- Email: [email protected]
Effect of several interventions on the frequency of handwashing among elementary public school children
Effect of several interventions on the frequency of handwashing among e l e m e n t a r y public school children |
Eve Early, MT, MA, CIC" Kimberly Battle, RNC, BSN ~ Eileen Cantwell, RN, BSN, CIC c Judith English, RN, MSN, CIC ~ J'Anne E. Lavin, RN, BSN, CRRN, CIC e Elaine Larson, RN, PhD, ClC b Rockville and Bethesda, Maryland, Washington, D.C., and Falls Church, Virginia
Background: The purpose of this educational project was to assess the effect of several
interventions on the frequency of handwashing among elementary public school children. Methods: Participants in this project were first-graders and fourth-graders from jurisdic-
tions within a mid-Atlantic metropolitan area. Phase I included a baseline assessment of bathroom cleanliness as well as adequacy of supplies for handwashing in each school. During phase 2, the frequency of handwashing before lunch or after bathroom use was monitored and recorded during a 2-month period. The schools were separated into four groups: a peer education group, a hand wipes and instructional poster group, a combination of the education and band wipes/poster groups, and a (control) comparison school. Results: Overall, a significant increase occurred in the proportion of handwashing frequency from preintervention to postintervention for each intervention group (wipes: 0.50 vs 0.66, p = 0.03; education only: 0.64 vs 0.72, p = 0.02; and education and wipes: 0.45 vs 0.67, p = 0.03) but not in the control group (0.42 vs 0.46, p = 0.26). When the first 3 weeks and the last 3 weeks after intervention were compared, handwashing frequency remained unchanged in the wipes only group (0.66 vs 0.66, p = 0.96), decreased in the education group (0.77 vs 0.65, p = 0.006), and increased in the education and wipes group (0.58 vs 0.75, p = 0.003), as well as in the control group (0.37 vs 0.52, p = 0.01). Conclusion: Education combined with accessible convenient hand hygiene may result in a sustainable increase in the frequency of handwashing among elementary school children. (AJIC Am J Infect Control 1998;26:263-9)
Hands are the primary mode of transmission of many infectious diseases, particularly among school-age children. Handwashing is the most effective means of preventing the spread of certain infectious diseases.l However, little is known about handwashing in public schools. Problems such as lack of time or inad-
From Shady Grove Adventist Hospital, Rockville, Md., a Georgetown University School of Nursing, Washington, D.C., b Northern Virginia Mental Health Institute, Falls Church, Va.,o National Naval Medical Center, Bethesda, Md., ~ National Rehabilitation Hospital, Washington, D.C. + Supported in part by Procter & Gamble, Cincinnati, Ohio. Reprint requests: Eve Early, MT, MA, CIC, Infection Control Practitioner, Shady Grove Adventist Hospital, 9901 Medical Center Dr., Rockville, MD 20850. Copyright 9 1998 by the Association for Professionals in Infection Control and Epidemiology, Inc. 0196-6553/98 $5.00 + 0
17/46/86759
equate washing facilities make it difficult for children to maintain adequate hand hygiene in school. The Washington, D.C. Metro Chapter of the Association for Professionals in Infection Control and Epidemiology (APIC), in collaboration with local public schools, undertook a project designed to assess the effectiveness of several interventions on increasing the frequency of handwashing among elementary school children.
METHODS Sample Public elementary schools were identified to participate in the project by school health educators, public school officials, or project team members. A series of preliminary planning meetings with school officials was conducted to discuss objectives and solicit support for the project. Although no standard consent procedures existed, appropriate permissions were obtained in accor-
AJIC
2 6 4 Early et al.
June 1998
(1)
(2)
(3)
(4)
(~
(6)
(7)
Bathroom
T o ilet/Uri na l s Total # Each
Sinks # Functional / Total
Soap Dispensers # Functional / Total
T y p e o f Soap Bar/Liquid
P a p e r Towel Dispenser # Functional / Total
Air Driers # Functional / Total
1. 2, 3. 4. 5. 6. 7. 8. 9. 10. (1) To be oampl~cd for each Bathroom = general appcatance, Le., any paper towels, at Irash on floor? Y = 1, N : 0 (3) Fuactic~al deiined as draioing~not occluded, and with tm~amgwat~ (4) r a n ~ o n ~ (soap in ~ s p e ~ ) (5) Bar = 2, IAquid = 1 (6) Functicdaaldefmedas with papertnesmt s Veac~oaat = Opwai,~d
Fig. 1. Uniform data collection sheet.
