literature review on poor personal hygiene

• Research article
• Open access
• Published: 06 February 2020

A systematic review of hand-hygiene and environmental-disinfection interventions in settings with children

• Leanne J. Staniford 1 &
• Kelly A. Schmidtke   ORCID: orcid.org/0000-0001-5993-0358 1  

BMC Public Health volume  20 , Article number:  195 ( 2020 ) Cite this article

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Helping adults and children develop better hygiene habits is an important public health focus. As infection causing bacteria can live on one’s body and in the surrounding environment, more effective interventions should simultaneously encourage personal-hygiene (e.g. hand-hygiene) and environmental-disinfecting (e.g. cleaning surfaces). To inform the development of a future multi-faceted intervention to improve public health, a systematic literature review was conducted on behavior change interventions designed to increase hand-hygiene and environmental-disinfecting in settings likely to include children.

The search was conducted over two comprehensive data-bases, Ebsco Medline and Web of Science, to locate intervention studies that aimed to increase hand-hygiene or environmental-disinfecting behavior in settings likely to include children. Located article titles and abstracts were independently assessed, and the full-texts of agreed articles were collaboratively assessed for inclusion. Of the 2893 titles assessed, 29 met the eligibility criteria. The extracted data describe the Behavior Change Techniques (version 1) that the interventions employed and the interventions’ effectiveness. The techniques were then linked to their associated theoretical domains and to their capability-opportunity-motivation (i.e., COM-B model) components, as described in the Behavior Change Wheel. Due to the heterogeneity of the studies’ methods and measures, a meta-analysis was not conducted.

A total of 29 studies met the inclusion criteria. The majority of interventions were designed to increase hand-hygiene alone ( N  = 27), and the remaining two interventions were designed to increase both hand-hygiene and environmental-disinfecting. The most used techniques involved shaping knowledge ( N  = 22) and antecedents ( N  = 21). Interventions that included techniques targeting four or more theoretical domains and all the capability-opportunity-motivation components were descriptively more effective.

Conclusions

In alignment with previous findings, the current review encourages future interventions to target multiple theoretical domains, across all capability-opportunity-motivation components. The discussion urges interventionists to consider the appropriateness of interventions in their development, feasibility/pilot, evaluation, and implementation stages.

Registration

Prospero ID - CRD42019133735.

Peer Review reports

The World Health Organization describes hygiene practices as those “that help to maintain health and prevent the spread of diseases” [ 1 ]. These practices include behaviors to disinfect one’s body and surrounding environment [ 2 ]. Because bacteria that cause infection can live on one’s body and in the surrounding environment, preventing the spread of infectious diseases may require interventions that simultaneously encourage both personal- and environmental-disinfecting [ 3 ]. To improve public health many hand-hygiene interventions have been conducted in school-settings, wherein students may act as “agents of change” by carrying lessons about hygiene from school back to their home to influence family behavior [ 4 , 5 , 6 ]. The current systematic review was conducted to inform the development of future multifaceted interventions that aim to increase hand-hygiene and environmental-disinfecting behaviors in settings likely to include children.

Two recent systematic reviews closely informed the current review. The first is Willmott et al.’s 2016 review that included 18 school-based randomized controlled trials with hand-hygiene focused interventions [ 7 ]. The effectiveness of the interventions were assessed in terms of their ability to reduce negative health-related outcomes: absences and/or the spread of respiratory tract or gastrointestinal infections. The descriptions of the interventions suggest that most involved education/training ( N  = 15) and fewer involved infrastructural changes ( N  = 4). Only one study included measures of environmental-disinfecting ( N  = 1) and none included direct measures of hand-hygiene behavior ( N  = 0). Overall, they found equivocal evidence for the effectiveness of school-based interventions. However, as none of the studies directly measured hand-hygiene, it is uncertain whether they even influenced the process variable they were designed to most directly influence: hand-hygiene behavior. One of the effective interventions in this review took place in a childcare center, and this intervention simultaneously targeted hand-hygiene and environmental-disinfecting [ 8 ]. To this end, the current review aims to include studies that assess the effectiveness of interventions designed to improve hand-hygiene and/or environmental-disinfecting.

The second review that influenced the current review was conducted by Huis et al. in 2012 [ 9 ]. Huis et al.’s review included 41 intervention studies published between 2000 and 2009 to increase healthcare workers’ hand-hygiene compliance. In this review, the interventions were categorized according to the behavioral determinants that they were designed to influence [ 10 , 11 ]. In so doing, this review brings together a wide range of interventions with a purposeful intervention terminology to guide future intervention development via the Behavior Change Wheel [ 12 , 13 ]. The Behavior Change Wheel is a formal methodology that helps interventionists identify the most common reasons for sub-optimal behavior by providing a comprehensive list of empirically and theoretically informed reasons, e.g. lacking knowledge or resources to perform the desired behavior. The Behavior Change Wheel can be used as part of the first step in the Medical Research Council’s four-step Complex Intervention Development and Evaluation Framework. The steps include (1) Design, (2) Feasibility/piloting, (3) Evaluation and (4) Implementation [ 14 ]. This first step is important, because interventions designed to target uncommon reasons are unlikely to yield practically significant improvements.

