Does a Playful Intervention Promote Hand Hygiene? Compliance and Educator's Beliefs about Hand Hygiene at a Daycare Center

Highlights

• Caregivers of daycare centers feel at risk of getting sick at the workplace.

• Caregiver's self-efficacy is higher after bathroom use and lower before eating.

• Playful intervention promotes hand hygiene among children and caregivers.

• Among children, hand hygiene before eating increased 28.5% after intervention.

• Hand hygiene after contact with body fluids increased 35.1% among caregivers.

Abstract

Purpose

Our purpose was to analyze hand hygiene compliance before and after a playful intervention, and caregivers' beliefs, perception of self-efficacy, and barriers to hand hygiene at a daycare center in Brazil.

Design and methods

This a quasi-experimental study was conducted from January to July 2017 in a daycare center that provides full-time education for children aged zero to four years from low-income families. The playful intervention with 24 caregivers included an emoji card game to address their beliefs and perception of self-efficacy and a product that reveals dirty areas on washed hands. For 126 children aged two to four years we used a story told through puppets, card games, songs, and a practice of washing hands colored with tempera paint.

Results

The results showed that the playful intervention with children and caregivers increased hand hygiene compliance from 13.3% to 41.4% with a significant statistical difference (p < 0.001) after the intervention. The caregiver's perception of self-efficacy for hand hygiene was higher after bathroom use (59.8%) and lower after playing outdoors (28.6%).

Conclusions

Playful interventions performed by nurses promote hand hygiene compliance among children and caregivers at daycare centers.

Practice implications

Practice implications include that health education provided by pediatric nurses is essential in promoting health and preventing the dissemination of infectious diseases to children and caregivers at daycare centers.

Introduction

When the context of childcare and education is strengthened by positive early experiences, children are more likely to grow into healthy adults (Center on the Developing Child at Harvard University, 2016). Early childhood education enrollment increased by nearly two-thirds between 1999 and 2012, totaling a world gross enrollment rate of 54% (National Center for Education Statistics [NCES], 2017). In 2017, 3406 thousand Brazilian children aged zero to three years were cared for at daycare centers, of which 65% were at government subsidized institutions (Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira, 2018).

However, child daycare attendance can be responsible for 33–50% of the episodes of respiratory infection and gastroenteritis among children (Ochoa, Sanchés, & Martin, 2007). In daycare centers, the transmission of infectious diseases is facilitated by the child's immature immune system, limited space for the number of children, intense contact among children and caregivers, and low compliance with hand hygiene practices (Ochoa et al., 2007; van Beeck et al., 2016; Zomer et al., 2013).

Hand hygiene is known as an effective measure to prevent gastrointestinal and respiratory infections among children and caregivers at early childhood educational services (Serra, 2014; Willmott et al., 2016). However, previous studies conducted in Dutch daycare centers revealed that hand hygiene compliance among educators was only 42% and varied from 15 to 48% for children (van Beeck et al., 2016; Zomer et al., 2013).

Considering this, interventions to promote hand hygiene compliance at daycare centers are mandatory. A randomized controlled trial conducted at 711 daycare centers in the Netherlands investigated the effectiveness of an intervention program that provided hand hygiene products, trained caregivers on hand hygiene guidelines, had two team training sessions aimed at goal setting and formulated hand hygiene improvement activities, and delivered reminders and cues for action. The results showed that hand hygiene compliance among caregivers increased because of the intervention; however, the intervention had no effect on supervising children's hand hygiene (Zomer et al., 2016). Similarly, Pickering et al. (2013) reported the effectiveness of an intervention that consisted of providing waterless hand sanitizer to promote hand hygiene compliance at primary schools in Kenya. The study indicated a hand hygiene compliance rate of 82% at schools provided with sanitizers, 38% at schools provided with soap, and 37% at control schools. Students at sanitizer schools were 23% less likely to have observed rhinorrhea than control students (p = 0.02). Likewise, a scalable village-level intervention that included community and school-based events incorporating an animated film, skits, and public pledging ceremonies to promote hand hygiene in rural India revealed that hand washing with soap increased from 1% to 37% after 6 months of the intervention (p = 0.02) (Biran et al., 2014).

Considering that hand hygiene compliance can be related to educators' beliefs, self-efficacy, and barriers to hand hygiene, we adopted the Health Belief Model (HBM) as the theoretical framework. This theoretical framework focuses on two aspects of individuals' representations of health and health behavior: threat perception and behavioral evaluation (Abraham & Sheeran, 2015). Threat perception comprises two key beliefs, namely perceived susceptibility to illness or health problems, and anticipated severity of the consequences of illnesses. Behavioral evaluation consists of two distinct sets of beliefs: those concerning the benefits or efficacy of a recommended health behavior, and those concerning the costs of or barriers to enacting the behavior (Abraham & Sheeran, 2015). The model also proposes health education, social influence, and individual perceptions of symptoms as triggers that can influence an individual's behavior when appropriate beliefs are held (Abraham & Sheeran, 2015).

Likewise, a cluster-randomized trial analyzed the effects of an intervention program developed based on the HBM on knowledge, attitudes, self-efficacy, and beliefs for hand washing among 80 preschool educators in Jerusalem. The intervention for educators included lectures by medical, epidemiological, and educational experts, along with printed materials and experiential learning. The findings revealed educators' belief that hand washing could affect health, their high levels of self-efficacy, and positive attitudes toward hand washing (Rosen, Zucker, Brody, Engelhard, & Manor, 2009).

Evidence regarding the effects of interventions designed to improve hand hygiene compliance among caregivers and preschool children at daycare centers is lacking, particularly in low and middle-income countries such as Brazil. Considering that playing is universal and represents one way in which children and adults can learn, we designed a low-cost playful intervention that could be useful in many contexts worldwide to promote hand hygiene among children and caregivers at daycare centers. Our study analyzed hand hygiene compliance before and after a playful intervention, and caregivers' beliefs, perception of self-efficacy, and barriers to hand hygiene at a daycare center in Brazil.