dance with specific directions from each jurisdiction or school. To identify a 25% improvement in the frequency of handwashing after the intervention with a power of 80% and an alpha o f p = 0.05, it was necessary to have at least 100 observations of handwashing opportunities before and after the intervention. 2 On the basis of this sample size calculation and the n u m b e r of bathrooms available in the schools for observation, bathrooms in six schools were observed and five schools were included in the intervention phase of study. Schools were assigned to one of the four intervention groups (described later) on the basis of practical issues such as physical layout, teacher availability, school preference, and timing (eg, school calendar and holiday schedules). Procedure
Phase I of the study was designed to assess b a t h r o o m cleanliness and adequacy of supplies for handwashing in each school. Six schools were visited on two separate occasions in the early morning, before normal operating hours. The b a t h r o o m s were observed for general tidiness (eg, absence of paper on the floor), running water in sinks, availability and type of soap, availability of paper towels or hot air dryers, and functioning toilets or urinals. Observations were m a d e on a u n i f o r m data collection sheet (Fig. 1) by trained m e m b e r s of the project team. In p h a s e II of the study, the f r e q u e n c y of h a n d w a s h i n g b e f o r e l u n c h or after b a t h r o o m
use w a s o b s e r v e d in the b a t h r o o m s of each p a r t i c i p a t i n g school b y t r a i n e d m e m b e r s of the p r o j e c t team. S o m e schools h a d only h a l l w a y b a t h r o o m s a n d o t h e r s h a d b a t h r o o m s in the classroom; b o t h types w e r e observed. Several variables w e r e collected on the data collection i n s t r u m e n t : o p p o r t u n i t y for h a n d w a s h i n g (after use of the toilet or urinal or i m m e d i a t e ly b e f o r e l u n c h ) , w h e t h e r h a n d w a s h i n g o c c u r r e d (with at least r u n n i n g w a t e r or a h a n d wipe), w h e t h e r s o a p w a s u s e d , a n d w h e t h e r h a n d s w e r e dried (unless a h a n d wipe w a s used). A pilot test w a s c o n d u c t e d b y t h r e e of the p r o j e c t t e a m m e m b e r s to d e t e r m i n e i n t e r r a t e r reliability until an a g r e e m e n t of >95% on all o b s e r v e d variables w a s attained. Subsequently, these t h r e e investigators t r a i n e d o t h e r observers. Observations were m a d e at three time intervals: before beginning any intervention (baseline), and then from 2 to 3 weeks, and from 4 to 6 weeks after the intervention. Observations during each time interval were m a d e on at least two separate occasions. Although the goal was to observe a m i n i m u m of 60 opportunities for h a n d w a s h i n g during each time interval, this was not possible at all schools b e c a u s e of insufficient opportunities for observation, even after several trips to each school. The average observation time was 2 to 3 hours per observation period or 10 to 15 hours p e r school. A m a x i m u m observation time of 4 to 6 hours per school per
AJIC
Early et al. 2 6 5
Volume26, Number3
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Fig. 2. Instructional poster.
time interval was set b e c a u s e of practical limitations on project t e a m time and b e c a u s e of the limitations of school hours. Although the control school received no intervention, the timing of observations for that school was consistent with the timing in the intervention schools. All observations occurred b e t w e e n October 1996 and J a n u a r y 1997. Observers were m e m b e r s of the project staff w h o were located unobtrusively in the girls' b a t h r o o m s (for hallway b a t h r o o m s ) or in the classrooms (for classroom bathrooms). Because all observers were women, hallway b a t h r o o m observations did not include male students; however, boys were observed in the classrooms. Classroom observations were scheduled before lunch. Teachers were instructed not to inform students that they were being observed for handwashing. Project staff m e m b e r s wore n a m e tags designating them as visitors to the school. If stu-
1 " a b l e 11, H y g i e n i c a s s e s s m e n t of b a t h r o o m s
Bathrooms clean Toilets flush Urinals flush Sinks operable with running water Soap dispensers filled and functional Paper towel dispensers with paper present Air dryers operational Type of soap in bathroom Bar Liquid Bar and liquid None
98.3% (59/60 observations) 99.4% (158/160) 100% (86/86) 100% (129/129) 34.1% (44/129) 90.6% (29/32) 66% (4/6) 13.3% (8/60) 78.3% (47/60) 6.7% (4/60) 1.7% (1/60)
dents asked an observer what she was doing, she was instructed to respond: "I am working with the school looking at cleanliness. I will be coming back several times."
AJIC 266
Early et al.
June 1998
Table 2. Handwashing frequency among four study groups Time
Baseline Preintervention
Postintervention
Preintervention to postintervention comparison
Postintervention: First 3 weeks compared with Last 3 weeks
Group
Control Education Wipes Education/wipes ControL Education Wipes Educati0n/wipes Control
Education Wipes Education/wipes Control
*Handwashing
0.42 0.64 0.50 0.45 0.46 0.72 0.66 0.67
Before intervention
After intervention
First 3 weeks
Second 3 weeks
(21/50) (164/256) (25/50) (10/22) (121/261) (280/387) (192/291) (186/277)
pValue
<0.01
<0.01
0.42 (21/50)
0,46 (121/261)
0.26
0.64 (164/256) 0.72 (280/387) 0.50 (25/50) 0.66 (192/291) 0.45 (10/22) 0.67 (186/277)
Education Wipes Education/wipes
0.37 (35/95)
0.52 (86/166)
0.02 0.03 0.03 0.01
0.77 (176/227) 0.66 (115/174) 0.58 (76/130)
0.65 (104/160) 0.66 (77/117) 0.75 (110/147)
0.006 0.96 0.003.
*Observed handwashes/handwashingindications(after using the bathroom or before lunch).