Since Huis et al.’s review, the possible reasons for sub-optimal behavior have been more completely described in a taxonomy called the Theoretical Domain Framework (TDF) [ 15 ]. The TDF condenses 112 behavioral constructs into 14 domains that affect behavior: ‘Knowledge,’ ‘Behavioral Regulation,’ ‘Memory attention and decision processes,’ ‘Skills,’ ‘Goals,’ ‘Intentions,’ ‘Beliefs about consequences,’ ‘Beliefs about capabilities,’ ‘Optimism,’ Social/Professional role and identity,’ ‘Reinforcement,’ ‘Emotions,’ ‘Social influences,’ and ‘Environmental context and resources.’ These 14 domains are further condensed into the COM-B model’s three components, which exclusively and exhaustively explain why behaviors do or do not occur. The three COM-B components (and subcomponents) include C apability (physical/psychological), O pportunity (social/physical), and M otivation (reflective/automatic); the ‘B’ stands for B ehavior. If even a single COM-B component is lacking, then a desired behavior is less likely to occur.

The TDF domains and COM-B model components are displayed in the second and third columns of Fig.  1 . The links between them are indicated with shared colors, e.g. a dark red color is used to describe the link between the ‘Knowledge’ domain and the C apability-psychological component. After diagnosing the reasons for suboptimal behavior, the Behavior Change Wheel helps interventionists select the most appropriate intervention techniques. Ninety-three empirically and theoretically informed techniques are grouped into 16 clusters by the Behavior Change Techniques (BCTs) Taxonomy, version 1, e.g. shaping knowledge, goals and planning, social support , etc. [ 16 ]. In Fig. 1 , the 16 BCT clusters are linked to their associated TDF domains by lines drawn across the first and second columns [ 17 ]. For example, the shaping knowledge technique is best suited to influence the ‘Knowledge’ domain.

Links between the BCT clusters, TDF domains, and COM-B model

Huis et al.’s 2012 review found that interventions targeting only one domain, e.g. only ‘Knowledge’ or only ‘Goals,’ were less effective than those that targeted multiple domains, e.g. ‘Knowledge’ and ‘Goals.’ Therefore, they suggest that future interventions should simultaneously target multiple domains, likely across the COM-B components, to increase optimal behavior. As the current review aims to influence the development of future multifaceted interventions, Huis et al.’s use of a purposeful intervention development terminology is desirable. Thus, the current review also categorizes interventions according to the techniques used and the domains/components targeted. In so doing, the current review will also guide future intervention development via the Behavior Change Wheel.

In summary, the current literature review was planned around two broad objectives. First, we aimed to learn what behavior change techniques had already been assessed to increase hand-hygiene and environment-disinfecting in settings likely to include children, e.g. schools, homes, etc. Second, where possible, we aimed to compare the effectiveness of these techniques and the domains/components they targeted. The discussion puts forth recommendations for the development of future multifaceted interventions.

The current systematic review is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement [ 18 ]. The review’s protocol was registered on 28th of May 2019 with PROSPERO: International Prospective Register of Systematic Review (Registration ID: CRD42019133735).

Eligibility criteria

The eligibility criteria were determined using the PICO characteristics, i.e. characteristics describing the studies’ population, intervention(s), comparison(s) and outcome(s) [ 19 ]. The population characteristic was defined to include humans in settings likely to contain children less than 10-years-old and to exclude settings unlikely to contain children (e.g. manufacturing settings) and studies focused on non-human species. The intervention characteristic was defined to include studies that manipulated malleable factors likely to influence human behavior and to exclude comparisons of cleaning materials and non-malleable variables like gender. The comparison characteristic was defined to include any control or comparison condition, i.e. both randomized and pre-post observational trials. Finally, the outcome characteristic was defined to include hand-hygiene and environmental-disinfecting behavior measures. Environmental-disinfecting behavior was understood to entail the use of cleaning products to kill harmful germs that can cause illness.

Information sources and search strategy

The search terms and selected databases were reviewed by the research team and library staff (Table  1 ). In addition to the search terms three inclusion criteria were applied. First, the articles had to be written in English, because no translation services were available to the research team. Second, the articles had to be published in peer-reviewed journals, to narrow the scope of the review to articles more likely to include relevant information. Third, the articles had to be published on or after January 2009. The final search was conducted on the 27th of April 2019 over EBSCOhost Medline and Web of Science Core Collection.

Study selection and data collection process

One researcher located the articles and then uploaded them to EndNote™ to combine, detect, and delete duplicate references. The remaining articles were uploaded to Rayyan QCRI [ 20 ]. Then, two researchers used Rayyan QCRI to independently screen titles and abstracts for inclusion. Full-text articles were collaboratively screened. The stages of the search and screening process are described in Fig.  2 .

Prisma diagram describing how articles were located and screened

Data extraction

Two reviewers extracted study data from the articles using data extraction questions first piloted on smaller samples of included studies. After the data extraction questions were finalized, each reviewer independently extracted data from approximately half of the included articles. The extracted data included study details, intervention descriptions, outcome descriptions, and findings. The interventions were defined according to the Behavioral Change Techniques Taxonomy, version 1 [ 16 ], and each technique’s cluster was linked to the theoretical domains and COM-B components, as described in Fig. 1 (also see Additional file  1 for the list of behavior change techniques and clusters); as discussed in the introduction, these links are informed by previous research [ 15 , 16 , 17 ]. The data extraction process was planned to permit a narrative summary of what types and numbers of behavioral domains and components were most likely to increase hand-hygiene and environmental-disinfecting.

