare quelle a trasmissione respiratoria e oro-fecale, oltre che ridurre l'assenteismo per malattia negli studenti e nello staff scolastico (Nandrup-Bus, 2009;Guinan, McGuckin, & Ali 2002). Studi, inoltre hanno dimostrato che controlli periodici da parte degli infermieri scolastici della presenza del materiale per l'igiene delle mani, con eventuale segnalazione ai funzionari scolastici, migliorano la disponibilità di tale materiale, con la conseguente possibilità, da parte di studenti e inseganti di lavare correttamente le mani (Ramos, Schrader, Trujillo, Blea, & Greenberg 2011). ...
Introduction:
School nurse is present today in many countries around the world. Its contribution within schools is described in the literature especially with regard to the management of chronic diseases and health education interventions. The Sars-CoV2 pandemic has forced many states to close schools, involving major psycho-social problems. The reopening of schools is a great challenge, in this regard this work has the goal of evaluating the literature that identifies the figure of the school nurse as a strength in containing the spread of contagious diseases and the actions that can be effective for this purpose.
Methods:
An integrative literature review was conducted by interrogating the main international medical-nursing databases, all research articles were included, editorials and letters were excluded. Results were screened independently by two investigators.
Results:
10 articles were included, the main purpose of which was to describe outbreak cases and strategies for their management. The major nursing interventions highlighted are surveillance, case reporting, education, management of relationships with families, collaboration with other professionals.
Discussion:
Although the identified literature was quantitatively poor, it is clear that the school nurse is central to syndromic surveillance, educational role, decision making, clinical management, collaboration with the team of experts and management of communication.
... Fourteen studies reported on the acceptability of interventions. Indicators assessed included mask comfort 38,52,53,59,66,70 , skin problems/irritation 41,60,62,63,65 , adverse events 49 , liking/positive impressions 36 and ease of understanding 35 , with a small number of participants experiencing discomfort or irritation in the majority of studies that reported these outcomes (see Table 4). ...
PURPOSE: Changing human behaviour is critical for stopping the spread of respiratory viruses, including SARS-CoV-2. This includes increasing personal protective behaviours: we need evidence to inform how to achieve this. We aimed to evaluate the acceptability, practicability, effectiveness, affordability, spill-over effects and equity impact of interventions to increase personal protective behaviours to limit the spread of respiratory viruses. METHODS: We used standard best practice for rapid evidence reviews. We searched Ovid MEDLINE and Scopus to identify interventions designed to change six personal protective behaviours: hand hygiene; avoiding touching the ‘T-Zone’; catching droplets in tissues; face mask use; disinfecting surfaces; and maintaining physical distancing. Primary research studies conducted in adults or children with active or passive comparators were included. 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. Interventions to increase hand hygiene had a medium, positive effect (_d_ = 0.62, 95% CI = 0.43-0.80, _p _< .001, I2 = 81.2%). Interventions targeting face mask use 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 positive effects of interventions targeting hand hygiene, with unclear results for interventions targeting face mask use.
... Similarly, combining appropriate education, personal & community hygiene practices and water treatment, the acute respiratory illness percentage in students, has shown decreasing trends. (8)(9)(10)(11)(12) The target group was students of the age 6 -16 years. The activities emphasized the importance of using soap at critical moments during the day (i.e. ...
... Anaemia and sickness absenteeism from school are critical determinants of cognitive and physical development of children (Baxter et al. 2011, Belachew et al. 2011, Engle et al. 2007, Nandrup-Bus 2009, Neervoort et al. 2013, Walker et al. 2007, Wang et al. 2013. Anaemia is widely prevalent in India, affecting almost 60% of Indian children (aged 6-59 months) in 2015 (International institute For Population Sciences 2017). ...
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.
... Handwashing with soap interrupts the transmission of infectious agents and can reduce the risk of diseases such as diarrhoea and acute respiratory infections by up to 23% and 21%, respectively [1,2]. It has also been linked to the reduction of certain neglected tropical diseases with high disease burden in children, such as trachoma [3] and soil-transmitted helminths [4,5], as well as lead to improvements in school attendance [6][7][8]. ...
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.
... Hand washing with soap is the most straightforward skill the elementary school-age children must have to prevent infectious diseases such as diarrhea, pneumonia, respiratory infections, intestinal worms, measles, etc. 1,2 Infectious diseases are considered to be a significant contributor to global morbidity and mortality in children. School-age children (5-14 years) in Indonesia contribute 1.9% of deaths caused by infectious diseases. ...
Hand washing with soap is the most straightforward skill that elementary school-aged children should have to avoid infectious disease transmission. Rapid development of today’s technology has led to efforts to develop android-based applications for smartphones to improve health-related knowledge. Sayang ke Buah Hati (SEHATI) application is an android-based application for improving mother’s knowledge on health-related issues. The objective of this study was to analyze the effects of SEHATI application in improving mothers' knowledge regarding hand washing and the relationship between mothers' knowledge and children's skills improvement in hand washing with soap. This was a quasi-experimental study with pretest-posttest one group design conducted in the period of February to March 2017 on 33 mothers and students of grades 1 and 2 of Uchuwwatul Islam Elementary School in Bandung city who met the inclusion criteria, not met exclusion criteria, and are willing to participate as respondents. Knowledge data were analyzed using paired t test while skill data were analyzed using Spearman rho. Results showed that SEHATI application improved mothers' knowledge on hand washing with soap (p
... Third, with respect to measurement procedures, some studies used process measures, such as the frequency of handwashing (e.g., Early et al., 1998;Rosen et al., 2006); however, it is unclear how accurately children washed their hands. Other studies used only outcome measures, such as incidence of illness or infection (e.g., Nandrup-Bus, 2009;Ponka et al., 2004;Roberts et al., 2000); however, these measures may not be accurate indices of hand cleanliness. ...
Young children who attend out‐of‐home care (e.g., preschool) are more susceptible to infections than children who do not attend out‐of‐home care. Previous research suggests handwashing is effective in reducing risk of infection and illness. However, research suggests that individuals do not routinely wash their hands using methods that healthcare agencies, such as the Centers for Disease Control and Prevention, have determined best practice. We evaluated the effects of a multicomponent handwashing intervention package on correct handwashing across groups of preschool children. Furthermore, we measured the degree to which their hands were clean using premeasures and postmeasures. Results suggest the intervention package was effective at increasing both correct handwashing and cleanliness of participants' hands.