Interventions
Four handwashing interventions were tested in five schools: a peer educational program (two schools), introduction of hand wipes with an instructional poster (Fig. 2) in bathrooms (one school), a combination of the educational program and hand wipes (one school), and a comparison school that had no intervention but handwashing was observed. The peer education program was suggested by public school officials who were interested in assessing the effectiveness of peer-presented material on student learning and behavior. Content of the program was based on materials developed by P r o c t e r & Gamble (Healthy Hygiene, Cincinnati, Ohio) for a national project to encourage handwashing by first-graders. Members of the project team provided an assembly-style class to the fourth-graders in two schools. Selected fourth-graders then conducted a class for the first-graders, with assistance from their teachers and project staff members. The content of the class for the fourth-graders included a video presentation of a clown doing a handwashing demonstration (developed by the project coordinators), storyboards, overheads, posters, and training on how to use various teaching techniques for firstgraders. Information in the educational materi-
al included the three main types of "germs" (bacteria, viruses, fungi), where germs live, how germs are transmitted, and when, why, and how to wash hands. The class for the first-graders included the use of storyboards, a video presentation, and an interactive song that emphasized the steps of handwashing. The fourth-graders also gave stickers to first-graders to denote their participation in t h e handwashing program. H a n d wipes impregnated with alcohol, a lemon fragrance, and an emollient were made available in one school, and students were instructed how to use the hand wipes with a large poster mounted in the bathrooms. Special containers were placed in each observation area and were stocked routinely during the study by either the housekeeping staff or the teacher (depending on the location of the bathrooms). Peer education a n d hand wipes, as described above, were combined and both were used in one school. In addition, one control school received no intervention but observations were made at the same intervals as in the intervention schools. D a t a analysis
The X2 statistic was used to compare handwashing frequency between schools at the baseline and after the intervention, preintervention to postintervention for each group, and postin-
AJIC
Early et al. 2 6 7
Volume 26, Number 3
tervention between the study groups. Additionally, changes in handwashing frequency were compared by using Z2 between the study groups for the first 3 weeks and the second 3 weeks after the intervention (to test the sustainability of the intervention). RESULTS Phase I
During a 2-month time period (November 1996 to J a n u a r y 1997), 30 bathrooms in the six schools were observed on two separate occasions (60 observations). During this time, five additional bathrooms were inaccessible to the observers because they were locked. Bathrooms generally were clean, except one bathroom that had towels or b a t h r o o m tissue on the floor. In the 30 bathrooms, there were a total of 86 urinals, 160 toilets, and 129 sinks. Generally, the toilets and urinals flushed (158 of 160 and 86 of 86 respectively). All (n = 129) of the sink faucets drained and had running water but 66% (85 of 129) of the soap dispensers were nonfunctional or had insufficient soap. In 13.3% (8 of 60) of the observations, bathrooms contained only bar soap, 78.3% (47 of 60) contained liquid, 6.7% (4 of 60) contained both bar and liquid soap, and 1.7% (1 of 60) contained no soap. Ninety percent (29 of 32) of the towel dispensers contained towels. One third of the air dryers (2 of 6) were mechanically inoperable (Table 1). P h a s e II
For the entire study group, handwashing overall occurred 58% (220 of 378) of the time at the baseline and 67% (186 of 277) of the time after intervention. During the baseline phase before intervention, significant differences in the p r o p o r t i o n of h a n d w a s h i n g between the four intervention groups existed. In the control school, handwashing occurred 42% of the time; wipes only, 50%; education only, 64%; and education and wipes, 45% (p < 0.01). After intervention, significant differences in the p r o p o r t i o n of h a n d w a s h i n g between the four intervention groups also existed. In the control school, handwashing occurred 46% of the time; wipes only, 66%; education only, 73%; and education and wipes, 67% (p < 0.01). Additionally, significant increases in the proportion of handwashing
from preintervention to postintervention for each intervention group occurred (wipes only, p = 0.02; education only, p = 0.02; education and wipes group, p = 0.02); but not in the control group (p = 0.26). In the education only group, handwashing frequency decreased during the last 3 weeks when c o m p a r e d with the first 3 weeks postintervention (p = 0.006); frequency of handwashing was unchanged over time in the wipes group (p = 0.96); and increased in both the control (p = 0.01 ) and the e d u c a t i o n and wipes groups (p = 0.003)(Table 2). DISCUSSION
Studies to improve handwashing frequency have focused primarily on adults, particularly health care workers. ~-3 This collaborative comm u n i t y education project was designed to improve the hand hygiene of public school children. Although Day and colleagues 4 concluded that education was insufficient to affect longterm changes in handwashing behavior among children, handwashing education programs in o t h e r studies have been associated with reduced absenteeism, better school attendance, and decreased transmission of enteric organisms. s-9 Studies from o t h e r countries have demonstrated correlations between community educational initiatives to improve handwashing and subsequent reductions in the prevalence of childhood diarrhea. ~0-~2 Community-based research is complex, presenting both administrative and feasibility challenges. A major administrative challenge in this study was the lack of a clear, identifiable decision-making procedure or authority within or among school districts. Although uniform e n t h u s i a s m for the project existed a m o n g school officials and teachers, it took months to negotiate t h r o u g h various school systems. Once schools within a district were identified for participation, our contacts within the schools ranged from principals, classroom teachers, health educators, to school nurses. The contacts' willingness and ability to facilitate the project varied considerably. Additionally, certain schools were willing to participate only in selected interventions, and this hindered the r a n d o m assignment of schools to the intervention groups. Other challenges to conducting this community-based research related to feasibility. The researchers and school officials spent consider-
2 6 8 Early et al.