Overall quality assessment

One researcher reviewed articles to assess the studies’ overall quality using tools developed by the United States Department of Health and Human Services for controlled intervention and observational pre-post studies [ 21 ]. Each tool contains a checklist of items, e.g. asking about the sample-size and participant retention rates. To summarize the quality of the articles a five-star assessment was used. Four of the stars were assigned by taking the total number of positively indicated items divided by the total number of items: 1 star was given for positively indicating 25 to 49% of the items, 2 for 50 to 74%, 3 for 75 to 99%, and 4 stars for 100%. An additional star was given to those articles that use a randomized controlled trial methodology.

Data synthesis

Narrative syntheses, with tallies, are used to summarize the findings. Tables are used to describe and aggregate summaries.

Of the 2893 titles assessed, 29 met the eligibility criteria (see Additional file  2 ). The reviewer agreements were moderate for screened titles (89.56%, Kappa = 0.42, p  < 0.001) and abstracts (81.02%, Kappa = 0.36, p  < 0.001). The studies took place mostly in Bangladesh ( N  = 6), and Kenya ( N  = 4). Fewer took place in India ( N  = 2), Peru ( N  = 2), South Africa ( N  = 2), the United States of America ( N  = 2), Zambia ( N  = 2), China ( N  = 1), Indonesia ( N  = 1), Iraq ( N  = 1), Laos ( N  = 1), Malawi ( N  = 1), Malaysia ( N  = 1), Nepal ( N  = 1), Tanzania ( N  = 1), and Zimbabwe ( N  = 1). Most of the studies were publically funded ( N  = 24).

Study characteristics

Regarding the study designs, 7 were pre-post without randomization, 18 were pre-post with randomization, and the remaining 4 were randomized controlled trials with only post-intervention comparisons. Approximately one-third of the studies were pre-registered ( N  = 11). Nearly all of the studies indicated being granted approval by an ethics committee before commencing ( N  = 28). The remaining study did not indicate whether ethical approval was sought [ 22 ]. Prior to collecting data, a power analysis was conducted for most studies ( N  = 22), but this analysis was not always for an observable, behavioral measure, e.g. alternative primary outcomes included diarrhea episodes [ 23 ] and microbial counts [ 24 ]. Most of the interventions took place in schools ( N  = 12) or households with children ( N  = 13); fewer took place in pediatric settings ( N  = 2) or involved multiple locations, such as schools and other community centers or households ( N  = 2).

Regarding whose behavior was measured, 11 studies focused on the behavior of household members including children and adults, 16 focused on children/students, 1 looked at mother and child pairs [ 6 ], and 1 looked at pediatric healthcare workers [ 25 ]. Only 17 of the studies indicated the gender of their participants. In 23 studies some information about participants’ age was provided or could be inferred, e.g. from participants’ grade levels.

All of the studies included a behavioral measure of hand-hygiene, but only 20 reported a significant increase in at least one measure of hand-hygiene, i.e. handwashing, handwashing with soap, or handwashing at key times (e.g. after defecation or before food preparation), compared to a control group or a pre-intervention measure. Nine interventions found no significant effect of the intervention condition on hand-hygiene. Only two studies included a measure of environmental-disinfecting, both were related to food preparation and both found significant increases. As so few articles were found for environmental-disinfecting, the remainder of the current results section focuses on hand-hygiene. In nearly half of the studies ( N  = 13), a health outcome measure was also recorded, such as absenteeism, diarrhea-symptoms, hospitalization episodes, and infection rates. The Additional file  3 provides details about the studies’ settings, participants, interventions, comparisons, outcome measurements, and results.

Behavior change technique clusters and the COM-B model

The types and numbers of behavior change technique clusters (BCTs) employed are summarized in Table  2 . Across the 29 studies the most commonly employed BCTs involved shaping knowledge ( N  = 22) and antecedents ( N  = 21). A moderate number of interventions involved associations ( N  = 14), social support ( N  = 12), feedback and monitoring ( N  = 10), comparison of behaviors ( N  = 8), and goals and planning ( N  = 7). Fewer interventions involved repetition and substitution ( N  = 5), reward and threat ( N  = 4), and scheduled consequences ( N  = 1) [ 26 ]. None of the interventions involved comparison of outcomes , regulation , self-belief , or covert learning . The interventions included as few as one BCT cluster [ 43 , 44 , 45 ] and as many as nine [ 34 , 42 ]. Of the 29 included studies, 3 used a single BCT cluster, 15 included 2 to 4, and 11 included 5 or more. The mean number of BCT clusters per intervention that did not find a significant benefit for hand-hygiene was 3.00 ( SD  = 1.94, Mdn  = 3). The mean number of interventions that did find a significant benefit was descriptively higher, i.e. 4.65 ( SD  = 2.30, Mdn  = 4).

