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Teaching Handwashing

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Handwashing is the most effective behavior to prevent illness.1,2 The behavior is simple, takes little time to perform effectively, and most lay people have the knowledge that handwashing is important in disease prevention.

Despite these facts, research indicates knowledge does not lead to correct behavior.

Evidence, in 1996, Wirthlin Worldwide, a research firm, conducted a telephone interview and an observational study of handwashing in association with Bayer Pharmaceutical and the American Society for Microbiology.

In the telephone interview, 94 percent of respondents stated they always washed their hands after using a public restroom. While the observational study of more than 6000 individuals in five major cities indicated that only 68 percent washed their hands after using a public restroom. This data suggested the knowledge of the importance of handwashing does not necessarily ensure the behavior will occur.3

Handwashing Interventions in the Education System

Since infection spreads easily in schools, there have been studies investigating possible methods to increase proper handwashing behavior among children.

One study assessed the effect of a comprehensive handwashing program on absenteeism in elementary schools. Students in kindergarten through third-grade were given a 1-hour educational intervention consisting of discussion, video and pamphlets. A dispenser of hand sanitizer was also installed in the test classrooms. The study showed significantly lower absenteeism rates in the participating classrooms.4

Perhaps the most comprehensive study in schools used different interventions with a population of elementary school children. Interventions used included a peer education program developed by Proctor & Gamble and hand wipes with posters placed throughout the school, or a combination of both. Results showed increases in handwashing from the pre-test to the post-test for all groups except the control school, in which no intervention was used.5

Current Research

The purpose of the research conducted by authors of this article was to develop, implement and evaluate a new handwashing intervention. Our program was based on a model of behavior change developed by Tousman & Zeitz. According to their model, behavior change is a function of factors related to the participant involved in the intervention, the structure of the intervention, and the techniques used in the intervention.6

Seven second-grade classes in the Rockford (IL) Public School System participated in the intervention. Each class had approximately 25 students, for a total sample of 148 participants. Staff for the handwashing program consisted of approximately 15 volunteers from the Northern Illinois Community Health Foundation (NICHF) and the Winnebago County Medical Society Alliance.

The intervention consisted of one 30-minute session per week for 5 weeks. This continued interaction with the children helped reinforce the correct handwashing behaviors by adding accountability of the past week's behaviors. The techniques used in the intervention focused on learner-centered interactive activities, such as guided interactive discussions. Handwashing-related activity sheets and stickers were given to students at the end of every session.


The focus for Week 1 was on assessing handwashing knowledge and skills, and to provide basic education. In order to assess knowledge, volunteers first administered a five-question quiz to the students.

Next, the staff put a lotion on all participants' hands that contained a fluorescent dye that is visible under a UV light. The less dye that is present under the light, the better the handwashing. The students were then instructed to wash their hands in their usual manner.

Upon returning to class, participants put their hands under the UV light. The hands of each of the participants were rated for cleanliness by staff members on a four-point scale based on the amount of fluorescent dye still showing under the UV light.

If participants' hands were between 75-100 percent clean, they received an M(Magnificent); hands that were 50-75 clean received an R(Really Good); hands 25-50 percent clean received a rating of E(Eww); and those only 0-25 percent clean were rated as G(Gross).

After all of the participants' hands were rated, they were instructed on the appropriate manner to wash their hands. As a means for the children to estimate the amount of time it takes to properly wash their hands, they were told to sing the "Happy Birthday" song while they washed their hands.

Each student was given a letter to their parents informing them that their child would be participating in the program.

Week 2 started with an interactive discussion regarding the students' handwashing behavior during the previous week. The discussion was then guided by staff to discuss where germs are typically located, how they spread and how to get rid of germs. The students were given wet wipes to clean off their desks and pencils and encouraged to continue washing their hands for the next week. A book, Germs Make Me Sick, was given to each class.

Week 3 began with another interactive discussion between the staff and the students. Key points from previous weeks were repeated and students discussed how they were washing their hands. After the discussion, an Agar plate was set-up on each student's desk. Students touched one side of the plate with one finger and then were told to wash their hands and touch the other side of the same Agar plate.

Inspection of the results of the Agar plate demonstration took place during the Week 4 session. The participants' Agar plate results were rated by comparing the "before hands were washed" side with the "after hands were washed" side. Results were listed as "1" if the "after washing" side had less growth, "2" if the sides were equal or "3" if the "after washing" side had more growth. Interactive discussions ensued with students depending on their results.

The same five-item test that was given at the pre-test was given during the Week 5 session. The lotion with the fluorescent dye was then put on the students' hands again. Students washed their hands, and then staff again did the 4-point assessment. An interactive discussion followed.

Teaching Handwashing

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