able time contemplating the issue of student privacy and consent procedures, because no u n i f o r m policies existed for the schools. Observation times had to conform to public school schedules; each school was scheduled for comparable hours of observation. However, the actual n u m b e r of preintervention observations for the control, wipes, and education and wipes groups were not equal. The impact on the conclusion of the study is unknown. In the schools in which observed students used hall bathrooms, the observations were completed only in the girls' bathrooms because no male observers were available. Even though the majority of observations were performed in classrooms with bathrooms where boys and girls were observed, we did not attempt to evaluate any potential differences in handwashing behavior between boys and girls. Therefore, the results of the study may not be generalized. Ideally, observers would be blinded to the study hypotheses. A limitation in this study was that the r e s e a r c h e r s served as data collectors because of budgetary constraints. The hand wipes provided information about the acceptance and logistics of the use of these products in a school setting. Another problem was the difficulty in keeping the bathrooms supplied with hand wipes. At one point, for example, the containers for the wipes were missing. Kimel 6 previously has reported aesthetic problems in elementary school bathroom facilities. The fact that we frequently found containers with insufficient soap and that the hand wipes were difficult to stock seems to be an ongoing problem in schools. However, this did not affect the study results, as a handwash was counted as long as the student used at least running water or a hand wipe. Finally, participating teachers cited lack of time in the school day to reinforce handwashing behavior or even to provide opportunity for students to wash their hands. Surprisingly, this problem was not mentioned in several previous studies. 6. Our results are congruent with previous findings regarding the immediate positive effect of handwashing education on modifying children's behavior. 9 However, we found that education alone was not effective in increasing the frequency of handwashing over time. Although the frequency of handwashing in the control grouP was not significantly different before and after the intervention period, a significant increase in handwashing among controls over time did
AJIC June 1998
exist between the first and second 3-week periods of postintervention observation. This clearly suggests that just the presence of the observers was associated with the Hawthorne effect, with handwashing increasing over time. This was not the case in either the education or hand-wipe groups, in which immediate statistically significant increases in h a n d w a s h i n g occurred but were not sustained after a few weeks. The group that received both the education and the hand wipes had the greatest increase in handwashing frequency, which was not only immediate but also sustained over time. Hence, we conclude that a simple, onetime peer education program that is reinforced by easy to use and accessible handwashing materials has the potential for a positive impact on the handwashing practices of elementary school children. We r e c o m m e n d several studies to extend this preliminary work. First, Zeitlyn and Islam 12 described the symbolic significance of soap and water in India. Public schools in the United States are characterized by increasing multiculturalism. E d u c a t i o n a l interventions related to hygiene must consider the cultural diversity of our communities, both in terms of teaching approaches and with regard to the meanings of hygienic practices across cultures. Future research should be designed to examine the correlation between handwashing frequency and illness among children and educators, to assess the effect of interventions over longer periods of time (months to years), and to examine the need for retraining or reinforcement at various age levels. In summary, education combined with accessible, convenient hand hygiene products m a y result in a sustainable increase in the frequency of handwashing among elementary school children. In addition to further research to extend and confirm these and other findings, we suggest that schools, through coordinated comprehensive school health programs, develop standard policies and procedures to facilitate collaboration with other agencies or individuals to conduct potentially useful community-based projects. Finally, equipment and supplies for hand hygiene in schools should be designed for durability to Prevent tampering or pilfering. We gratefully acknowledge the assistance and collaboration of Anne Wiseman, RN, CPHQ (Project Coordinator), and the five Maryland and Virginia public elementary schools that participated in this study.
AJIC
Early et al. 2 6 9
Volume 26, Number 3
References 1. Lachin JM. Introduction to sample size determination and power analysis for clinical trials. Controlled Clin Trials 1981;2:93-113. 2. Larson E. A causal link between handwashing and risk of infection? Examination of the evidence. Infect Control Hosp Epidemiol 1988;9:28-36. 3. Bryan JL, Cohran J, Larson E. Handwashing: a ritual revisited. In: Rutula WA, editor. Chemical germicides in health care. Morin Heights: Association for Professionals in Infection Control and Epidemiology, Inc. and Polyscience; 1994. p. 163-78. 4. Day RA, Amaud S, Monsoma M. Effectiveness of a handwashing program. Clin Nurs Res 1993;2:24-40. 5. Niffenegger JE Proper handwashing promotes wellness in children. J Pediatr Health Care 1997; 11:26-31. 6. Kimel LS. Handwashing education can decrease illness absenteeism. J Sch Nurs 1996;12:14-8.
7. Krilov LR, Barone SR, Mandel FS, Cusack TM, Gaber DJ, Rubino JR. Impact of an infection control program in a specialized preschool. Am J Infect Control 1996;24:167-73. 8. Mohle-Boetani JC, Stapleton M, Finger R, Bean NH, Poundstone J, Blake PA, et al. Community-wide Shigellosis: control of an outbreak and risk factors in child daycare centers. Am J Public Health 1995;85:812-6. 9. Monsma M, Day R, Arnaud S. Handwashing makes a difference. J Sch Health 1992;62:109-11. I0. Ferson MJ. Control of infections in child care. Med J Aust 1994;161:615-8. 11. Haggerty PA, Muladi K, Kirkwood BR, Ashworth A, Mannuebo M. Community-based hygiene education to reduce diarrheal disease in rural Zaire. Impact of the intervention on diarrhoeal morbidity. Int J Epidemiol 1994;23:1050-9. 12. Zeitlyn S, Islam E The use of soap and water in two Bangladeshi communities. Implications for the transmission of diarrhea. Rev Infect Dis 1991; 13(Suppl):S259-64.