Using the links provided in Fig. 1 , the number of studies that targeted each TDF domain and COM-B component were tallied. The most frequently targeted domains were ‘Knowledge’ and ‘Environmental context and resources’ (both N ’s = 22). Fewer studies targeted ‘Emotions’ ( N  = 20), ‘Beliefs in consequences’ ( N  = 15), ‘Social Influences’ ( N  = 14), ‘Behavioral Regulation’ ( N  = 10), ‘Goals’ ( N  = 7), ‘Intentions’ ( N  = 7), ‘Reinforcement’ ( N  = 5), ‘Skills’ ( N  = 4), and ‘Optimism’ ( N  = 1 [ 26 ];. No interventions targeted ‘Beliefs about capabilities.’ As a reminder no BCTs are linked to the ‘Memory attention and decision processes’ domain or ‘Social/Professional role and identity’ domain, and therefore it is not surprising that these domains were not targeted by any interventions. The studies targeted between 1 and 9 domains, with the average study targeting 4.38 domains ( SD  = 2.51, Mdn  = 4). Of the 14 studies that targeted less than 4 domains, 7 (50%) found positive effects of the intervention. In contrast, of the 15 studies that targeted 4 or more domains, 13 (87%) found positive effects of the intervention.

Regarding the COM-B model, almost all the studies targeted Capability ( N  = 28), and many targeted O pportunity ( N  = 24) and M otivation ( N  = 21). Five of the studies only targeted one component, of which four targeted O pportunity and one targeted M otivation; only three of these five studies (60%) found a significant benefit. Four of the studies only targeted two components, of which three targeted C apability and O pportunity and one targeted M otivation and O pportunity; only two of these studies (50%) found a significant benefit. The remaining 20 studies targeted all three COM-B components, and 15 of these studies (75%) found a significant benefit.

Methodological quality

The quality assessment for each study is provided in Additional file  4 . As a reminder the studies were assessed with five stars, where four stars were allocated based on the percentage of assessment criteria met, and one star was added to studies that used a randomized controlled trial methodology. Of the 29 studies included, 2 studies received one star [ 36 , 44 ], 21 received three stars, 2 received four stars [ 6 , 43 ], and 4 received two stars [ 25 , 27 , 32 , 33 ].

Synthesis of results

The co-authors agreed that a pooled estimate of the effects would be misleading, due to the heterogeneity of the populations examined, research methods employed, and outcomes measured.

The current systematic review located 29 studies with interventions designed to increase hand-hygiene in settings likely to include children. Of the 29 studies, only 2 were also designed to increase environmental-disinfecting behavior. Individual study results suggest that interventions may increase hand-hygiene and environmental-disinfecting, but the behavior change techniques they employed and domains/components they targeted varied. The most targeted domains were ‘Knowledge’ and ‘Environmental context and resources.’ Descriptively, interventions targeting four or more theoretical domains and those targeting all the COM-B components were more likely to succeed.

The findings of this literature review align with other reviews emphasizing the value of multifaceted interventions. As stated in the introduction, the COM-B model proposes that people need sufficient C apability, O pportunity, and M otivation to perform a desired behavior. If even a single component is lacking, then people will be less likely to perform the desired behavior [ 12 ]. Agreeing with the COM-B framework, Harvey and Kitson argue that interventions meant to influence a greater range of people with more complex problems often require multifaceted approaches [ 50 ]. As hand-hygiene is likely a complex behavioral problem, interventions designed to affect a single component may prove inadequate to produce either population-level benefits (as individuals experience different barriers) or individual-level benefits (as each individual experiences multiple barriers that need to be simultaneously overcome).

Comparing interventions designed to affect each TDF domain or COM-B component, in isolation and combination, would help interventionists better understand how these domains/components influence each other. However, such factorial experimental designs will prove difficult to conduct given real-world constraints. Further the scientific exactness of factorial designs are likely outside the scope of many studies with more practical aims. In many studies, hand-hygiene is operationalized as a process variable (that may or may not be measured) meant to impact a health outcome (that is measured), and previous systematic reviews have largely focused on practical health outcomes. For example, Willmott et al.’s (2016) review located 18 randomized controlled trials that investigated the effectiveness of hand-hygiene interventions on children’s absences and infections [ 7 ]; Meadows et al.’s (2004) review located 6 studies evaluating the effectiveness of antimicrobial rinse-free hand sanitizer interventions on elementary school children’s absenteeism due to communicable illness [ 51 ]; and Wilson et al.’s (2006) located 12 studies that investigated the effectiveness of hand-hygiene interventions to decrease infections and absenteeism [ 52 ].

Studies focusing on hand-hygiene behavior itself are likely more common in health care settings [ 53 , 54 , 55 ], where hand-hygiene compliance audits are already common. In contrast, in school-settings hand-hygiene compliance audits may prove difficult to fund, develop, and faithfully implement. As a result of these difficulties, interventions in school settings are often evaluated using the data that schools already regularly collect, e.g. absences, or that parents/students can self-report with reasonable face-validity, e.g. diarrhea episodes. While outcomes like absences and diarrhea episodes are certainly important, the present research team argues that there is already sufficient evidence that hand-hygiene impacts these health outcomes [ 56 , 57 ]. Therefore, more studies and reviews looking at the effectiveness of hand-hygiene interventions should prioritize observable hand-hygiene behavior measures when assessing their interventions’ effects.