... Poor water conditions result in about 443 million lost school days worldwide every year (Human Development Report 2006). A study of primary school children in Denmark illustrated that, even in a highly developed, modern society, handwashing is effective in reducing infectious illnesses and absenteeism (Nandrup-Bus 2009). In addition, children in all parts of the world can benefit from the provision of water and encouragement to drink it because adequate hydration improves their cognitive abilities, attention, and memory (Benton 2011). ...
Framed by a social practice perspective, this article presents a theoretical, political, and practical rationale for implementing and expanding water, sanitation and hygiene education (WASH) in preschools throughout the world. Every day thousands of young children die, while others suffer serious illness or stunting from water-, sanitation-, and hygiene-related causes. Many of these consequences could be prevented with low-cost interventions. Although there is little peer-reviewed research on preschool WASH, justifications and ideas for action can be found in the results of WASH studies in primary schools. Pre-primary education and WASH are priorities within the global Sustainable Development Goals (SDG) for 2015–2030. Numerous materials and methods from school-based WASH can be used or adapted for preschool. However, early childhood and WASH professionals and advocates must launch preschool initiatives and also advocate for incorporation of WASH curricula into pre-service and in-service teacher education. More research needs to be conducted on outcomes of WASH-focused experiences in preschool. Advocacy actions with governments, UNICEF, NGOs, and other organizations can ensure that aspirations and good intentions for WASH initiatives are realized, but such progress will require adequate funding.
... Hand washing promotion in schools has also been shown to play a role in reducing absenteeism due to illness [Lopez-Quintero et al., 2009;IngeNandrup-Bus, 2009] which would reduce lost school and work days and health care costs on families. ...
... Worldwide about 400 million children are infected with worms due to poor hand washing practices. These worms cause: malnutrition, abdominal malfunction and impaired learning capacity [1]. In developing countries, 80% of the diseases are associated with poor domestic and personal hygiene [2]. ...
... University of Idaho Extension receives frequent requests for hand-washing education. Schools and teachers recognize the need for their students to use proper hand-washing skills because illness is a major contributor to absenteeism in schools (Nandrup-Bus, 2009). In general, inadequate hand washing by youths has been a concern for decades. ...
We conducted a study to determine the effectiveness of a 30-min hand-washing instruction among youths in kindergarten through fifth grade. Two months after implementing the instruction, we gathered survey data to assess knowledge gained and student behaviors. Results revealed that high proportions of youths in kindergarten through second grade (n = 90) were able to recognize various situations requiring hand washing and that majorities of youths in third grade through fifth grade (n = 172) tended to wash their hands at relevant times (e.g., after using the bathroom). Overall, we concluded that youths taught a 30-min hand-washing lesson reduced microbial counts on washed hands, maintained knowledge, and made positive behavior changes.
... Hygiene education and handwashing are among the simplest and most cost-effective applications for reducing such contagious diseases significantly (Fewtrell & Kay, 2015). It has been put forth that improving hand hygiene during childhood decreases diarrhea-related diseases by 40% (Ejemot-Nwadiaro et al., 2015), respiratory system diseases by 23% (Aunger et al., 2016), and infection-related school absences by 26% (Chittleborough, Nicholson, Basker, Bell, & Campbell, 2013;Lee, Leung, Tong, Chen, & Lee, 2015;Nandrup-Bus, 2009;Willmott et al., 2016). Proper hand hygiene practices prevent the spreading of secondary infections in the society while also decreasing the health expenses and the burden on the family due to impact on the leave of absence periods as a result of childcare (Chittleborough et al., 2013). ...
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.
... As opposed to the above games, our game focuses on creating awareness about hygiene and responsible antibiotic use among children. Hand hygiene significantly reduces illness related absences [22], whereas antibiotic resistance is an ongoing concern and responsible antibiotic use could help alleviate this issue [8]. With the aim of addressing these issues, the desktop version of the game has been adapted [9] for play on mobile devices as an app [19]. ...
Edugames4all MicrobeQuest! is a mobile game that aims to teach microbiology and create awareness about important healthcare issues among 9 to 12 years old. This article presents the game, discusses the game design and integration of the learning objectives into the game mechanics. A pilot study has been performed to assess the game effectiveness in teaching the learning objectives integrated into the game. The study showed that the game can teach the learning objectives, however, the knowledge difference has not been statistically significant across all three learning objectives.
... Future studies might also collect data that allows researchers to evaluate the impact of WinS on absenteeism (e.g. (Nandrup-Bus, 2009) in the Indonesian context and examine further the role of quality of service provision and toilet usage (e.g. (Garn et al., 2014)). ...
This study assesses the effect of improved water, sanitation, and hygiene (WASH) services on students’ absenteeism in government basic schools for 10–19 years old in Nepal. This study applied an ex post facto research design on two groups of students: with and without improved school WASH services. This study showed that students in schools with improved WASH services were more likely to be regular in attendance (80%) compared to those without (58%), p < 0.001. There was an association between students’ school absenteeism and student grades, p < 0.05. Moreover, the caste, religion, and grades of students were also associated with students’ school absenteeism, p < 0.001. The analysis further showed that students with improved WASH were more likely to be regular [crude odds ratios (COR) = 0.353; 95% confidence interval (CI); 0.256–0.487, p < 0.001] than those without. This trend was maintained across all demographics. It was significant even after the inclusion of all sociodemographic characteristics and increased rapidly [adjusted odds ratio (AOR) = 0.508; 95% CI; 0.334–0.773, p < 0.01]. The Brahmin/Chhetri-Terai and the Dalit students were more likely to be absent (COR = 0.315; 95% CI; 0.153–0.648, p < 0.01 and AOR = 0.274; 95% CI; 0.139–0.542, p < 0.001, respectively) than Brahmin/Chhetri-Hill, Janajati, and other castes. This study underscores the importance of WASH services in schools in reducing students’ school absenteeism. Access to WASH services is recommended with several awareness programs to reduce absenteeism and increase students’ school regularity.