Availability of Journal back issues As a service to our subscribers, copies of back issues of AJIC: American Journal of Infection Control for the preceding 5 years are maintained and are available for purchase from the publisher, Mosby, at a cost of $12.00 per issue until inventory is depleted. The following quantity discounts are available: 25% off on quantities of 12 to 23, and one third off on quantities of 24 or more. Please write to Mosby, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, MO 63146-3318, or call 800-453-4351 or 314-453-4351 for information on availability of particular issues. If unavailable from the publisher, photocopies of complete issues may be purchased from UMI, 300 N. Zeeb Rd., Ann Arbor, MI 48106, 313-761-4700.
Eve Early, MT, MA, CIC" Kimberly Battle, RNC, BSN ~ Eileen Cantwell, RN, BSN, CIC c Judith English, RN, MSN, CIC ~ J'Anne E. Lavin, RN, BSN, CRRN, CIC e Elaine Larson, RN, PhD, ClC b Rockville and Bethesda, Maryland, Washington, D.C., and Falls Church, Virginia
Background: The purpose of this educational project was to assess the effect of several
interventions on the frequency of handwashing among elementary public school children. Methods: Participants in this project were first-graders and fourth-graders from jurisdic-
tions within a mid-Atlantic metropolitan area. Phase I included a baseline assessment of bathroom cleanliness as well as adequacy of supplies for handwashing in each school. During phase 2, the frequency of handwashing before lunch or after bathroom use was monitored and recorded during a 2-month period. The schools were separated into four groups: a peer education group, a hand wipes and instructional poster group, a combination of the education and band wipes/poster groups, and a (control) comparison school. Results: Overall, a significant increase occurred in the proportion of handwashing frequency from preintervention to postintervention for each intervention group (wipes: 0.50 vs 0.66, p = 0.03; education only: 0.64 vs 0.72, p = 0.02; and education and wipes: 0.45 vs 0.67, p = 0.03) but not in the control group (0.42 vs 0.46, p = 0.26). When the first 3 weeks and the last 3 weeks after intervention were compared, handwashing frequency remained unchanged in the wipes only group (0.66 vs 0.66, p = 0.96), decreased in the education group (0.77 vs 0.65, p = 0.006), and increased in the education and wipes group (0.58 vs 0.75, p = 0.003), as well as in the control group (0.37 vs 0.52, p = 0.01). Conclusion: Education combined with accessible convenient hand hygiene may result in a sustainable increase in the frequency of handwashing among elementary school children. (AJIC Am J Infect Control 1998;26:263-9)
Hands are the primary mode of transmission of many infectious diseases, particularly among school-age children. Handwashing is the most effective means of preventing the spread of certain infectious diseases.l However, little is known about handwashing in public schools. Problems such as lack of time or inad-
From Shady Grove Adventist Hospital, Rockville, Md., a Georgetown University School of Nursing, Washington, D.C., b Northern Virginia Mental Health Institute, Falls Church, Va.,o National Naval Medical Center, Bethesda, Md., ~ National Rehabilitation Hospital, Washington, D.C. + Supported in part by Procter & Gamble, Cincinnati, Ohio. Reprint requests: Eve Early, MT, MA, CIC, Infection Control Practitioner, Shady Grove Adventist Hospital, 9901 Medical Center Dr., Rockville, MD 20850. Copyright 9 1998 by the Association for Professionals in Infection Control and Epidemiology, Inc. 0196-6553/98 $5.00 + 0
17/46/86759
equate washing facilities make it difficult for children to maintain adequate hand hygiene in school. The Washington, D.C. Metro Chapter of the Association for Professionals in Infection Control and Epidemiology (APIC), in collaboration with local public schools, undertook a project designed to assess the effectiveness of several interventions on increasing the frequency of handwashing among elementary school children.
METHODS Sample Public elementary schools were identified to participate in the project by school health educators, public school officials, or project team members. A series of preliminary planning meetings with school officials was conducted to discuss objectives and solicit support for the project. Although no standard consent procedures existed, appropriate permissions were obtained in accor-
AJIC
2 6 4 Early et al.
June 1998
(1)
(2)
(3)
(4)
(~
(6)
(7)
Bathroom
T o ilet/Uri na l s Total # Each
Sinks # Functional / Total
Soap Dispensers # Functional / Total
T y p e o f Soap Bar/Liquid
P a p e r Towel Dispenser # Functional / Total
Air Driers # Functional / Total
1. 2, 3. 4. 5. 6. 7. 8. 9. 10. (1) To be oampl~cd for each Bathroom = general appcatance, Le., any paper towels, at Irash on floor? Y = 1, N : 0 (3) Fuactic~al deiined as draioing~not occluded, and with tm~amgwat~ (4) r a n ~ o n ~ (soap in ~ s p e ~ ) (5) Bar = 2, IAquid = 1 (6) Functicdaaldefmedas with papertnesmt s Veac~oaat = Opwai,~d
Fig. 1. Uniform data collection sheet.