Limitations

Several limitations of the current review will now be acknowledged. First, the search only included two data-bases, articles published in the English language, and did not extend to the grey literature. Given the current research team’s time and resource constraints, these restrictions were necessary. A future review aiming to understand what techniques have been attempted (with or without being assessed) may find it useful to include the grey literature. Another limitation of the review is its rigid focus on observable behaviors. Indeed, most studies discarded from the review during the full-text screening were lost because they did not include measures of observable behavior, but rather only included self-reported measures.

Recommendations for future intervention studies

The current review recommends that future interventions designed to increase hand-hygiene or environmental-disinfecting in settings likely to include children target multiple theoretical domains and all COM-B components. Which domains are targeted will depend on the particular setting and population. For example, if the particular setting already includes sufficient infrastructure for children to carry out hand-hygiene, e.g. soap and a water basin, then providing more soap or installing new water basins is unlikely to produce a beneficial effect; though, making children aware of such materials might. The only way to be more certain about what barriers a particular population experiences is to conduct formative research in the selected setting with the selected population, e.g. structured observations, focus groups, interviews, surveys, etc. Such formative research should aim to comprehensively examine all the possible barriers that could influence hand-hygiene, because if even a single component is lacking, then beneficial effects of the intervention are less likely to be realized. The Behavior Change Wheel can be used to guide the development of multifaceted interventions, and the selection of the most appropriate intervention functions (e.g. education or persuasion) and policy categories (e.g. guidelines or legislation) through which those interventions can be delivered [ 58 ].

Of course, selecting behavior change techniques is only part of the intervention development process. Beyond targeting the right barriers, the intervention must be implemented through an appropriate mode. To bolster the appropriateness of the ultimate intervention, interventionists can use the APEASE criteria [ 59 ]. APEASE is an acronym in which each letter stands for a different appropriateness-criterion: Affordability, Practicality, Effectiveness, Acceptability, Side-effects, and Equity. A sample of questions researchers might ask themselves about each criterion are provided in Table  3 . The APEASE criteria should be consulted iteratively during an intervention’s development, feasibility/pilot testing, evaluation, and implementation [ 58 ]. Considering the APEASE criteria during the development phase is important; if stakeholders do not believe the intervention is appropriate, then the intervention will prove difficult to scale and spread even if the intervention’s effects are found to be beneficial.

The present review focused on the behavior change techniques, theoretical domains, and COM-B components interventionists should consider when developing a multifaceted intervention. After developing a multifaceted intervention, the Behavior Change Wheel and the Medical Research Council’s Complex Intervention Development and Evaluation Framework recommend feasibility/pilot testing [ 12 , 14 ]. Specific information regarding how to feasibility/pilot test an intervention study is outside the scope of the present review. Briefly here, note that while one may be uncertain about the benefits of a intervention before full-scale testing, feasibility/pilot tests help one to become more certain about the parameters needed for a fair full-scale test of that intervention’s effectiveness. Many, often costly, trials that do not first feasibility/pilot test their interventions ultimately fail to find significant effects due to factors that better planning may have mitigated, e.g. the sample-size was too low, people found the intervention unacceptable, or intervention implementation was inadequate [ 60 , 61 , 62 ].

The current literature review identified 29 studies with interventions that aimed to increase hand-hygiene, 2 of which also aimed to increase environmental-disinfecting. In alignment with previous findings, this review finds that interventions that simultaneously target more theoretical domains and all COM-B components are descriptively more likely to succeed. The review also notes that very few trials examine hand-hygiene and environmental-disinfecting simultaneously and encourages more studies to do so, as this may be the most cost-effective way to halt reinfection cycles. In the discussion, interventionists were urged to consider the appropriateness of their interventions in the development, feasibility/pilot, evaluation, and implementation stages. This iterative and methodical process can encourage better scale and spread of effective interventions that increase hand-hygiene and environmental-disinfecting behaviors in settings likely to include children.

Availability of data and materials

The reviews protocol is available on PROSPERO. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Control Group

Environmental Disinfecting

• Handwashing

Handwashing with soap

Intervention Group

Theoretical Domains Framework

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The authors would like to acknowledge the support of the funder and Manchester Metropolitan University’s library staff in conducting the current review. The authors also acknowledge Pendaran Roberts’ help editing the manuscript.

This research was supported by Global Hygiene Council. The Global Hygiene Council had no role in the design of the study and collection, analysis, and interpretation of data, and in writing the manuscript. The views expressed are those of the authors and not necessarily those of the Global Hygiene Council.

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Staniford, L.J., Schmidtke, K.A. A systematic review of hand-hygiene and environmental-disinfection interventions in settings with children. BMC Public Health 20 , 195 (2020). https://doi.org/10.1186/s12889-020-8301-0

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Personal hygiene in schools: retrospective survey in the northern part of Côte d’Ivoire

Introduction.

Students’ personal hygiene helps maintain health and promote good academic performance. When health facilities are insufficient, this hygiene can be difficult to achieve. We wanted to analyse the determinants of personal hygiene in schools in the northern region of Côte d’Ivoire.

The retrospective cross-sectional study brings together data on 2,035 schoolchildren recruited from thirty schools in northern Côte d’Ivoire. Indexes on personal hygiene were constructed and analysed in comparison to the socio-demographic characteristics of students, homes and schools. They were analysed with R Software version 1.1.463, the χ 2 test and a logistic regression model.