Background: Human hands play a significant role in the spread of diseases, especially respiratory and diarrheal diseases, which continue to be the leading cause of morbidity and mortality among children worldwide. Hand washing is the most widely used preventive measure to lessen the spread of infectious diseases. It involves washing hands with ordinary or antimicrobial soap and water. This is especially important for school-age children, since they may be more susceptible to diseases associated with poor hygiene than adults’ age. There is evidence linking the promotion of hand washing habits through health education to a lower incidence of communicable diseases in school-age children. Objectives: To determine the socio-demographic characteristics of the respondents and to find out the practice of hand washing among the secondary school children. Materials & Methods: A cross sectional study was conducted on 340 school students from 1st June 2022 to 30th November 2022 in Alekjan Memorial High School and College, Durgapur, Adarsha Sadar, Cumilla. Purposive sampling was used to gather all pertinent data using a structured questionnaire. Results: In schools, 69.7% of the respondents washed their hands properly. 96.7% of them used soap to wash their hands. About 98.2%, 95%, 86.8%, 82.9% and 80.3% of school children reported that they wash their hands before eating, after using the restroom, after eating, after playing and after working. Conclusion: According to the study, having access to soap and water is necessary for good hand washing technique as the majority of the students used soap during hand washing. By installing hand washing stations in schools, the regional government, that is, the education and health bureaus-should enhance the hand washing practices in schools. It is important for parents and other family members to focus more on behavior guidance related to hand washing. Eastern Med Coll J. July 2023; 8 (2): 40-44
Eskuen garbiketa ezinbestekoa da eskolan gaixotasun infekziosoen hedapena ekiditeko. Baieztapen hau eta lehendik egindako zenbait ikerketa aintzat hartuz, ikerketa bat aurkezten da. Ikerketa garatzeko, galdetegi bat prestatu da ikastetxe bateko 3. zikloko ikasleei bideratuta. Galdetegi honek, ikasle horien eskuak garbitzeko ohiturak eta mikroorganismoen munduaren inguruko ezagutzak batzen ditu. Emaitzak bat datoz lehenik egindako ikerketekin, eskuen garbiketa ohitura eta mikroorganismoekiko ezagutza eskasa erakutsiz. Hori dela eta, beharrezkoa da eskolen inplikazio handiagoa, eskuen garbiketa ohiturak bultzatzeko eta mikroorganismoekiko ezagutzan sakontzeko eta, horrez gain, sentsibilizazio kanpainak egitea fenomeno honen garrantziaren inguruan kontzientziazio lana bultzatzeko.
Background: Personal hygiene is the behaviors that must be practiced in daily life, starting from morning to sleep time to protect our health. Objectives: This study aimed to assess the role of health education in promoting knowledge of personal hygiene among Primary School Pupils in Umbada locality, Khartoum State Sudan (2018 - 2020) Materials and methods: The study design an observational interventional study was conducted where a pre and post- assessment was done. Pre-test and post-test was used to determine the practices of hygiene among primary school Pupils in some selected schools of Umbada locality al emir unit. The targeted population was primary school Pupils in Government schools only. The study populations were the pupils in the Primary public schools with a total number of 37850 Pupils (grade 5, grade 6 and grade7) distributed among 180 public primary schools in the locality. The sample size consisted of (800) pupils during the period of the study. A pre and post- questionnaire was carefully prepared, tested and directed to the pupils . It covers pupil’s age, sex, and the classroom. , source of water supply and latrine in the house there, and to obtain data regarding knowledge, attitude, and practices (as regards personal hygiene in both pre and post-intervention phases. Data was analyzed using Statistical Package for Social Sciences SPSS Computer Program Version (19.0). Results: The study revealed that the overall knowledge of pupils about personal hygiene was increase from 38.7% to 61.3% after intervention of health education packages. Conclusion: Due to gaps in many items of knowledge, attitude and practice regarding personal hygiene, there is need of the proper health education intervention through framework of schools to the school children, for improvement regarding personal hygiene among them, throughout the nation. Health education has significant role in promoting knowledge of school pupils regarding personal hygiene.
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.
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.
Background: Personal hygiene is the behaviors that must be practiced in daily life, starting from morning to sleep time to protect our health. Objectives: This study aimed to assess the role of health education in promoting knowledge of personal hygiene among Primary School Pupils in Umbada locality, Khartoum State Sudan (2018 - 2020) Materials and methods: The study design an observational interventional study was conducted where a pre and post- assessment was done. Pre-test and post-test was used to determine the practices of hygiene among primary school Pupils in some selected schools of Umbada locality al emir unit. The targeted population was primary school Pupils in Government schools only. The study populations were the pupils in the Primary public schools with a total number of 37850 Pupils (grade 5, grade 6 and grade7) distributed among 180 public primary schools in the locality. The sample size consisted of (800) pupils during the period of the study. A pre and post- questionnaire was carefully prepared, tested and directed to the pupils . It covers pupil’s age, sex, and the classroom. , source of water supply and latrine in the house there, and to obtain data regarding knowledge, attitude, and practices (as regards personal hygiene in both pre and post-intervention phases. Data was analyzed using Statistical Package for Social Sciences SPSS Computer Program Version (19.0). Results: The study revealed that the overall knowledge of pupils about personal hygiene was increase from 38.7% to 61.3% after intervention of health education packages. Conclusion: Due to gaps in many items of knowledge, attitude and practice regarding personal hygiene, there is need of the proper health education intervention through framework of schools to the school children, for improvement regarding personal hygiene among them, throughout the nation. Health education has significant role in promoting knowledge of school pupils regarding personal hygiene.
This study assesses the effect of improved water, sanitation, and hygiene (WASH) services on students' absenteeism in government basic schools for 10-19 years old in Nepal. This study applied an ex post facto research design on two groups of students: with and without improved school WASH services. This study showed that students in schools with improved WASH services were more likely to be regular in attendance (80%) compared to those without (58%), p < 0.001. There was an association between students' school absenteeism and student grades, p < 0.05. Moreover, the caste, religion, and grades of students were also associated with students' school absenteeism, p < 0.001. The analysis further showed that students with improved WASH were more likely to be regular [crude odds ratios (COR) = 0.353; 95% confidence interval (CI); 0.256-0.487, p < 0.001] than those without. This trend was maintained across all demographics. It was significant even after the inclusion of all sociodemographic characteristics and increased rapidly [adjusted odds ratio (AOR) = 0.508; 95% CI; 0.334-0.773, p < 0.01]. The Brahmin/Chhetri-Terai and the Dalit students were more likely to be absent (COR = 0.315; 95% CI; 0.153-0.648, p < 0.01 and AOR = 0.274; 95% CI; 0.139-0.542, p < 0.001, respectively) than Brahmin/Chhetri-Hill, Janajati, and other castes. This study underscores the importance of WASH services in schools in reducing students' school absenteeism. Access to WASH services is recommended with several awareness programs to reduce absenteeism and increase students' school regularity.