dance with specific directions from each jurisdiction or school. To identify a 25% improvement in the frequency of handwashing after the intervention with a power of 80% and an alpha o f p = 0.05, it was necessary to have at least 100 observations of handwashing opportunities before and after the intervention. 2 On the basis of this sample size calculation and the n u m b e r of bathrooms available in the schools for observation, bathrooms in six schools were observed and five schools were included in the intervention phase of study. Schools were assigned to one of the four intervention groups (described later) on the basis of practical issues such as physical layout, teacher availability, school preference, and timing (eg, school calendar and holiday schedules). Procedure
Phase I of the study was designed to assess b a t h r o o m cleanliness and adequacy of supplies for handwashing in each school. Six schools were visited on two separate occasions in the early morning, before normal operating hours. The b a t h r o o m s were observed for general tidiness (eg, absence of paper on the floor), running water in sinks, availability and type of soap, availability of paper towels or hot air dryers, and functioning toilets or urinals. Observations were m a d e on a u n i f o r m data collection sheet (Fig. 1) by trained m e m b e r s of the project team. In p h a s e II of the study, the f r e q u e n c y of h a n d w a s h i n g b e f o r e l u n c h or after b a t h r o o m
use w a s o b s e r v e d in the b a t h r o o m s of each p a r t i c i p a t i n g school b y t r a i n e d m e m b e r s of the p r o j e c t team. S o m e schools h a d only h a l l w a y b a t h r o o m s a n d o t h e r s h a d b a t h r o o m s in the classroom; b o t h types w e r e observed. Several variables w e r e collected on the data collection i n s t r u m e n t : o p p o r t u n i t y for h a n d w a s h i n g (after use of the toilet or urinal or i m m e d i a t e ly b e f o r e l u n c h ) , w h e t h e r h a n d w a s h i n g o c c u r r e d (with at least r u n n i n g w a t e r or a h a n d wipe), w h e t h e r s o a p w a s u s e d , a n d w h e t h e r h a n d s w e r e dried (unless a h a n d wipe w a s used). A pilot test w a s c o n d u c t e d b y t h r e e of the p r o j e c t t e a m m e m b e r s to d e t e r m i n e i n t e r r a t e r reliability until an a g r e e m e n t of >95% on all o b s e r v e d variables w a s attained. Subsequently, these t h r e e investigators t r a i n e d o t h e r observers. Observations were m a d e at three time intervals: before beginning any intervention (baseline), and then from 2 to 3 weeks, and from 4 to 6 weeks after the intervention. Observations during each time interval were m a d e on at least two separate occasions. Although the goal was to observe a m i n i m u m of 60 opportunities for h a n d w a s h i n g during each time interval, this was not possible at all schools b e c a u s e of insufficient opportunities for observation, even after several trips to each school. The average observation time was 2 to 3 hours per observation period or 10 to 15 hours p e r school. A m a x i m u m observation time of 4 to 6 hours per school per
AJIC
Early et al. 2 6 5
Volume26, Number3
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time interval was set b e c a u s e of practical limitations on project t e a m time and b e c a u s e of the limitations of school hours. Although the control school received no intervention, the timing of observations for that school was consistent with the timing in the intervention schools. All observations occurred b e t w e e n October 1996 and J a n u a r y 1997. Observers were m e m b e r s of the project staff w h o were located unobtrusively in the girls' b a t h r o o m s (for hallway b a t h r o o m s ) or in the classrooms (for classroom bathrooms). Because all observers were women, hallway b a t h r o o m observations did not include male students; however, boys were observed in the classrooms. Classroom observations were scheduled before lunch. Teachers were instructed not to inform students that they were being observed for handwashing. Project staff m e m b e r s wore n a m e tags designating them as visitors to the school. If stu-
1 " a b l e 11, H y g i e n i c a s s e s s m e n t of b a t h r o o m s
Bathrooms clean Toilets flush Urinals flush Sinks operable with running water Soap dispensers filled and functional Paper towel dispensers with paper present Air dryers operational Type of soap in bathroom Bar Liquid Bar and liquid None
98.3% (59/60 observations) 99.4% (158/160) 100% (86/86) 100% (129/129) 34.1% (44/129) 90.6% (29/32) 66% (4/6) 13.3% (8/60) 78.3% (47/60) 6.7% (4/60) 1.7% (1/60)
dents asked an observer what she was doing, she was instructed to respond: "I am working with the school looking at cleanliness. I will be coming back several times."
AJIC 266
Early et al.
June 1998
Table 2. Handwashing frequency among four study groups Time
Baseline Preintervention
Postintervention
Preintervention to postintervention comparison
Postintervention: First 3 weeks compared with Last 3 weeks
Group
Control Education Wipes Education/wipes ControL Education Wipes Educati0n/wipes Control
Education Wipes Education/wipes Control
*Handwashing
0.42 0.64 0.50 0.45 0.46 0.72 0.66 0.67
Before intervention
After intervention
First 3 weeks
Second 3 weeks
(21/50) (164/256) (25/50) (10/22) (121/261) (280/387) (192/291) (186/277)
pValue
<0.01
<0.01
0.42 (21/50)
0,46 (121/261)
0.26
0.64 (164/256) 0.72 (280/387) 0.50 (25/50) 0.66 (192/291) 0.45 (10/22) 0.67 (186/277)
Education Wipes Education/wipes
0.37 (35/95)
0.52 (86/166)
0.02 0.03 0.03 0.01
0.77 (176/227) 0.66 (115/174) 0.58 (76/130)
0.65 (104/160) 0.66 (77/117) 0.75 (110/147)
0.006 0.96 0.003.
*Observed handwashes/handwashingindications(after using the bathroom or before lunch).