Overall, the majority of students had good personal hygiene (82.75%) with an average personal hygiene score of 4.74 ± 1.36. The predictors of good personal hygiene among schoolchildren were female gender (OR = 1.5; 95% CI = 4.31-16.37), father’s primary education level (OR = 1.55; 95% CI = 1.07-2.29), the father’s income level above 60,000 FCFA (90 Euros) and modern housing (OR = 1.45; 95% CI = 1.05-2.03). However, the poor level of home sanitation resulted in poor personal hygiene among the students (OR = 0.34; 95% CI = 0.23-0.5).

Conclusions

Measures to raise the standard of living of families and the provision of sanitary facilities in homes becomes necessary in order to improve students personal hygiene.

Personal hygiene refers to the set of practices that help maintain good health and prevent the spread of diseases. This involves regular washing of the body, hands, trimming of the nails, washing clothes, washing the hair and brushing the teeth [ 1 ]. In schools, students spend most of their time closer to each other, resulting in rapid transmission of infections, due to their naturally weak immune system and lack of knowledge of basic hygiene practices [ 2 , 3 ]. Hygiene therefore plays an essential role in the prevention of communicable diseases [ 4 ]. These pathologies are the cause of absenteeism (75% in Malaysia in 2019), resulting in working time loss for parents, significant medical expenses due to medical visits and antibiotic prescriptions [ 5 ]. More than 1.9 billion school days could be gained if the supply of drinking water, sanitation were achieved and the incidence of diarrhoeal diseases would be reduced [ 3 , 6 ]. The provision of drinking water and sanitary facilities at schools contribute to improved personal hygiene with a positive impact on the health of students [ 7 ]. In Kenya, for example, diarrhoea cases were reduced by half in 2004 [ 8 ]. In Burkina Faso, in the study conducted by Erismann et al., the prevalence of helminthiasis was decreased in schools, from 11.4% in 2015 to 8.0% in 2016 [ 9 ]. The provision of facilities also encourages the improvement of good hygiene practices as noted in the study by Chard et al. in 2014 in Laos, where we observed an increase in the number of students who used the toilet and washed their hands with soap after using the toilet [ 10 ]. However, these facilities are not always available at schools, especially in the underdeveloped countries. In 2018, only 51% of schools in these countries have access to adequate water supply and 45% had adequate sanitation [ 7 ]. However, the origins of many adult diseases have their roots from childhood health behaviour. School-aged children can learn specific health-promoting behaviours, even if they do not always understand the links between illness and behaviour [ 11 ]. Therefore, hygiene education in schools can promote behaviour that will improve students’ academic performance by reducing the rate of morbidity and absenteeism [ 1 , 4 , 12 ]. Instilling good hygiene practices at a younger age could have a lasting impact on the health of schoolchildren [ 2 , 13 ]. The factors associated with the personal hygiene of pupils are well elucidated in the literature [ 14-17 ], namely the inadequate and insufficient sanitation facilities in schools, the level of education of the father, the level of income of the father, access to drinking water, gender and class of students, cleanliness of toilets, lack of separated toilets only for girls and lack of soap and water in handwashing device.

Meanwhile in Côte d’Ivoire, these factors are little studied. It is with this in mind that we analysed the determinants of personal hygiene in the school environment in the northern region of Côte d’Ivoire, based on a database on intestinal helminthiasis carried out in 2016 which made it possible to highlight the personal hygiene index [ 18 , 19 ].

Material and methods

Type of study and population.

Between October 2016 and January 2017, a cross-sectional study was carried out in 4 departments in the northern area of Côte d’Ivoire, namely the departments of Tengrela, Boundiali, Ferkéssedougou, Dabakala. The study examined elementary school children aged 5 to 15. All schoolchildren present during the survey period and who had lived in the north for more than 3 months were included. However, schoolchildren who had been dewormed 3 weeks before the start of the study were excluded.

The educational departments of northern Côte d’Ivoire comprised 536 primary schools, with 81,041 schoolchildren enrolled in the period for the 2014-2015 school year [Department of Strategies, Planning and Statistics (DSPS, 2014-2015)]. To calculate the minimum number of schools and children to be included, the sample size was determined using Schwartz’s formula with a theoretical prevalence of 50%, accuracy of 5%. The calculated sample was 384 students extrapolated to 510 students per region. The total enrollment was 2,040 schoolchildren.

In each region we have made the reasoned choice to take 60 classes, which brings us to an enrollment of 8.5 students per class, rounded off to 10 students per class. Each school has 6 classes, we have selected 10 schools per region.

Once in the classroom, the schoolchildren were randomly selected until they reached ten pupils.

COLLECTION OF DATA

Data were collected using a standardized questionnaire forms. These data related to age, sex, class, taking dewormer, the student housing environment (rural or urban), certain behaviors (for example, defecating habits, visiting rivers) and status. socio-economic status of the mother. The investigation included the functional signs related to various stages of schistosomiasis, such as itching, headache, stomach upset or diarrhea.