The Economic and Health Well-Being highlights the need for putting people at the centre of policy. It is essential to move for education, health, and the environment, toward a growth model that is equitable and sustainable for the next generation. An economy of well-being has three main pillars. The first pillar is education and skills. Skills are the most critical driver of long-term economic growth. Returns to education more than double once health and employment benefits are accounted for, and education makes reducing inequalities. The second pillar is health. Evidence shows that good health fuels economic growth, productivity, and individual earnings. The third pillar is the environment. Studies focus that the environment is playing a vital role in making countries' economic growth and health improvement.
There are other dimensions to an economic and health well-being; for instance, the factors of accessibility can be combined availability, affordability, and acceptability, as well as the equitable access to those; and of course, the quality of the environment that significantly affects health outcomes, especially among the poorest. This book will
receive proper attention and support from researchers, scholars, and policymakers.
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.
Knowledge of Diarrhoeal Diseases and Hygiene Practices of InSchool Adolescents
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.
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.
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.
Personal hygiene is critical for preventing the spread of infection. One important component of personal hygiene is handwashing. This review summarizes research on behavioral strategies to address handwashing in children, offers areas for additional research, and suggests a treatment package to teach handwashing to young 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.
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.
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.
This study has concentrated on sanitation awareness among the students of Varendra University Bangladesh and how they can protect themselves from various contagious diseases spread by bacteria, fungus, virus, dust, food elements, germs, etc., following a standard sanitation guideline. So, maintaining good sanitation helps of feeling better self-esteem. Conversely, it can make feel people less confident and unmotivated which impacts on workability. This study is based on primary data collected from students of nine academic departments with a self-administered questionnaire using a simple random sampling without a replacement method. IBM version 17 has used to code the data. Frequency distributions, cross tables, a multinomial logistic regression model, statistical charts and tests are also used to validate the assumptions. It has found that the majority of the respondents (86.6%) always follows washing hands before having food, 69.5% use soaps always to clean hands, 93.9% clean hands always after using a toilet, 85.3% take a bath daily, 76.1% wear clean clothes always, and 82.6% go to the washroom with footwear. 124 (32.6%) respondents have suffered from food poising, 104 (27.4%) from gastroenteritis, 80 (21.1%) from diarrhea, 16 (4.2%) from pneumonia, and 56 (14.7%) from skin infections. So, it is practically effective to nourish the habit of exercising proper health sanitation and this area can be a vast scope of the further study.
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.
Abstract
Appropriate hand-washing practice with an adequate level of frequency is an essential skill for leading healthy lives. A cross-sectional, school study was conducted over a period of 3 months (October-December, 2016). The participants were students from grade 1 to grade 12, randomly chosen from 14 public schools in Jordan. Complete data regarding their hand-washing habits was obtained. The Pearson chi-square test was computed. Odds ratio was calculated with a 95% confidence interval to show the effect size and the strength of relationship between variables. The findings showed that the majority of the students (97.5%) washed their hands with water, and nearly 70% of them used soap. Furthermore, the majority washed their hands after using the toilet (86.7%) and after touching rubbish (84.4%). Reasons for not washing their hands from the students' perspective included: ‘no need’ (70.8%) and ‘the hand-washing facilities were not clean’ (62.3%). The findings revealed that a low percentage of school students ignored hand-washing after different critical situations, this figure decreased with age. However, the practice should be improved further. Health promotion programmes should be implemented for students and their families in the community or in school settings.
Keywords: Hand-washing, Hygiene, School students, Community health, Public health
Absenteeism due to communicable illness is a major problem encountered by North American elementary school children. Although handwashing is a proven infection control measure, barriers exist in the school environment, which hinder compliance to this routine. Currently, alternative hand hygiene techniques are being considered, and one such technique is the use of antimicrobial rinse-free hand sanitizers.
A systematic review was conducted to examine the effectiveness of antimicrobial rinse-free hand sanitizer interventions in the elementary school setting. MEDLINE, EMBASE, Biological Abstract, CINAHL, HealthSTAR and Cochrane Controlled Trials Register were searched for both randomized and non-randomized controlled trials. Absenteeism due to communicable illness was the primary outcome variable.
Six eligible studies, two of which were randomized, were identified (5 published studies, 1 published abstract). The quality of reporting was low. Due to a large amount of heterogeneity and low quality of reporting, no pooled estimates were calculated. There was a significant difference reported in favor of the intervention in all 5 published studies.
The available evidence for the effectiveness of antimicrobial rinse-free hand sanitizer in the school environment is of low quality. The results suggest that the strength of the benefit should be interpreted with caution. Given the potential to reduce student absenteeism, teacher absenteeism, school operating costs, healthcare costs and parental absenteeism, a well-designed and analyzed trial is needed to optimize this hand hygiene technique.
Good hand hygiene may reduce the spread of infections in families with children who are in out-of-home child care. Alcohol-based hand sanitizers rapidly kill viruses that are commonly associated with respiratory and gastrointestinal (GI) infections. The objective of this study was to determine whether a multifactorial campaign centered on increasing alcohol-based hand sanitizer use and hand-hygiene education reduces illness transmission in the home.
A cluster randomized, controlled trial was conducted of homes of 292 families with children who were enrolled in out-of-home child care in 26 child care centers. Eligible families had > or =1 child who was 6 months to 5 years of age and in child care for > or =10 hours/week. Intervention families received a supply of hand sanitizer and biweekly hand-hygiene educational materials for 5 months; control families received only materials promoting good nutrition. Primary caregivers were phoned biweekly and reported respiratory and GI illnesses in family members. Respiratory and GI-illness-transmission rates (measured as secondary illnesses per susceptible person-month) were compared between groups, adjusting for demographic variables, hand-hygiene practices, and previous experience using hand sanitizers.
Baseline demographics were similar in the 2 groups. A total of 1802 respiratory illnesses occurred during the study; 443 (25%) were secondary illnesses. A total of 252 GI illnesses occurred during the study; 28 (11%) were secondary illnesses. The secondary GI-illness rate was significantly lower in intervention families compared with control families (incidence rate ratio [IRR]: 0.41; 95% confidence interval [CI]: 0.19-0.90). The overall rate of secondary respiratory illness was not significantly different between groups (IRR: 0.97; 95% CI: 0.72-1.30). However, families with higher sanitizer usage had a marginally lower secondary respiratory illness rate than those with less usage (IRR: 0.81; 95% CI: 0.65-1.09).
A multifactorial intervention emphasizing alcohol-based hand sanitizer use in the home reduced transmission of GI illnesses within families with children in child care. Hand sanitizers and multifaceted educational messages may have a role in improving hand-hygiene practices within the home setting.