Interventions
Four handwashing interventions were tested in five schools: a peer educational program (two schools), introduction of hand wipes with an instructional poster (Fig. 2) in bathrooms (one school), a combination of the educational program and hand wipes (one school), and a comparison school that had no intervention but handwashing was observed. The peer education program was suggested by public school officials who were interested in assessing the effectiveness of peer-presented material on student learning and behavior. Content of the program was based on materials developed by P r o c t e r & Gamble (Healthy Hygiene, Cincinnati, Ohio) for a national project to encourage handwashing by first-graders. Members of the project team provided an assembly-style class to the fourth-graders in two schools. Selected fourth-graders then conducted a class for the first-graders, with assistance from their teachers and project staff members. The content of the class for the fourth-graders included a video presentation of a clown doing a handwashing demonstration (developed by the project coordinators), storyboards, overheads, posters, and training on how to use various teaching techniques for firstgraders. Information in the educational materi-
al included the three main types of "germs" (bacteria, viruses, fungi), where germs live, how germs are transmitted, and when, why, and how to wash hands. The class for the first-graders included the use of storyboards, a video presentation, and an interactive song that emphasized the steps of handwashing. The fourth-graders also gave stickers to first-graders to denote their participation in t h e handwashing program. H a n d wipes impregnated with alcohol, a lemon fragrance, and an emollient were made available in one school, and students were instructed how to use the hand wipes with a large poster mounted in the bathrooms. Special containers were placed in each observation area and were stocked routinely during the study by either the housekeeping staff or the teacher (depending on the location of the bathrooms). Peer education a n d hand wipes, as described above, were combined and both were used in one school. In addition, one control school received no intervention but observations were made at the same intervals as in the intervention schools. D a t a analysis
The X2 statistic was used to compare handwashing frequency between schools at the baseline and after the intervention, preintervention to postintervention for each group, and postin-
AJIC
Early et al. 2 6 7
Volume 26, Number 3
tervention between the study groups. Additionally, changes in handwashing frequency were compared by using Z2 between the study groups for the first 3 weeks and the second 3 weeks after the intervention (to test the sustainability of the intervention). RESULTS Phase I
During a 2-month time period (November 1996 to J a n u a r y 1997), 30 bathrooms in the six schools were observed on two separate occasions (60 observations). During this time, five additional bathrooms were inaccessible to the observers because they were locked. Bathrooms generally were clean, except one bathroom that had towels or b a t h r o o m tissue on the floor. In the 30 bathrooms, there were a total of 86 urinals, 160 toilets, and 129 sinks. Generally, the toilets and urinals flushed (158 of 160 and 86 of 86 respectively). All (n = 129) of the sink faucets drained and had running water but 66% (85 of 129) of the soap dispensers were nonfunctional or had insufficient soap. In 13.3% (8 of 60) of the observations, bathrooms contained only bar soap, 78.3% (47 of 60) contained liquid, 6.7% (4 of 60) contained both bar and liquid soap, and 1.7% (1 of 60) contained no soap. Ninety percent (29 of 32) of the towel dispensers contained towels. One third of the air dryers (2 of 6) were mechanically inoperable (Table 1). P h a s e II
For the entire study group, handwashing overall occurred 58% (220 of 378) of the time at the baseline and 67% (186 of 277) of the time after intervention. During the baseline phase before intervention, significant differences in the p r o p o r t i o n of h a n d w a s h i n g between the four intervention groups existed. In the control school, handwashing occurred 42% of the time; wipes only, 50%; education only, 64%; and education and wipes, 45% (p < 0.01). After intervention, significant differences in the p r o p o r t i o n of h a n d w a s h i n g between the four intervention groups also existed. In the control school, handwashing occurred 46% of the time; wipes only, 66%; education only, 73%; and education and wipes, 67% (p < 0.01). Additionally, significant increases in the proportion of handwashing
from preintervention to postintervention for each intervention group occurred (wipes only, p = 0.02; education only, p = 0.02; education and wipes group, p = 0.02); but not in the control group (p = 0.26). In the education only group, handwashing frequency decreased during the last 3 weeks when c o m p a r e d with the first 3 weeks postintervention (p = 0.006); frequency of handwashing was unchanged over time in the wipes group (p = 0.96); and increased in both the control (p = 0.01 ) and the e d u c a t i o n and wipes groups (p = 0.003)(Table 2). DISCUSSION
Studies to improve handwashing frequency have focused primarily on adults, particularly health care workers. ~-3 This collaborative comm u n i t y education project was designed to improve the hand hygiene of public school children. Although Day and colleagues 4 concluded that education was insufficient to affect longterm changes in handwashing behavior among children, handwashing education programs in o t h e r studies have been associated with reduced absenteeism, better school attendance, and decreased transmission of enteric organisms. s-9 Studies from o t h e r countries have demonstrated correlations between community educational initiatives to improve handwashing and subsequent reductions in the prevalence of childhood diarrhea. ~0-~2 Community-based research is complex, presenting both administrative and feasibility challenges. A major administrative challenge in this study was the lack of a clear, identifiable decision-making procedure or authority within or among school districts. Although uniform e n t h u s i a s m for the project existed a m o n g school officials and teachers, it took months to negotiate t h r o u g h various school systems. Once schools within a district were identified for participation, our contacts within the schools ranged from principals, classroom teachers, health educators, to school nurses. The contacts' willingness and ability to facilitate the project varied considerably. Additionally, certain schools were willing to participate only in selected interventions, and this hindered the r a n d o m assignment of schools to the intervention groups. Other challenges to conducting this community-based research related to feasibility. The researchers and school officials spent consider-
2 6 8 Early et al.
