H E A LT H S E R V I C E S A P P L I C A T I O N

Inexpensive and Time-Efcient Hand Hygiene Interventions Increase Elementary School Childrens Hand Hygiene Rates

MICHELLE SNOW, RN, MSPH, MSHRa,b GEORGE L. WHITE, JR., PhD, MSPHc HAN S. KIM, PhD, MSPHd

outine hand hygiene has been cited by the World Health Organization and the Centers for Disease Control and Prevention as a cost-effective and important hygiene measure in preventing the spread of infectious diseases.1-5 Several studies have explored childrens hand hygiene habits, effects of scheduled hand hygiene, hand hygiene environmental barriers, educational programs, and application of various hand hygiene products, all with the aim of increasing the frequency of hand hygiene in children and decreasing absenteeism at school. Though these studies did have merit and achieved statistical signicance, sustainability of hand hygiene was not evaluated.6-9,11-14 In addition, no published peer-reviewed research was found that explored the inuence of a verbal cue to action coupled with teacher modeling or hand hygiene education that included a visual experience for the children to see the effectiveness of their hand washing. Therefore, this project focused on 2 interventions. Intervention 1 involved verbal cue to action coupled with teacher modeling of hand hygiene, and intervention 2 involved teacher cue to action, hand hygiene education, and an opportunity for children to see the effectiveness of their hand hygiene efforts. METHODS Subjects In 2006, a public elementary school with a range of household incomes from public assistance to $200,0001 per year, located in urban Utah, was selected for this study. A series of preliminary planning meetings with school ofcials and faculty was conducted to discuss the project goals, objectives, and protocols. The Joint Staff Service Committee, consisting of the principal, vice principal, and faculty members, was informed, and support for the project was

Assistant Professor, (michellesnow@weber.edu), Department of Health Administrative Services, Weber State University, 3911 University Circle, Ogden, UT 84408-3911. Doctoral Student, University of Utah.

b c

Professor, Past Director, (georgewhite@utah.edu), Department of Public Health Program, University of Utah, 375 Chipeta Way, Suite A, Salt Lake City, UT 84108. Assistant Professor, (hankim@utah.edu), Department of Public Health Program, University of Utah, 375 Chipeta Way, Suite A, Salt Lake City, UT 84108.

Address correspondence to: Michelle Snow, Assistant Professor, (michellesnow@weber.edu), Department of Health Administrative Services, Weber State University, 3911 University Circle, Ogden, UT 84408-3911.

230

Journal of School Health

April 2008, Vol. 78, No. 4

2008, American School Health Association

obtained. The project was approved by the school district and the University of Utahs Institutional Review Board. A total of 492 children, grades 1 through 6, participated in this project. From each grade, 3 classes were randomized to either a control group or 1 of 2 hand hygiene interventions. After receiving their assigned intervention, students were observed for hand hygiene behavior prior to lining up for lunch. After cueing students to line up for lunch, hand hygiene was recorded by classroom teachers for 1 week. After the observational period, each classroom received intervention 2 due to the remarkable increase in student hand hygiene of those originally assigned to this intervention. Three months post intervention, teachers recorded student hand hygiene behaviors in classroom prior to lining up for lunch. A hand hygiene attempt was dened as rubbing hands with alcohol hand sanitizer or applying soap to hands and rubbing under running water. Procedure Phase I. Classrooms were divided into 3 groups: control, intervention 1, and intervention 2. Students in the control group were instructed by the teacher per school policy to Wash your hands then line up for lunch. Intervention 1 consisted of the teacher instructing the students to Wash your hands then line up for lunch, followed by the teacher walking over to the classroom sink and washing his/her hands. Intervention 2 involved a guest educator teaching a 30-minute grade-appropriate lesson that introduced what germs are, how germs can make people ill, when to wash hands, how to wash your hands, and when it is appropriate to use alcohol hand sanitizers. After the guest educator presented the information, students were given an on-hands experience using simulated germ lotion to see the effectiveness of their hand washing using soap and water. The teacher instructed the students every day following the guest presentation to Wash your hands and line up for lunch, and remember we dont want germs on our hands. Over the week of observation, teachers were instructed to record student hand hygiene using soap and water or alcohol sanitizer prior to lining up for lunch. Males and females were to be tallied separately and classroom absences were to be noted as well in order to stratify data based on sex and calculate percentages of hand hygiene. Students were not told that they were being observed for hand hygiene. Phase II. Three months post intervention, teachers were instructed to observe hand hygiene practices on a specied day and record student attempts at hand hygiene using alcohol hand sanitizer or soap and water after giving the verbal cue Wash your hands and line up for lunch.
Journal of School Health
d

