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Electronic Hand Hygiene Quality and Duration Monitoring in Pre-School

Children: A Feasibility Study

Article  in  International Quarterly of Community Health Education · July 2021

DOI: 10.1177/0272684X211033448

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Applied Research

International Quarterly of
Community Health Education
Electronic Hand Hygiene Quality and 0(0) 1–7
! The Author(s) 2021
Duration Monitoring in Pre-School Article reuse guidelines:
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Children: A Feasibility Study DOI: 10.1177/0272684X211033448
journals.sagepub.com/home/qch

Mohd Dzulkhairi Mohd Rani1, Nurul Azmawati Mohamed1 ,

Tengku Zetty Maztura Tengku Jamaluddin2, Zarini Ismail1,
Shalinawati Ramli1, Habibah Faroque1, Farishah Nur Abd Samad1,
Abdul Rasyid Ariffien1, Aisyah Ar Redha Che Amir Farid1, and
Ilina Isahak1

Abstract
Background: Hand hygiene is regarded as the most important measure to prevent spread of infectious diseases. The aim of this study
was to assess the feasibility of a prototype application in an electronic device in educating, stimulating and monitoring hand hygiene
quality in young children.
Method: A pre-school was provided with an interactive hand hygiene application for two months. The device features an online
administrator dashboard for data collection and for monitoring the children’s hand washing steps and duration. A good hand washing
is defined as hand washing which comprise all of the steps outlined in the World Health Organization (WHO) guidelines.
Results: The prototype managed to capture 6882 hand wash performed with an average of 20.85 seconds per hand wash. Washing
hands palm to palm was the most frequent (79.9%) step performed, whereas scrubbing fingernails and wrists were the least (56%)
steps performed.
Conclusions: The device is a good prototype to educate, stimulate and monitor good hand hygiene practices. However, other
measures should be undertaken to ensure sustainability of the practices.

