Can a handwashing intervention make a difference? Results from a randomized controlled trial in Jerusalem preschools

doi:10.1016/j.ypmed.2005.09.012

Preventive Medicine

Volume 42, Issue 1, January 2006, Pages 27-32

https://doi.org/10.1016/j.ypmed.2005.09.012 Get rights and content

Abstract

Background.

Preschools are often focal points for the spread of illness among young children. The objective of this preschool intervention trial was to determine whether a hygiene program can promote handwashing and thereby reduce illness absenteeism.

Methods.

This cluster randomized trial included 40 Jerusalem preschools with 1029 children for 6 baseline days and 66 study days, yielding 73,779 child days. The main outcomes were rates of handwashing and illness absenteeism. The intervention included an educational program and environmental changes. A simultaneous subtrial was run to test a home component.

Results.

This multi-site intervention program produced sustained behavioral and environmental changes over a 6-month period. An approximately threefold increase in handwashing with soap was observed among preschool children exposed to the intervention. Neither the preschool nor the home intervention program reduced illness absenteeism or overall absenteeism.

Conclusions.

This trial illuminates the potential of the preschool as a promising venue for health promotion activities leading to sustained behavioral change, yet suggests the need for enhanced approaches for reducing illness absenteeism.

Introduction

Communicable diseases, particularly lower respiratory infections and diarrhea, remain a major burden [1], [2]. Schools and day care centers have repeatedly been implicated in the spread of communicable disease, both among the children themselves and among their families and communities [3], [4].

Much attention has been given to handwashing as a means to prevent infection, particularly in hospitals [5]. A meta-analysis [1] found a 47% reduction in diarrhea in community-based handwashing trials. In the past two decades, nine controlled trials in schools or daycare centers [6], [7], [8], [9], [10], [11], [12], [13], [14] have examined the effects of hand hygiene programs on illness absenteeism. While many of the trials exhibited significant decreases in illness absenteeism [7], [8], [10], [11], [12], [13], most have serious methodological flaws. Of the trials just cited, only one [9] was a properly randomized trial whose analysis followed the intent-to-treat principle and accounted for the clustered nature of the data. The aim of our trial was to test a handwashing program for preschool children in a rigorous way, avoiding the deficiencies of other trials.

Section snippets

Methods

The primary objective of this trial was to evaluate the effects of a comprehensive hygiene program on handwashing and illness absenteeism in public preschools. A cluster randomization design was employed, with randomization at the level of the preschool, stratified by sector (secular and religious). All preschool teachers of 3- and 4-year-old children in the state-run public system of the Jerusalem region were potentially eligible for inclusion. Preschool teachers likely to comply with the

Participation and compliance

Educator recruitment rates and parental participation rates of the survey were very high (at least 88% of educators and 95% of parents). Dropout and loss to follow-up were minimal: no dropout of preschools occurred, dropout of children was 0.9%, and loss to follow-up of children was 0.7%. During the study, two intervention group preschools were unexpectedly exposed to raw sewage due to faulty plumbing. A sensitivity analysis excluding those preschools was conducted, and results were unchanged.

Discussion

This was the largest and most comprehensive randomized field trial of a hand hygiene intervention ever reported among toilet-trained preschool children. The design overcame methodological problems commonly seen in hand hygiene and community health trials, through cluster randomization and appropriate statistical analyses. For the first time in a school/daycare-based trial, a home component was introduced and tested in an embedded individually randomized subtrial, which proved an efficient way

Conclusions

This is the first report showing that a hygiene program can produce a sustained increase in handwashing rates among toilet-trained preschool children at a large number of geographically disparate locations. The program did not reduce overall or illness absenteeism. The findings illuminate the potential of the preschool as a promising venue for health promotion activities leading to sustained behavioral change, while suggesting the need for enhanced and/or alternative approaches to illness

Acknowledgments

The authors gratefully acknowledge grants received from The Chief Scientist's Office of the Ministry of Health; Associate Director General's Unit for Health Promotion of the Ministry of Health; and the National Institute for Health Services Research. We are also indebted to the Preschool and Public Health Departments of the Municipality of Jerusalem for logistical assistance.