Data Analysis A 2-sample test of proportion was used to test for signicant differences between the control group and each intervention group as well as the subgroups male and female. The proportions were calculated by taking the total number of teacher-observed hand washes or alcohol hand sanitizer rubs, after the verbal cue to wash and line up for lunch, divided by the number of students in each classroom during the observational period. Statistical calculations were performed using Stata software 8.0 2003 (Statacorp LP, College Station, TX). RESULTS Phase I. Percentage of hand hygiene was calculated per grade level, sex, and by intervention (Table 1). Regardless of intervention, rst graders had the highest rate of hand hygiene, with 85.0% of the children performing hand hygiene before lining up for lunch. Second through fourth graders were next in rate of hand hygiene with a range of 66%, 58%, and 64%, respectively. A signicant drop in hand hygiene rates was observed in the fth and sixth graders. Only 32% of the fth graders and 36% of the sixth graders practiced some form of hand hygiene after the teacher gave the verbal cue to wash and line up for lunch. Additional statistical comparisons were computed between the overall proportion of hand hygiene of the control and intervention groups; as complexity of interventions increased, so did the rate of student hand hygiene. These ndings did not change when the results were stratied by sex (Table 2). Phase II. Three months post intervention, hand hygiene rates remained virtually unchanged for the total population, with 78% of the children attempting
Table 1. Proportion of Hand Hygiene Sorted by Intervention, Sex, and Aggregate
% Hand Hygiene Intervention 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 Grade 1 2 4 5 6 1 2 3 4 5 6 1 2 3 4 5 Male 56 19 68 00 23 100 74 54 20 33 29 100 93 37 93 44 (28/50) (15/80) (41/60) (0/90) (15/65) (55/55) (59/80) (43/80) (12/60) (28/85) (19/65) (55/55) (65/70) (33/90) (51/55) (40/90) Female 69 40 82 23 52 85 76 97 22 33 36 100 95 41 100 60 (45/65) (20/50) (49/60) (17/75) (49/95) (51/60) (38/50) (58/60) (12/55) (26/80) (31/85) (55/55) (57/60) (37/90) (60/60) (45/75) Aggregate 63 30 75 12 38 93 75 76 21 33 33 100 94 39 97 52

April 2008, Vol. 78, No. 4

2008, American School Health Association

231

Table 2. Hand Hygiene Frequency Among Intervention Groups: Phase I

Group Aggregate Control Intervention 1 Intervention 2 Stratification by sex Malescontrol Malesintervention 1 Malesintervention 2 Femalescontrol Femalesintervention 1 Femalesintervention 2 Hand Hygiene* 0.38 (321/845) 0.53 (430/815) 0.78 (627/800) 0.29 0.51 0.75 0.47 0.55 0.82 (122/425) (216/425) (308/410) (199/420) (214/390) (319/390) p Value

,.01 ,.01 ,.01 ,.01 ,.01 .01 ,.01

*Total observed classroom hand washes or alcohol hand sanitizing after teachers verbal cue/number of children in attendance. Control proportion compared to intervention proportions and stratification by sex, male and female, using a 2-sample test of proportion.

to wash their hands before lining up for lunch. Furthermore, when stratied by sex, 74% of the males and 82% of the females attempted to wash their hands or use alcohol hand sanitizer. The differences between male and female controls and males and females in interventions 1 and 2 were all statistically signicant (p , .01).

DISCUSSION The goal of this project was to improve the hand hygiene of elementary school children using an inexpensive intervention that could be completed within 30 minutes or less and would ultimately improve the rates of hand hygiene. The costs for the project were as follows: simulated germ lotion 3 bottles at a cost of $41.85 (only 2.25 bottles were actually used) and 1 black light at a cost of $21.95. No nancial or material support for this project was obtained from the simulated germ lotion company, nor were any of the authors employed by the simulated germ lotion company. Overall, teacher support was high for the project. One teacher refused to have her class participate due to her claim that her grown son received a hand washing lesson while attending elementary school and exhibiting compulsive hand and foot hygiene habits that took years to overcome. Three other teachers did not wish to observe and record the frequency of hand hygiene but did want their students to receive intervention 2. The teachers decision resulted in the class being removed from the project, which affected the ability to completely randomize the study population. Due to the remarkable increase in hand hygiene rates among children who received intervention 2, all students received intervention 2 after the study was completed. Teachers did not want to record hand hygiene for all 30 days; however, they did agree to

observe and record student hand hygiene at 1 week 3 months post intervention. The true impact of this project is unknown due to teachers only observing the classroom sinks with no attempt to monitor bathroom sinks. Bathroom sinks were not monitored out of concern of a Hawthorne effect, creating a higher frequency of hand hygiene as a direct result of teacher observation in the bathroom. The likelihood of children washing their hands in the bathroom prior to going to the lunchroom was very remote due to children lining up at the classroom door and being escorted to the lunchroom by their teacher. Classroom observation was performed from the teachers desks, which were located directly across the room from the classroom sinks. No children commented or appeared to notice the teachers tallying of hand hygiene behavior during phase I or II. Difculties identied during the project included 2 of the 16 sinks were clogged, 1 broken paper towel dispenser, and 1 empty paper towel dispenser. These difculties did not affect the recording of student hand hygiene behavior as teachers recorded any attempt at hand hygiene not completion of the task, that is, drying of hands. Facility and hand hygiene product difculties such as those experienced in this project appear to be common and have been noted in other studies.10,15 The information gleaned from this project is congruent with previous studies regarding elementary schoolaged childrens short-term hand hygiene practices after introducing hand hygiene education. However, we found that hand hygiene education need not be expensive or lengthy to impact the rate of student hand hygiene. Intervention 1, a verbal cue to action, was coupled with the teacher modeling hand hygiene. This method did not cost any money and took only 23 minutes of the teachers time. It is worth mentioning that teacher modeling of hand hygiene appeared to inuence male students frequency of hand hygiene to a larger extent than that of female students; perhaps this observation is due to a higher baseline of hand hygiene among female students. The cost of intervention 2 was $63.80. The presentation lasted between 25 and 35 minutes per classroom depending on the class size and the number of student questions. Intervention 2 demonstrated a dramatic overall increase in rates of hand hygiene, almost a 3-fold increase, when compared to the control group. Once again, male students demonstrated a larger proportional increase in hand hygiene over female students using the visual exercise of intervention 2, which demonstrated the effectiveness of each students hand hygiene using simulated germ lotion. Based on results of this work, both intervention 1 and intervention 2 were superior to the control group in facilitating higher rates of hand hygiene behavior.