Background:
Diarrhoea is a common cause of morbidity and a leading cause of death among children aged less than five years, particularly in low- and middle-income countries. It is transmitted by ingesting contaminated food or drink, by direct person-to-person contact, or from contaminated hands. Hand washing is one of a range of hygiene promotion interventions that can interrupt the transmission of diarrhoea-causing pathogens.
Objectives:
To evaluate the effects of interventions to promote hand washing on diarrhoeal episodes in children and adults.
Search strategy:
In May 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2007, Issue 2), MEDLINE, EMBASE, LILACS, PsycINFO, Science Citation Index and Social Science Citation Index, ERIC (1966 to May 2007), SPECTR, Bibliomap, RoRe, The Grey Literature, and reference lists of articles. We also contacted researchers and organizations in the field.
Selection criteria:
Randomized controlled trials, where the unit of randomization is an institution (eg day-care centre), household, or community, that compared interventions to promote hand washing or a hygiene promotion that included hand washing with no intervention to promote hand washing.
Data collection and analysis:
Two authors independently assessed trial eligibility and methodological quality. Where appropriate, incidence rate ratios (IRR) were pooled using the generic inverse variance method and random-effects model with 95% confidence intervals (CI).
Main results:
Fourteen randomized controlled trials met the inclusion criteria. Eight trials were institution-based, five were community-based, and one was in a high-risk group (AIDS patients). Interventions promoting hand washing resulted in a 29% reduction in diarrhoea episodes in institutions in high-income countries (IRR 0.71, 95% CI 0.60 to 0.84; 7 trials) and a 31% reduction in such episodes in communities in low- or middle-income countries (IRR 0.69, 95% CI 0.55 to 0.87; 5 trials).
Authors' conclusions:
Hand washing can reduce diarrhoea episodes by about 30%. This significant reduction is comparable to the effect of providing clean water in low-income areas. However, trials with longer follow up and that test different methods of promoting hand washing are needed.
Infectious diseases (ID) circulating in the home and community remain a significant concern. Several demographic, environmen- tal, and health care trends, as reviewed in this report, are combining to make it likely that the threat of ID will increase in coming years. Two factors are largely responsible for this trend: first, the constantly changing nature and range of pathogens to which we are exposed and, secondly, the demographic changes occurring in the community, which affect our resistance to infection. This report reviews the evidence base related to the impact of hand hygiene in reducing transmission of ID in the home and community. The report focuses on developed countries, most particularly North America and Europe. It also evaluates the use of alcohol-based hygiene procedures as an alternative to, or in conjunction with, handwashing. The report compiles data from intervention studies and considers it alongside risk modeling approaches (both qualitative and quantitative) based on microbiologic data. The main conclusions are as follows: (1) Hand hygiene is a key component of good hygiene practice in the home and community and can produce significant benefits in terms of reducing the incidence of infection, most particularly gastrointestinal infections but also respiratory tract and skin infections. (2) Decontamination of hands can be carried out either by handwashing with soap or by use of waterless hand sanitizers, which reduce contamination on hands by removal or by killing the organisms in situ. The health impact of hand hygiene within a given community can be increased by using products and procedures, either alone or in sequence, that maximize the log reduction of both bacteria and viruses on hands. (3) The impact of hand hygiene in reducing ID risks could be increased by convincing people to apply hand hygiene procedures correctly (eg, wash their hands correctly) and at the correct time. (4) To optimize health benefits, promotion of hand hygiene should be accompanied by hygiene education and should also involve promotion of other aspects of hygiene. (Am J Infect Control 2007;35:S27-64.)
To examine evidence of a causal link between handwashing and risk of infection, a review of published literature from 1879 through 1986 was conducted. In the 107 years studied, 423 articles specifically related to handwashing were found. Articles were categorized as studies to evaluate products (50.8%), review articles (29.1%), behavioral studies (10.9%), methodologic studies (2.8%), studies linking handwashing to infection (3.3%), and other (3.1%). There was an increase in the proportion of handwashing articles published in the 1980s with the rate (9.4/10 citations/year) being almost double that of any other period studied. Nonexperimental and experimental studies related to handwashing were reviewed and evidence for a causal association evaluated. Except for specificity, all the elements for causality, including temporality, strength, plausibility, consistency of the association, and dose response were present. It was therefore concluded that emphasis on handwashing as a primary infection control measure has not been misplaced and should continue.
‘‘Hygiene’’ refers to conditions or practices by which people maintain or promote good health by keeping themselves and their surroundings clean. Even in our contemporary society, good hygiene practices continue to be the primary disease-prevention strategy. As described earlier, hygiene is one of the silent victories of public health. This article focuses on hygiene in the newest frontier of disease prevention—the 21st-century home. Do personal hygiene and household cleanliness practices affect the risk of spreading infectious disease? In this article, we’ll review the ‘‘hygiene barrier’’ concept and the range of hygiene needs within the home environment, and discuss diseasecausing microbes—their sources, how they spread, and how their transmission can be controlled by proper personal hygiene and household cleaning practices. This information offers a framework for developing practical home strategies to manage risk from infections. THE HYGIENE BARRIER A ‘‘hygiene barrier’’ gives us the freedom to experience our lives and do so without the impediments of debilitating diseases or the tragedy of premature death. It is a direct result of the innovations brought about by the health and sanitary revolutions that have swept regions of the world. Through the combined benefits of improved food and water quality and home and personal cleaning practices, the hygienic quality of our environment dramatically reduces routine exposures to pathogenic microorganisms. This reduction in pathogen exposure results in dramatic reductions in infectious diseases and premature death. As is the case with most societal breakthroughs, many people in developed countries have grown to accept reduced rates of illness as the norm, and outbreaks that once would have been accepted as an unavoidable part of life are now viewed as crises of public health requiring swift and decisive interventions.
A questionnaire survey was carried out anonymously among 2557 health care workers in Denmark and Norway to identify and quantify factors that affect the handwashing behavior of physicians, nurses, and other staff groups who perform direct patient care. For number of daily patient contacts physicians reported significantly fewer instances of hand hygiene (HH) per day than did those in other medical professions. Male physicians reported significantly fewer HH per day than did their female colleagues. Significant differences were found among staff groups in emphasis on factors motivating and discouraging HH. The main motivating factor for all groups, however, was an awareness that HH is important for the prevention of infection. Skin problems from frequent handwashing and the use of agents that irritate and dry the skin were the main reasons for disinclination toward HH. The number of points given to these statements correlated well with the stated frequency of HH in staff groups with relatively many (9 to 24) patient contacts per day. Many studies have revealed low standards of HH in health care settings. Whenever HH is taught, the significance of HH for the prevention of infection is always stressed. The participants in this survey were well aware of this significance, but there is still a discrepancy between theory and practice. Goal-specific strategies to improve HH practices would probably be more effective if more were done to minimize the factors that health care workers find detrimental to HH. Continual evaluation of the possibly detrimental effects of current hand washing agents should also be carried out.