Keywords
hand hygiene, pre school, device, monitoring

Introduction The quality of hand hygiene practice is determined by correct

Hand hygiene is believed to be a global and critical factor
in prevention of infectious diseases.1 Many studies have
reported an association between improvements in hand
hygiene and reduction in rates of infectious illnesses in
young children.2,3 High hand hygiene compliance does not
guarantee infection prevention if all skin surfaces are not
properly cleaned. Currently, there are numerous studies
which explore on hand hygiene compliance of healthcare
workers compared to that of young children.4–6 There are a
total of five examples of widely used intervention strategies
for hand hygiene initiatives such as education and training,
track and measure performance with feedback, reminders,
use of multidisciplinary teams and systematic performance
improvement methods.7
Hand hygiene quality, in addition to hand hygiene
compliance are essential to prevent spread of infections.
techniques or steps as recommended by the World Health
Organization (WHO) with the primary objective of ensuring
adequate coverage of all hand skin surfaces.8 However, the
quality of the activity is usually not monitored since there is
no established methodology for the routine assessment of
hand hygiene technique. Hand hygiene quality had been
assessed by direct observation9 and UV light assessment10
1
Faculty of Medicine & Health Sciences, Universiti Sains Islam Malaysia, Nilai,
Malaysia
2
Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Serdang,
Malaysia
Corresponding Author:
Nurul Azmawati Mohamed, Faculty of Medicine & Health Sciences, Universiti
Sains Islam Malaysia, Persiaran Ilmu, 71800 Nilai, Negeri Sembilan, Malaysia.
Email: drnurul@usim.edu.my
2 International Quarterly of Community Health Education 0(0)
methods which was time consuming and required dedicated
observers.
Successful hand hygiene improvements require behavioral
change.11 Monitoring is one of the multimodal implementa-
tion strategies to improve hand hygiene12 and electronic
automated systems can potentially be of value in monitor-
ing.13 There are abundance of tools and methods for moni-
toring and reporting hand hygiene adherence,14 from direct
observation15 to measurement of hand hygiene products
usage16 to emerging automated oversight technologies.17 To
date, there are limited studies that utilize electronic devices to
monitor hand washing quality as most studies on automated
systems focused mainly on monitoring hand washing
compliances.18
We conducted a prospective trial on pre-school children
aged five to six years old as they are more receptive to learn-
ing and adopting new behaviours.19 The aim of this study
was to assess the feasibility of a prototype application in an
electronic device to educate, stimulate and monitor hand
washing quality among pre-school children.
Methods
Study Location and Population
We identified several pre-schools which is logistically suitable
focusing on the availability of hand washing facilities for the
study and selected a pre-school in Putrajaya, Malaysia
named as School P. There were approximately 300 students
enrolled in this pre-school and they were divided into
11 classes. Each class has its own toilet which was equipped
with four wash basins. Two wash basins were utilized per
class while the rest were sealed off. The students were pro-
vided with the hand hygiene sets which included paper
towels, waste bins and antiseptic skin cleanser. The study
was done from end of September until end of November
(total of 8 weeks). There was a week holiday at week
4 (thus the total number of intervention week was only
7 weeks). Parental consent was obtained from all
participants.
Tablets and ‘Hand Hygiene’ Application
We used a prototype electronic device in a form of android
tablet. A total of twenty-two tablets were fixed in the basin
area above the twenty-two assigned wash basins throughout
the two-month study period. A “Hand Hygiene” application
was installed in all tablets. Prior to the study, the teachers
and students were trained on how to use the application. To
initiate the application, the users had to wave to the tablet
camera. Trained personnel was also stationed at the school
throughout the study period to guide the children and to
conduct regular checks in all classes to ensure proper and
continued use of the tablets. The pre-school children were
encouraged and instructed to wash their hands by their
teachers as per usual.
The “Hand Hygiene” application is a new, high-
technology application developed by Mundipharma
Pharmaceuticals Sdn. Bhd. The application displayed a
visual step-by-step guidance of proper hand washing tech-
nique. The prototype assessed eight hand washing steps
which include the six items for adequate hand surface cover-
age as recommended by the World Health Organization.12
The eight steps include washing hands palm to palm, between
fingers, back of hands, base of thumbs, back of fingers, fin-
gernails, wrists followed by rinse and dry.
The application utilized artificial intelligence to monitor
the children’s hand washing steps real-time. The built-in
camera detected hand movements and identified whether
each step was performed and its duration. The application
applied a reward system whereby for each step performed,
the user gained a star to a maximum of eight stars per hand
wash. However, for each step missed, the application would
intervene by sounding an alarm to further motivate their
efforts towards proper hygiene. The stars collected were
then displayed to the user at the end of the hand wash
which were then converted into scores for analysis.
The data from the tablets were linked remotely to the
developer dashboard, from which we have the access. The
dashboard displays several data collected for interpretation.
Lists of data which could be obtained from the applications
were the number of hand-washes per day during the time of
the day scheduled for school activities, the duration of hand
washing, the completion of handwashing steps and the qual-
ity of hand wash.
The prototype devices were supplied with power packs
that lasted for more than a day. The tablets were pro-
grammed to be switched on only during school hours. The
data collected from the application was uploaded to a
password-protected dedicated internet website.
Data Analysis
Data was extracted from the application in the form of
MicrosoftVR Excel. Statistical analyses were performed using
the Statistical Package for the Social Science (SPSS) soft-
ware, version 20.0. Hand washing steps and quality were
presented as means and standard deviation. Independent
t-test was used to evaluate the hand washing skills progress.
Test was assessed with a significance level of 0.050.
Results
A total of 297 pre-school children aged 5 to 6 years old were
involved where 52.4% (161) were boys.
Table 1 described the weekly variation in the total number
of hand washes recorded by all the tablets. Throughout the
eight-week trial period, a total of 6882 hand washes were
recorded. In week one alone, 394 hand washes were
Mohd Rani et al. 3

Table 1. Frequency, Scores and Duration of Hand Washes During the Table 2. Percentage of Students Performing Specific Step of Hand
Study Period. Washing

Scores Duration of hand Percentage (%)