SAMPLE COLLECTION AND LABORATORY PROCEDURES

Faecal samples were taken from schoolchildren directly using the plastic pots and analyzed using the Kato-Katz method. A stool sample was taken for each child. This technique has been used to identify S. mansoni eggs and the presence of other helminths, including roundworms, whipworms, hookworms and Taenia sp. Thus a database on hookworms in schools conducted in the north of Côte d’Ivoire was set up. Our study was based on this database, which also contained variables on the personal hygiene of the student, the socio-demographic and environmental characteristics of the student, his family and the variables related to sanitation at school. Schools in the northern region of Côte d’Ivoire face a double challenge : insufficient access to drinking water and poor hygiene and sanitary conditions. Indeed, the average performance in mathematics and reading (-53.8 points and -34.9 points) in the Northern region are lower than the national averages in both subjects and irrespective of the level [ 20 ].

The data was exported to an Excel table for the construction of new variables.

Dependent variable

The personal hygiene variable was constructed by referring to the personal hygiene index developed by Jeyakumar et al. [ 21 ]. The personal hygiene items (explained variable) consisted of four domains including hand hygiene, nail hygiene, wearing shoes, school excreta disposal. For hand hygiene, 3 criteria were retained, for nail hygiene and the wearing of shoes, these criteria were two in number and one criterion was retained for the elimination of excreta. The personal hygiene variable therefore included a total of 8 criteria ( Tab. I ). Hand hygiene was said to be good if the student always washed his hands before eating and after bowel movements, using soap and water. Nail hygiene was good if the student did not bite his or her nails and had clean nails. Foot hygiene was correct if the student had shoes that he always put on. Excreta disposal was correct if the student used the toilet. Each observation could get a score of 0 or 1. When the observed practice was positive, a score of 1 was assigned. The level of personal hygiene was therefore calculated by adding the scores. Thus, the total personal hygiene score was between 0 and 8. A poor personal hygiene practice corresponded to a score less than or equal to 3, a good personal hygiene practice to a score between 4 and 5 and a very good personal hygiene practice corresponded to a score between 6 and 8.

Indexes to assess personal hygiene.

EXPLANATORY VARIABLES

The explanatory variables were the socio-demographic characteristics of the students, the area of residence, sanitation at school, the socio-economic characteristics of families and access to water and sanitation in households. The student’s socio-demographic variables included age, gender, and educational attainment. The school sanitation was assessed on the basis of the answers to the existence of toilets in the school and the state of cleanliness of these toilets. The school sanitation was assessed on the basis of the answers to the existence of toilets in the school and the state of cleanliness of these toilets. Thus, the level of hygiene in the school was good when there was at least one toilet and when the facilities were clean.

The socio-demographic variables of the family consisted of the level of education of the father and the mother, the monthly income of the parents recoded into 2 salary levels with reference to the guaranteed minimum inter-professional wage (SMIG) in force in Côte d’Ivoire < 60,000 FCFA and ≥ 60,000 FCFA or 90 Euros.

The habitat type has been dichotomized into the modern type habitat and rural type habitat.

The household’s water supply source was informed through the availability or not of drinking water at home. Access to good sanitation at home was treated like the disposal of excreta at school.

STATISTICAL ANALYSIS

The analysis of the data thus generated was carried out with R Software version 1.1.463.

Each variable was subjected to descriptive analysis. Associations between levels of personal hygiene and the variables studied were explored using the χ 2 test in univariate analyzes. A p value < 0.05 was considered indicative of a statistically significant association. Individuals with missing data for dependent variables were not retained for analysis. For multivariate analyzes, the analysis strategy was to include in the model all variables that had a p-value of less than 20% in univariate. This threshold has been favored so as not to immediately eliminate the important variables. Then, the variable which, at each step, provided the least information was removed from the model while checking that it was not a confounding factor (percentage of variation in odds ratio greater than 20-25%). This progressive elimination procedure was carried out until a model was obtained which consisted only of significant variables (p-values < 5%). Once the reduced model was obtained, relevant interaction terms were introduced and a top-down procedure was performed again to find out whether any interaction terms were significant (significance level set at 5%). The variables involved in a significant interaction were maintained in the model.

MISSING DATA

Pre-treatment.

The pre-processing of the data consisted in listing the number of non-response by variable.

Data cleaning and missing data management. The non-response rates were estimated and were relatively low because only 5 (0.24%) children were concerned, which allowed us not to take them into account in our study and to have a correct database.

ETHICAL CONSIDERATIONS

The agreement of the head of the parasitology-mycology department of the Faculty of Pharmacy and Biological Sciences has been obtained for the use of the database. The original file was anonymous.

SOCIODEMOGRAPHIC CHARACTERISTICS

Table II shows the socio-demographic characteristics of students, parents and households. There were 2,035 students with a sex ratio (M/F) of 1.24. There were practically the same number of pupils in the 3 levels CP, CE and CM (33%). The mean age was 9.2 (± 2.33) years. Most students attended schools with toilets (71.9%), however, 84% had poor sanitation in the schools. Most of the students had parents who were not educated, respectively 46% for fathers and 58% for mothers. More than half of the parents had a monthly income greater than or equal to the minimum wage (61% of fathers and 62% of mothers). Almost all of the students came from households where the parents lived as a couple (96.71%). Their housing was 68.55% rural. They had access to drinking water (97%) and a good level of sanitation (75%).

Socio-demographic characteristics of students in the north of Côte d’Ivoire (n = 2,035).