The study was designed to compare the efficacies of bland soap handwash and isopropyl alcohol hand rinse in preventing transfer of aerobic gram-negative bacilli to urinary catheters via transient hand colonization acquired from direct patient contact. Glove juice recovery of gram-negative bacteria was considered transient colonization; catheter recovery was considered transfer colonization.
The contact source for gram-negative bacteria was a single "high burden" groin skin carrier (greater than or equal to 10(4)/ml cup scrub fluid). Using a two-period cross-over design, 6 healthcare workers had 2 15-second contacts for each hand followed by either soap handwash or alcohol hand rinse (12 experiments with each treatment). Between 4 to 5 minutes after contact, each hand manipulated a catheter; the catheter was then cultured and the hand was glove juice tested.
Soap handwash failed to prevent gram-negative bacteria transfer to the catheter in 11 of 12 (92%) experiments; alcohol hand rinse in 2 of 12 (17%) (p less than .001). Soap handwash failed to prevent transient colonization in 12 of 12 (100%) experiments; alcohol in 5 of 12 (42%) (risk ratio 2.4, 95% confidence interval 1.2-4.7). Single gram-negative bacteria species carried at source levels greater than or equal to 5.5 x 10(3)/ml (heavy contamination) established transient colonization in 23 of 30 (77%) exposures following soap handwash; single gram-negative bacteria species carried at levels less than or equal to 3.5 x 10(3)/ml established colonization in 1 of 22 (5%) similar exposures (p less than .001).
Bland soap handwash was generally ineffective in preventing hand transfer of gram-negative bacteria to catheters following brief contact with a heavy-contamination patient source; alcohol hand rinse was generally effective.
A retrospective investigation was undertaken of the connection between absence on account of illness and the hygienic routines in 28 day institutions in the County of Storstrøm. A total of 953 children aged 0-6 years were involved. Absence on account of illness was described on the basis of registration for three months carried out by the staffs of the day institutions. On the basis of information about sick-leave, interview investigations were carried out the hygienic routines in the six day institutions which showed the highest and lowest absenteeism on account of illness, respectively. Only slight differences were found in the hygienic routines in the institutions investigated and no connections were found between sickness and hygiene. On the other hand, there appears to have been a connection between absence on account of illness and time spent out-of-doors; the greatest illness being observed in the institutions where the children spent least time out-of-doors. With the object preventions of illness among children in day institutions, further investigations concerning the significance of time spent out-of-doors and the indoor environment for these children would be of interest.
On an average, preschool children have 6-8 acute infections annually. This corresponds to approximately 80 sick-days including mild colds. If days in which the general health is affected only are included, approximately 25 days per child per annum are concerned. The amount of sickness in children attending day care centres is between 2-7 times as great as that of children cared for in their own homes. In particular, an increased risk has been demonstrated for children attending day care centres to develop conditions such as secretory otitis media, pneumonia, gastroenteritis, hepatitis A and meningitis. A close dose-response connection can be demonstrated between ill health and the number of children with whom the child is cared for. The increased possibilities of exposure to infection in day institutions must, therefore, be assumed to be the central factor for the excess morbidity demonstrated. The significances of a series of modifying factors in the pathogenesis, including age, genetically determined immunity, psychosocial stress, atmospheric contamination, quality of atmosphere and low temperatures, are reviewed. Despite the term "colds", there is no evidence that upper respiratory infections have any connection with cooling. With the object of establishing rational measures against spread of infection, the occurrence and routes of infection of the relevant microorganisms are reviewed. About 80% of the infections must be presumed to be viral. In children attending day care centres, viruses have been demonstrated in 10% of the children without symptoms. Air-borne infection appears to be responsible for a very limited proportion of infections. The routes of infection are mainly by direct or indirect contact infection e.g. via tables and toys.(ABSTRACT TRUNCATED AT 250 WORDS)
The object of this investigation was to assess the extent to which absence on account of illness in children attending day-nurseries expressed the total morbidity. In four day-nurseries with a total capacity for 164 children, absence on account of illness and symptoms in the children present were registered over a period of 101 weekdays. Children were absent on 5.8% of the days on account of illness. The commonest causes were epidemic children's diseases, colds, sore throats and pyrexia. More than one third of the children present in the day-nurseries presented sign of illness. The most frequent of these were colds. Children were present in the day-nurseries five times as frequently with at least one symptom than they were absent on account of illness. Absence on account of illness provides an incomplete indication of illness among children attending day-nurseries as absence due to illness only represents a lesser quantitative fraction of the total morbidity among these children.
A pilot study to develop and evaluate a program to teach 13 Grade 1 children with disabilities about handwashing was conducted at Glenrose School, which is located within Glenrose Rehabilitation Hospital. Children aged 6 to 8 years were taught how and when to wash their hands. Handwashing skills were evaluated before the teaching began, immediately following the teaching program, and at 1, 3, and 5 months postteaching. The children's handwashing skills did improve, with the girls generally scoring higher than the boys on both washing techniques and times of washing on all the testing occasions. Although the children had fewer visits to the doctor, took fewer prescribed antibiotics, and had fewer infectious illnesses than they did for the same time period the previous year, other variables, in addition to the teaching program, may have contributed to the outcome. A revised handwashing program is now included in the Grade 1 curriculum.
This article summarizes a critical analysis of 18 studies that examined the link between hand washing and infection. Although several factors made it difficult to evaluate the effect of hand washing, the authors conclude that (1) hand washing can add incremental value to infection-control strategies in acute care settings, (2) patient hand hygiene may influence infection rates, and (3) the effect of "ideal" hand washing on nosocomial infection rates is unlikely to be quantifiable.
The purpose was to determine the effectiveness of an instructional program on handwashing. The hypothesis stated that an instructional program on germs and handwashing in child care could significantly reduce the spread of infectious diseases in the test center.