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Childhood Handwashing Habit Formation and Later COVID-19 Preventive Practices: A Cohort Study
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This study identified developmental patterns of handwashing habit formation during childhood and examined their associations with later COVID-19 preventive practices.
We used data from the Taiwan Birth Cohort Study, which included 11,254 adolescents with complete data on childhood handwashing behavior and age-15 COVID-19 survey items. Bias-adjusted 3-step latent class analysis was used to test study hypotheses.
The rates of handwashing and mask-wearing during the pandemic were 63.8% and 93.8%, respectively. Five distinct patterns of handwashing habit formation were identified: early formation (14.89%), delayed formation (17.73%), gradual formation (42.98%), inconsistent formation (9.78%), and nonformation (14.62%). Compared with adolescents with an early formation pattern of handwashing habits, those with other patterns exhibited lower odds ratios (ORs) of handwashing during COVID-19; these ORs were 0.67 (95% confidence interval [CI], 0.49–0.85), 0.60 (95% CI, 0.44–0.77), 0.29 (95% CI, 0.08–0.49), and 0.21 (95% CI, 0.01–0.40) for those with delayed formation, gradual formation, inconsistent formation, and nonformation patterns, respectively. Moreover, relative to that of adolescents with the early formation pattern, mask-wearing was less common among adolescents with gradual formation, inconsistent formation, and nonformation patterns, with ORs of 0.54 (95% CI, 0.16–0.92), 0.50 (95% CI, 0.03–0.96), and 0.26 (95% CI, 0.00–0.65), respectively.
The early formation of hygienic habits is associated with higher adherence to pandemic preventive practices among adolescents. Our findings suggest that interventions to promote hygienic behaviors can start as early as age 3 through the introduction of healthy habits such as handwashing.
Effectiveness of a hand hygiene program to reduce acute gastroenteritis at child care centers: A cluster randomized trial
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We aimed to assess the effectiveness of an educational and hand hygiene program in daycare centers (DCCs) and homes on acute gastroenteritis (AGE) incidence in children attending DCCs.
A randomized, controlled, and open study of 911 children aged 0-3 years attending 24 DCCs in Almería (Spain) with an 8-month follow-up was employed. Two intervention groups of DCCs families performed educational and hand hygiene measures, 1 with soap and water (soap and water group; n = 274), another with hand sanitizer (hand sanitizer group [HSG]; n = 339), and the control group (CG; n = 298) followed usual handwashing procedures. We compared AGE episode rates with Poisson regression model.
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Therefore, the simplified 5-step handwashing technique may be cleaner, with fewer steps, than handwashing under usual practice. Developmental milestones may influence the behavioral change process.18 A study conducted in Hong Kong found that schoolchildren in grades 5-9 performed handwashing better than those in grades 1-4.13
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The impact of the school-based hand hygiene program was positive. It can be used in both the planning and development of a hand hygiene protocol to increase the handwashing compliance rate of schoolchildren and to reduce school absenteeism in developing countries.
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We carried out a comprehensive search in the EMBASE database from 1946 to 2016. Health care trials with a S-P design in human subjects were included. Three authors screened and assessed the studies, and the data were extracted on methodology and reporting standards based on CONSORT.
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S-P designs can be useful complex designs but challenging to report. Researchers need to clearly describe the rationale, sample size calculation, and participant flow. We provide a suggested CONSORT style participant flow diagram to aid reporting. There is need for more research regarding sample size calculation for S-P.
Illness-related absence among preschool children: Insights from a health intervention in Swedish preschools
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Our result that the hygiene intervention did not reduce absence due to illness on average, differs from the results in some previous evaluations of hygiene interventions in preschools in the Nordic countries; see Lennel et al. (2008); Uhari and Möttönen (1999) and Ladegaard and Stage (1999). Rosen et al. (2006), on the other hand, do not find reduced absence due to illness following a hand washing intervention in Israeli preschools. We believe there are two important differences between the intervention we study and the above mentioned ones.
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Can a handwashing intervention make a difference? Results from a randomized controlled trial in Jerusalem preschools

Abstract

Background.

Methods.

Results.

Conclusions.

Introduction

Section snippets

Methods

Participation and compliance

Discussion

Conclusions

Acknowledgments

Lancet, Infect. Dis.

AJIC

AJIC

Summary: the global burden of disease

Viruses in families: surveillance of families as a key to epidemiology of virus infections

A study of illness in a group of Cleveland families X

Am. J. Hyg.

A causal link between handwashing and risk of infection? Examination of the evidence

Infect. Control Hosp. Epidemiol.

Handwashing education can decrease illness absenteeism

J. Sch. Nurs.

Scheduled handwashing in an elementary school population

Fam. Med.

Effect of infection control measures on the frequency of upper respiratory infection in child care: a randomized controlled trial

Pediatrics

Alcohol-free instant hand sanitizer reduces elementary school illness absenteeism

Fam. Med.