Does a Playful Intervention Promote Hand Hygiene? Compliance and Educator's Beliefs about Hand Hygiene at a Daycare Center
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.
Section snippets
Study design and setting
This quasi-experimental before-after study was carried out at a public daycare center in Sao Paulo, Brazil. The daycare center provides full-time education for 212 children aged zero to four years from a community of low-income families.
Sample size and participants
The sample size of observed hand hygiene opportunities was calculated based on the compliance rate found by Zomer et al. (2013) and van Beeck et al. (2016) at Dutch daycare centers. They found a hand hygiene compliance rate of 42% among caregivers and 31% among
Results
The playful intervention to promote hand hygiene was carried out with 24 caregivers and 126 preschool children. All caregivers (N = 24) were female with an average age of 40.4 years and median of 36 years (range 28–60 years). The average years of work experience as a caregiver was 15.3 years and the median was 16 years (range 4–30 years). Most had obtained a Bachelors of Education degree (84.2%), and 15.8% completed a 2-year teacher education program. Of the 24 caregivers, 12.5% worked in
Discussion
Our findings 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. Caregivers' perception of self-efficacy for hand hygiene was higher after bathroom use (59.8%) and lower after playing outdoors (28.6%). Caregivers reported the high number of children in each classroom as the main barrier to hand hygiene, particularly when children arrive at the daycare
Conclusion
Health promotion targeting caregivers and children at daycare centers is essential in promoting children's health and development in the early years of childhood. Our results showed the effectiveness of a low-cost playful intervention in promoting hand hygiene compliance among children and caregivers at a daycare center. Health education provided by pediatric nurses is essential in promoting health and preventing the dissemination of infectious diseases to children and caregivers at daycare
Acknowledgments
We would like to thank children, families and educators of Centro Assistencial Cruz de Malta for their engagement and support. We also thank Jonas Weissmann Gaiarsa for conducting statistical analysis of our data, Maisa Weissmann Gaiarsa and Claudio Martins Gaiarsa for providing the proofreading revision of our manuscript.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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