A longitudinal study was conducted in a field setting with a test group and a control group of 3- to 5-year-old children and their teachers in two similar child care settings. For 21 weeks illnesses and symptoms of infectious diseases were assessed with a health assessment checklist. The test group received a developmentally appropriate instructional program on germs and handwashing. The teachers in the test group attended workshops on infectious diseases and handwashing. The control group maintained their usual handwashing procedures.
At weeks 1 through 11 benchmark data were collected. At weeks 12 through 21, peak cold and flu season, the test group had significantly fewer colds than the control group (chi-squared analysis, 4.338, 1 df, p < .05); thus the hypothesis was confirmed.
Handwashing has been recognized as one way to manage the spread of infectious diseases in child care centers. Handwashing helped to reduce colds at the test center where frequent and proper handwashing practices were incorporated into the curriculum through an intervention program.
Hand washing prevents communicable illness. We evaluated the effect of a mandatory, scheduled hand-washing program in elementary school children on absenteeism due to acute communicable illness.
The study was conducted at Trombley Elementary School in Grosse Pointe Park, Mich. The intervention group, approximately half of the school children (n = 143, including all grades 1-5), washed their hands a minimum of four scheduled times a day. The control group (n = 162) continued hand-washing practices as usual.
Of the 37 school days examined, children in the hand-washing group were absent fewer days than the control group due to all acute communicable illness (relative risk = .75). There were less days of absence due to gastrointestinal symptoms (relative risk = .43). The difference in absence due to respiratory symptoms was not statistically significant.
A scheduled hand-washing program will reduce acute communicable (gastrointestinal) illnesses in elementary school-age children.
Child care outside the home increases children's infections substantially. We have to evaluate the possibilities for reducing the transmission of infections by an infection prevention program.
A 15-month randomized controlled trial involving 20 day-care centers was conducted to evaluate the efficacy of an infection prevention program. The program was introduced in 10 centers and the other matched 10 centers served as controls. Records were made of the occurrence of infections and absences from care or work because of infections among the children, their parents and the personnel of the day-care centers.
Both the children and the personnel in the program centers had significantly fewer infections than those in the control centers, the reduction being 9% [95% confidence interval (95% CI), 4 to 16%, P < 0.002] among 3-year-old children and 8% (95% CI 0 to 14%, P = 0.049) among the older children. The children at the program centers received 24% fewer prescriptions of antimicrobials (95% CI 22 to 27%, P < 0.001). Likewise there were 2.5 man-year fewer absences from work on the part of parents because of a child's illness during 1 year in the program centers, a 24% difference (95% CI 18 to 29%, P < 0.001).
Effective prevention of infections is possible in child day-care centers, and this can benefit both the families and the personnel. Such a program is cost-effective even if a specialist nurse implements it.
The purpose of the study was to evaluate the effect of intensified hygiene with frequent handwashing and several educational procedures in day-care centres. The study was conducted as a controlled trial, with an intervention group and an observation group. There was a 34% reduction in expected sickness in children in the intervention group. In the categories diarrhoea and eye-infection there was a significant drop in sickness. We conclude that broad intervention concerning hand-hygiene has a positive effect on sickness in children attending day-care centres.
Acute upper respiratory infections are common in children who attend child care, and preventing transmission of disease in this setting depends on actions by child care staff. We set out to discover whether transmission of respiratory infections in child care could be reduced by improved infection control procedures.
We performed a cluster, randomized, controlled trial of an infection control intervention conducted in child care centers in 1 city in Australia. The intervention was training of child care staff about transmission of infection, handwashing, and aseptic nosewiping technique. Implementation of the intervention was recorded by an observer. Illness was measured by parent report in telephone interviews every 2 weeks.
There were 311 child-years of surveillance for respiratory symptoms. By multivariable analysis, there was no significant reduction in colds in intervention center children across the full age range. However, a significant reduction in respiratory illness was present in children 24 months of age and younger. When compliance with infection control practices was high, colds in these children were reduced by 17%.
This trial supports the role of direct transmission of colds in young children in child care. The ability of infection control techniques to reduce episodes of colds in children in child care was limited to children 24 months of age and under.
Several studies have indicated a connection between handwashing and illness-related absenteeism in school settings. The difficulty of ensuring consistent and effective handwashing among student populations has also been noted. The purpose of this study was to assess the effectiveness of the use of an alcohol gel hand sanitizer in the classroom to help decrease the illness-related absentee rate for elementary school students.
This study involved 5 individual school districts, 16 individual schools, and more than 6000 students in Delaware, Ohio, Tennessee, and California. Individual schools in each district were paired into product and control groups. In the product group schools, an alcohol gel hand sanitizer was used by the students and staff when entering and leaving the classroom. Absenteeism due to infection was recorded, and the data were statistically analyzed.
The overall reduction in absenteeism due to infection in the schools included in this study was 19.8% for schools that used an alcohol gel hand sanitizer compared with the control schools (P <.05). Data from the school system with the largest teacher population (n = 246) showed that teacher absenteeism decreased 10.1% (trend) in the schools where sanitizer was used.
Elementary school absenteeism due to infection is significantly reduced when an alcohol gel hand sanitizer is used in the classroom as part of a hand hygiene program.
BACKGROUND AND HYPOTHESES: A substantial percentage of school absenteeism among children is related to transmissible infection. Rates of transmission can be reduced by hand washing with soap and water, but such washing occurs infrequently. This study tested whether an alcohol-free instant hand sanitizer (CleanHands) could reduce illness absenteeism in school-age children.
A 10-week, open-label, crossover study was performed on 420 elementary school-age children (ages 5-12). Students were given a brief orientation immediately prior to the start of the study on the relationship of germs, illness, and hand washing. Each student in the treatment group then received the test product in individual bottles, with instructions to apply one to two sprays to the hands after coming into the classroom, before eating, and after using the restroom, in addition to their normal hand washing with soap and water. The control group was instructed to continue hand washing as normal with non-medicated soap. After 4 weeks of treatment and a 2-week wash-out period, the control and experimental groups were reversed. Data gathered on absenteeism were classified as gastrointestinal or respiratory related and normalized for nonillness-related absenteeism and school holidays.
Compared to the hand washing-only control group, students using CleanHands were found to have 41.9% fewer illness-related absence days, representing a 28.9% and a 49.7% drop in gastrointestinal- and respiratory-related illnesses, respectively. Likewise, absence incidence decreased by 31.7%, consisting of a 44.2% and 50.2% decrease in incidence of gastrointestinal- and respiratory-related illnesses, respectively. No adverse events were reported during the study.
Daily use of the instant hand sanitizer was associated with significantly lower rates of illness-related absenteeism.