232

Journal of School Health

April 2008, Vol. 78, No. 4

2008, American School Health Association

The practical application of this study may be as simple and cost free as having the classroom teachers cue students to wash their hands prior to lining up for lunch as he/she sets the example by immediately washing his/her hands at the classroom sink. Or if there are parent volunteers and approximately $65.00 available through the Parent Teachers Association or Community Counsel, the school nurse could train volunteers to teach a hand hygiene module using germ-simulating lotion. As our study demonstrated, both of these interventions signicantly contributed to an increase in alcohol hand sanitizing rubs and hand washing rates among children. We recommend additional research focusing on the long-term effects of teacher hand hygiene verbal cues to action, modeling, and educational interventions used in this project to determine if a long-term, 3 months, sustainable increase in student hand hygiene might be demonstrated. In summary, teacher verbal cue to action and modeling, as well as hand hygiene education coupled with a visual exercise of the effectiveness of student hand hygiene, resulted in a sustainable increase in the frequency of hand hygiene among elementary school aged children.

REFERENCES
1. World Health Organization, Regional Ofce for Africa. Division of Healthy Environments and Sustainable Development. Food Safety Unit (FOS). Handwashing and food safety. Available at: http://www.afro.who.int/des/fos/afro_codex-fact-sheets/handwash-fact-sheet2.pdf. Accessed March 19, 2006. 2. World Health Organization. Hand-washing could save the lives of millions of children. Bull World Health Organ. 2004;82(8). Available at: http://www.who.int/bulletin/volumes/82/8/en/news. pdf. Accessed March 19, 2006.

3. World Health Organization. Annex 1: Hand washing. Practical guidelines for infection control in health care facilities. December 2004. Available at: www.wpro.who.int/sars/docs/practicalguidelines/dec2004/annexes.pdf. Accessed March 19, 2006. 4. United States Department of Health and Human Services, Centers for Disease Control and Prevention, Ofce of Communication, Division of Media Relations. Hand hygiene guidelines fact sheet. October 25, 2002. Available at: http://www.cdc.gov/od/oc/ media/pressrel/fs021025.htm. Accessed March 20, 2006. 5. Guideline for hand hygiene in health-care settings. Recommendations of the Health-care Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recomm Rep. October 25, 2002/51(RR16);1-44. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5116a1.htm. Accessed March 20, 2006. 6. Guinan M, McGucklin M, Ali Y. The effect of a comprehensive hand washing program on absenteeism in elementary schools. AM J Infect Control. 2002;30(4):217-220. 7. Thompson K. The effects of alcohol hand sanitizer on elementary school absences. Am J Infect Control. 2004;332:E127. 8. Morton JL, Schultz AA. Healthy hands: use of alcohol gel as an adjunct to handwashing in children. J Sch Nurs. 2004;20(3): 161-167. 9. Master D, Hess-Longe S, Dickson H. Scheduled hand washing in an elementary school population. Fam Med. 1997;29(5):336-339. 10. Early E, Battle K, Cantwell E, English J, Lavin JE, Larson E. Effect of several interventions on the frequency of handwashing among elementary public school children. Am J Infect Control. 1998; 26(3):263-269. 11. Hammond B, Ali Y, Fendler E, Dolan M, Donovan S. Effect of hand sanitizer use on elementary school absenteeism. Am J Infect Control. 2000;28(5):340-346. 12. Dyer DL, Shinder A, Shinder F. Alcohol-free instant hand sanitizer reduces elementary school illness absenteeism. Fam Med. 2000;32(9):633-638. 13. Gore J, Lambert JA. Does use of an instant hand sanitizer reduce elementary school illness absenteeism? J Fam Pract. 2001;50(1):64. 14. Hezel L, Bartlett C, Hileman JW, Dillon L, Cessna T. Effective hand washing in an elementary school. Sch Nurse News. 2000; 17(3):26-30. 15. Kimel LS. Handwashing education can decrease illness absenteeism. J Sch Nurs. 1996;12:14-18.

Journal of School Health

April 2008, Vol. 78, No. 4

2008, American School Health Association

233