COMPONENTS OF PERSONAL HYGIENE

Analysis of personal hygiene in Table III shows that the components “hand hygiene”, “foot hygiene” and “nail hygiene” were poor in 91, 72 and 67% of students, respectively. The most correct hygienic practice was the disposal of excreta (about 2 out of 3 students). Overall personal hygiene was good with an average score of 4.74 ± 1.36. Thus, 8 out of 10 students had good personal hygiene.

Distribution of students according to the components of personal hygiene (n = 2,035).

UNIVARIATE ANALYSIS

The univariate analysis presented in Table IV revealed that personal hygiene was better in girls (p = 0.002), in students over 10 years old (p = 0.031) and when school sanitation was good (p < 0.001). Family characteristics related to personal hygiene were parents education level, level of their income above the minimum wage, modern housing and adequate sanitation (p < 0.001). When the household had access to good drinking water, the personal hygiene of the students was also better (p = 0.008).

Univariate analysis of factors associated with student personal hygiene.

MULTIVARIATE ANALYSIS

In the final logistic regression model, student sex, school and home sanitation, father’s income and education level, family home type were the predictors of good personal hygiene for students ( Tab. V ). Compared to boys, female students and those whom fathers received an elementary or secondary school education were 1.5 times more likely to have good personal hygiene. The same was true for modern-type housing compared to rural-type housing. The father’s income level above the minimum wage doubled the student’s probability of having good personal hygiene. Adequate sanitation at school was strongly associated with good student personal hygiene (8 times). Poor sanitation at home reduced by a third the probability of the student having good personal hygiene.

Personal hygiene and predictive factors among students in the north of Côte d’Ivoire.

This study took place in primary schools in northern Côte d’Ivoire with a sample of 2,035 students. Overall, in our study the majority of students had good personal hygiene (82%), as in the study conducted by Baba et al. in Nigeria, where 74% of school children had good personal hygiene [ 16 ]. This personal hygiene was associated with gender (p = 0.002) with girls being 1.5 times cleaner than boys. This trend has also been reported in studies by Motakpalli et al. and Sakar in India [ 4 , 11 ]. Among the socio-demographic variables of the parents, the primary and secondary education level of the father encouraged more than once a good personal hygiene in the pupils and personal hygiene improved with the advancement in the education level of the pupil and father. Rather, Lopez in 2007 noted that handwashing among students increased with mother’s level of education [ 17 ]. Pupils whose fathers had a monthly income greater than or equal to 60,000 FCFA (90 Euros) were 2.36 times cleaner than those whose fathers earn a lower income (p < 0.001). This result could be explained by the fact that the father’s income below the minimum wage is low, however several charges in the household fall on the father, namely sanitary products and sanitary facilities as well as access to potable drinking water which incur costs making this income very insufficient for household needs. These results are similar to those of Oga in 2004 in Agboville where the prevalence of intestinal helminthiasis decreased when the father’s income increased [ 22 ].

In terms of the household and school environment, our study showed that children who lived in modern-type houses were 1.45 times cleaner than those in rural-type houses (p < 0.001). According to Bewa et al. (2016), in Benin, the type of housing was an indirect reflection of the economic level of the household [ 23 ]. In fact, in these households, children do not benefit from amenities such as drinking water supply and excreta disposal and may have difficulty practicing hygiene measures [ 24 ]. When schools had good sanitation, students were almost 8 times cleaner than those in schools with poor sanitation (p < 0.001). According to Koné in 2012, in Mali, such unsanitary conditions favour student absenteeism and the spread of diseases linked to faecal peril, in particular diarrheal diseases, typhoid fever and polio [ 25 ].

Among students aged 10 and above with poor home sanitation, personal hygiene was still 3.38 times more important. This could be related to the adaptability of children’s development as they grow older. It has been reported that the ability to understand and apply basic personal hygiene advice would be improved in older children compared to younger children even if home sanitation was not adequate [ 16 ].

STUDY LIMITATIONS

This study highlights the level of hygiene of school children in the North as well as the risk factors. Outcomes should be considered cautiously as behaviours are self-reported. However, any bias in the responses can overestimate or underestimate the behaviours. The results of this study cannot be generalized to other hygiene practices in the country since the sampling is not representative of the country and it is a retrospective study.

The personal hygiene of pupils in northern Côte d’Ivoire was good. Thus girls had better hygiene than boys, children aged 10 and above were cleaner, the more higher the father’s education level was, and the pupil’s personal hygiene increased. Modern housing and sanitation at home and at school promoted good hygiene. Personal hygiene in students therefore requires the provision of health infrastructure both at home and at school, not to mention the training of students. This suggests an effective involvement of education authorities, the economy, without forgetting the participation of teachers, parents and students.

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Acknowledgements.

Funding sources: this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The authors give sincere thanks to the Department of Parasitology-Mycology of the Faculty of Pharmacy and Biological Sciences for their collaboration.

Conflicts of interest statement

The authors declare no conflict of interest.

Authors’ contributions

SKJ: conception, design, data collection, supervision and writeup of the manuscript.

DAA: writing original draft.

KBP: data collection.

KJ : data analysis and interpretation.

TML, GBM † , KKL: review.

All authors have read and agreed to the published version of the manuscript.