Hand washing is the most effective way to prevent the spread of communicable disease. The purpose of this double-blind, placebo-controlled study was to assess whether an alcohol-free, instant hand sanitizer containing surfactants, allantoin, and benzalkonium chloride could reduce illness absenteeism in a population of 769 elementary school children and serve as an effective alternative when regular soap and water hand washing was not readily available. Prior to the study, students were educated about proper hand washing technique, the importance of hand washing to prevent transmission of germs, and the relationship between germs and illnesses. Children in kindergarten through the 6th grade (ages 5-12) were assigned to the active or placebo hand-sanitizer product and instructed to use the product at scheduled times during the day and as needed after coughing or sneezing. Data on illness absenteeism were tracked. After 5 weeks, students using the active product were 33% less likely to have been absent because of illness when compared with the placebo group.
Handwashing is one of the most important factors in controlling the spread of micro-organisms and in preventing the development of infections. The objective of this study was to determine the effectiveness of a comprehensive handwashing program on absenteeism in elementary grades. Two hundred ninety students from 5 independent schools were enrolled in the study. Each test classroom had a control classroom, and only the test classroom received the intervention (education program and hand sanitizer). Absenteeism data were collected for 3 months. The number of absences was 50.6% lower in the test group (P <.001). The data strongly suggest that a hand hygiene program that combines education and use of a hand sanitizer in the classroom can lower absenteeism and be cost-effective.
The purpose of this review was to present the existing evidence of the relation between children's absence from day-care centres caused by disease and environmental factors, such as hygienic standard, space per child, and indoor climate in day-care centres. The review is based on results from cohort studies and randomised, controlled studies identified through literature searches. There is good evidence that improved hand hygiene may reduce the morbidity and absence among children attending day-care centres. The effect of the efforts varies from a few to 50 per cent. On the background of cohort studies there is some evidence that available space per child in the day-care centres is also correlated to the rate of absence caused by diseases. The impact of noise and indoor climate in day-care centres and the time spent outdoors has so far only been sparsely investigated but seems to be of some importance.
We set out to determine the impact of washing hands with soap on the risk of diarrhoeal diseases in the community with a systematic review with random effects meta-analysis. Our data sources were studies linking handwashing with diarrhoeal diseases. Seven intervention studies, six case-control, two cross-sectional, and two cohort studies were located from electronic databases, hand searching, and the authors' collections. The pooled relative risk of diarrhoeal disease associated with not washing hands from the intervention trials was 1.88 (95% CI 1.31-2.68), implying that handwashing could reduce diarrhoea risk by 47%. When all studies, when only those of high quality, and when only those studies specifically mentioning soap were pooled, risk reduction ranged from 42-44%. The risks of severe intestinal infections and of shigellosis were associated with reductions of 48% and 59%, respectively. In the absence of adequate mortality studies, we extrapolate the potential number of diarrhoea deaths that could be averted by handwashing at about a million (1.1 million, lower estimate 0.5 million, upper estimate 1.4 million). Results may be affected by the poor quality of many of the studies and may be inflated by publication bias. On current evidence, washing hands with soap can reduce the risk of diarrhoeal diseases by 42-47% and interventions to promote handwashing might save a million lives. More and better-designed trials are needed to measure the impact of washing hands on diarrhoea and acute respiratory infections in developing countries.
Several studies have indicated a connection between hand sanitization and infection control in numerous settings such as extended care facilities, schools, and hospitals. The purpose of this study was to assess the effectiveness of both a hand-hygiene message campaign and the use of an alcohol gel hand sanitizer in decreasing the incidence of upper-respiratory illness among students living in university residence halls.
This study involved a total of 430 students recruited from 4 residence halls during the fall semester at the University of Colorado at the Boulder campus. Dormitories were paired into control and product groups. In the product groups, alcohol gel hand-sanitizer dispensers were installed in every room, bathroom, and dining hall. The data were statistically analyzed for the differences between product and control groups in reported symptoms, illness rates, and absenteeism from classes.
The overall increase in hand-hygiene behavior and reduction in symptoms, illness rates, and absenteeism between the product group and control group was statistically significant. Reductions in upper respiratory-illness symptoms ranged from 14.8% to 39.9%. Total improvement in illness rate was 20%. The product group had 43% less missed school/work days.
Hand-hygiene practices were improved with increased frequency of handwashing through increasing awareness of the importance of hand hygiene, and the use of alcohol gel hand sanitizer in university dormitories. This resulted in fewer upper respiratory-illness symptoms, lower illness rates, and lower absenteeism.
Elementary school-age children are particularly vulnerable to infections. While handwashing is the best method of preventing infections, many elementary schools are housed in buildings that have barriers to effective hand hygiene. The purpose of this study was to determine the effectiveness of an alcohol gel as an adjunct to handwashing in reducing absenteeism secondary to infectious illness. Two-hundred and fifty-three elementary school children were randomized by classroom into an experimental or control group. With a crossover design, all children participated in both groups, with a one-week washout period between phases. A 45-minute "Germ Unit" was taught to all children as they started the experimental phase and a standard unit on hand hygiene was taught as they started the control phase. Sixty-nine children were absent due to illness while in the control group. Thirty-nine children became ill while in the experimental group. Alcohol gel as an adjunct to handwashing was shown to be effective in reducing absenteeism due to infectious illness by 43%.
To determine the effect of handwashing on the risk of respiratory infection.
We searched PubMed, CAB Abstracts, Embase, Web of Science, and the Cochrane library for articles published before June 2004 in all languages. We had searched reference lists of all primary and review articles. Studies were included in the review if they reported the impact of an intervention to promote hand cleansing on respiratory infections. Studies relating to hospital-acquired infections, long-term care facilities, immuno-compromised and elderly people were excluded. We independently evaluated all studies, and inclusion decisions were reached by consensus. From a primary list of 410 articles, eight interventional studies met the eligibility criteria.
All eight eligible studies reported that handwashing lowered risks of respiratory infection, with risk reductions ranging from 6% to 44% [pooled value 24% (95% CI 6-40%)]. Pooling the results of only the seven homogenous studies gave a relative risk of 1.19 (95% CI 1.12%-1.26%), implying that hand cleansing can cut the risk of respiratory infection by 16% (95% CI 11-21%).
Handwashing is associated with lowered respiratory infection. However, studies were of poor quality, none related to developing countries, and only one to severe disease. Rigorous trials of the impact of handwashing on acute respiratory tract infection morbidity and mortality are urgently needed, especially in developing countries.
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