A theory-based hand hygiene educational intervention for enhancing proper handwashing behaviour among school children in the Ejisu-Juaben Municipality of Ghana

ABSTRACT Background Handwashing with soap (HWWS) has been described as the single most cost-effective approach to reducing infectious disease burden in both the developed and developing worlds. With respect to the promotion of HWWS in schools, hand hygiene education appears to be the most common behaviour change strategy, especially in the developing world. Ironically, there is a paucity of robust evidence in Africa on the effectiveness of a theory-based hand hygiene educational intervention targeting the cognitive, affective, and psychomotor learning domains. Principal Objective To determine the effect of a theory-based hand hygiene educational intervention (HandsCare) on handwashing behaviour; describe the distribution of functional hand hygiene facilities and examine the psychosocial predictors of reported handwashing behaviour (HWB) in the Ejisu-Juaben Municipality. Methods The study began with an observation of hand hygiene facilities in 37 basic schools. Analysis methods for data on facilities included the Scalogram model. The thrust of the study was a cluster-randomised controlled trial consisting of four clusters. Schools constituted the clusters and were randomly allocated to an intervention arm or a control arm. At baseline, 328 and 389 pupils were allocated to the intervention and control arms respectively. Outcomes were behavioural intention and practice of HWWS and these were measured at two-weeks follow-up. Data on handwashing behaviour were gathered using a structured observation, and analysed using the Student’s t-test. Data on psychosocial predictors of reported HWB were gathered using a structured questionnaire, and analysed using linear regression models. All statistical analyses were done using Stata/SE 14. Results A hand hygiene facility deficiency was observed across a range of schools. Only 16% of schools had functional handwashing stations. The observed rate of HWWS after toilet use was 2%, while that of HWWS before meals was 1%. At follow-up, the intervention led to a detection of a significant difference between the study arms with regard to intention to wash hands with soap [after toilet use (p=0.032, d=0.5); and before meals (p=0.020, d=0.2)]. Similarly, a significant difference was detected between the study arms with regard to the practice of HWWS [after toilet use (p=0.005; d=2.6); before meals (p=0.012; d=0.5)]. Handwashing skill (p=0.008; β=0.037; 95% CI 0.01-0.07), attitude to handwashing (p=0.046; β=0.120; 95% CI 0.00-0.24), subjective norms (p=0.011; β=0.055; 95% CI 0.01-0.10), and perceived susceptibility (p=0.001; β=0.101; 95% CI 0.04-0.16) were identified as predictors of intention to wash hands with soap and/or the practice of HWWS. With regard to the intention-behaviour relationship, the result indicates that intention to wash hands with soap does predict handwashing behaviour [(p=0.003, β=0.247; 95% CI 0.08-0.41) and (p<0.001, β=0.346; 95% CI 0.19-0.50) for HWWS after toilet use and HWWS before meals respectively]. Conclusion A school-based hand hygiene educational intervention underpinned by psychosocial theories which targets the cognitive, affective and psychomotor learning domains has a medium to a very large effect size, with respect to the practice of HWWS; and a low to a medium effect size with respect to behavioural intention. Handwashing skill as a predictor of HWWS implies the need to prioritise skill-based hand hygiene education in schools. Addressing the problem of hand hygiene facility deficiency and the low rates of HWWS requires a collaborative effort involving the government, educational authorities, development partners and civil society organisations.

Source: KNUST