able time contemplating the issue of student privacy and consent procedures, because no u n i f o r m policies existed for the schools. Observation times had to conform to public school schedules; each school was scheduled for comparable hours of observation. However, the actual n u m b e r of preintervention observations for the control, wipes, and education and wipes groups were not equal. The impact on the conclusion of the study is unknown. In the schools in which observed students used hall bathrooms, the observations were completed only in the girls' bathrooms because no male observers were available. Even though the majority of observations were performed in classrooms with bathrooms where boys and girls were observed, we did not attempt to evaluate any potential differences in handwashing behavior between boys and girls. Therefore, the results of the study may not be generalized. Ideally, observers would be blinded to the study hypotheses. A limitation in this study was that the r e s e a r c h e r s served as data collectors because of budgetary constraints. The hand wipes provided information about the acceptance and logistics of the use of these products in a school setting. Another problem was the difficulty in keeping the bathrooms supplied with hand wipes. At one point, for example, the containers for the wipes were missing. Kimel 6 previously has reported aesthetic problems in elementary school bathroom facilities. The fact that we frequently found containers with insufficient soap and that the hand wipes were difficult to stock seems to be an ongoing problem in schools. However, this did not affect the study results, as a handwash was counted as long as the student used at least running water or a hand wipe. Finally, participating teachers cited lack of time in the school day to reinforce handwashing behavior or even to provide opportunity for students to wash their hands. Surprisingly, this problem was not mentioned in several previous studies. 6. Our results are congruent with previous findings regarding the immediate positive effect of handwashing education on modifying children's behavior. 9 However, we found that education alone was not effective in increasing the frequency of handwashing over time. Although the frequency of handwashing in the control grouP was not significantly different before and after the intervention period, a significant increase in handwashing among controls over time did
AJIC June 1998
exist between the first and second 3-week periods of postintervention observation. This clearly suggests that just the presence of the observers was associated with the Hawthorne effect, with handwashing increasing over time. This was not the case in either the education or hand-wipe groups, in which immediate statistically significant increases in h a n d w a s h i n g occurred but were not sustained after a few weeks. The group that received both the education and the hand wipes had the greatest increase in handwashing frequency, which was not only immediate but also sustained over time. Hence, we conclude that a simple, onetime peer education program that is reinforced by easy to use and accessible handwashing materials has the potential for a positive impact on the handwashing practices of elementary school children. We r e c o m m e n d several studies to extend this preliminary work. First, Zeitlyn and Islam 12 described the symbolic significance of soap and water in India. Public schools in the United States are characterized by increasing multiculturalism. E d u c a t i o n a l interventions related to hygiene must consider the cultural diversity of our communities, both in terms of teaching approaches and with regard to the meanings of hygienic practices across cultures. Future research should be designed to examine the correlation between handwashing frequency and illness among children and educators, to assess the effect of interventions over longer periods of time (months to years), and to examine the need for retraining or reinforcement at various age levels. In summary, education combined with accessible, convenient hand hygiene products m a y result in a sustainable increase in the frequency of handwashing among elementary school children. In addition to further research to extend and confirm these and other findings, we suggest that schools, through coordinated comprehensive school health programs, develop standard policies and procedures to facilitate collaboration with other agencies or individuals to conduct potentially useful community-based projects. Finally, equipment and supplies for hand hygiene in schools should be designed for durability to Prevent tampering or pilfering. We gratefully acknowledge the assistance and collaboration of Anne Wiseman, RN, CPHQ (Project Coordinator), and the five Maryland and Virginia public elementary schools that participated in this study.
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Volume 26, Number 3
References 1. Lachin JM. Introduction to sample size determination and power analysis for clinical trials. Controlled Clin Trials 1981;2:93-113. 2. Larson E. A causal link between handwashing and risk of infection? Examination of the evidence. Infect Control Hosp Epidemiol 1988;9:28-36. 3. Bryan JL, Cohran J, Larson E. Handwashing: a ritual revisited. In: Rutula WA, editor. Chemical germicides in health care. Morin Heights: Association for Professionals in Infection Control and Epidemiology, Inc. and Polyscience; 1994. p. 163-78. 4. Day RA, Amaud S, Monsoma M. Effectiveness of a handwashing program. Clin Nurs Res 1993;2:24-40. 5. Niffenegger JE Proper handwashing promotes wellness in children. J Pediatr Health Care 1997; 11:26-31. 6. Kimel LS. Handwashing education can decrease illness absenteeism. J Sch Nurs 1996;12:14-8.
7. Krilov LR, Barone SR, Mandel FS, Cusack TM, Gaber DJ, Rubino JR. Impact of an infection control program in a specialized preschool. Am J Infect Control 1996;24:167-73. 8. Mohle-Boetani JC, Stapleton M, Finger R, Bean NH, Poundstone J, Blake PA, et al. Community-wide Shigellosis: control of an outbreak and risk factors in child daycare centers. Am J Public Health 1995;85:812-6. 9. Monsma M, Day R, Arnaud S. Handwashing makes a difference. J Sch Health 1992;62:109-11. I0. Ferson MJ. Control of infections in child care. Med J Aust 1994;161:615-8. 11. Haggerty PA, Muladi K, Kirkwood BR, Ashworth A, Mannuebo M. Community-based hygiene education to reduce diarrheal disease in rural Zaire. Impact of the intervention on diarrhoeal morbidity. Int J Epidemiol 1994;23:1050-9. 12. Zeitlyn S, Islam E The use of soap and water in two Bangladeshi communities. Implications for the transmission of diarrhea. Rev Infect Dis 1991; 13(Suppl):S259-64.
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