Frequency wash (seconds)
Week N (%) Mean Min Max Mean Average
Step performed (week 1 to 8) Week 1 Week 3 Week 8
1 394 (5.7) 6 3 8 21.59
2 1362 (19.8) 6 3 8 21.80 1. Palm to palm 79.9 81.5 81.5 74.4
3 1468 (21.3) 6 3 8 21.15 2. Between fingers 72.4 74.4 73.0 69.7
4 0 (0) 0 0 0 0 3. Back of hands 66.2 70.3 66.6 64.7
5 942 (13.7) 5 3 8 21.16 4. Base of thumbs 64.3 65.5 65.4 59.6
6 936 (13.6) 5 3 8 20.74 5. Back of fingers 62.5 61.2 65.1 58.3
7 1101 (16.0) 5 3 8 19.94 6. Fingernails 57.6 56.9 58.9 53.9
8 679 (9.9) 5 3 8 19.55 7. Wrists 56.1 60.2 58.4 49.9
Average 983 5.4 – – 20.85 8. Rinse and dry 77.7 81.2 78.4 71.0

performed. The number increased significantly in week two
(1362) and week three (1468). No hand wash was recorded
during week four which was a school holiday week. The
number of hand washes in the fifth week (942) significantly
decreased for about eight percent from week three. The
remaining weeks managed to capture another 2716 hand
washes.
Analysis showed the average hand washing duration
throughout study period was 20.85 seconds. It also showed
that the mean duration for each hand wash became shorter as
the study progressed. Initially, the mean duration was 21.59
seconds per hand wash in the first week. The duration
remained longer than 21 seconds until the fifth week. The
duration decreased from 21.16 seconds in week five to
19.55 seconds in the final week. The longest mean duration
recorded was week two at 21.08 seconds.
The hand washing scores were displayed in the form of
stars which calculated according to the eight completed hand
washing steps as instructed by the application. The minimum
score for hand washing technique was one star and the max-
imum was eight stars as set within the application system.
The mean score obtained by the students was 5.429.
However, the weekly mean score showed a significant down-
ward trend from week one to week eight. Initially, during the
first three weeks of trial period, the round of weekly mean
scores was six. After school holiday, the score dropped by
one point to five. The actual mean score for the first week
was 5.56 and in the final week, the score dropped to 5.11.
Based on independent t-test analysis, there was significant
decrease in the mean score of the hand washing technique
(P ¼ 0.001).
On average across the weeks as shown in Table 2, washing
hand palm to palm was performed by 79.9% of the students.
The base of thumbs and back of fingers coverage rate was
only 64.3% and 62.5%, respectively. The least performed
step was washing the wrists, 56.1% followed by cleaning
the fingernails, 57.6%. From week one to week three, there
was a decrease in percentage performed for majority of the
steps except for steps five and six. Decline of percentages
between week three to week eight for all the steps was
observed.
Observation
Based on the observations done by the study personnel
throughout this study, an attractive visual aid such as a
hand washing application is useful as it was found that chil-
dren required continuous motivation and guidance besides
reminders to perform hand wash. Majority of them were
seen using the application in order to gain the perfect score
at the end of their hand washing routine. Those children who
gained little points were then motivated to repeat washing
their hands in order to score more points. Some of them
only washed their hands after being instructed by the teach-
ers to do so especially during their meal time. Technical dif-
ficulties were also reported. 1) Malfunctioning devices
towards the end of the study. Number of valuable hands
washing data and trends of hand washing times could not
be accessed. 2) Three power packs were non-functioning and
replaced. 3) Teachers forgot to charge the power pack
overnight.
Discussion
There are abundance of tools and methods for monitoring
and reporting hand hygiene adherence; from direct observa-
tion to volume-based measurement to emerging automated
oversight technologies. The ‘gold standard’ of monitoring
hand washing compliance is via direct observation.12
Unfortunately, this would require a lot of time and is
labour intensive.4 There are also issues regarding
Hawthorne effect20 and not to mention the presence of
human factors including bias between interviewers and
respondents.21 Fortunately, development of technology may
potentially eliminate this issue.11,21
The prototype application used in this study, had provided
specific data on the score of hand washing quality and
4 International Quarterly of Community Health Education 0(0)
duration of hand wash throughout the eight-week period and
on a weekly basis which also provided the users with guid-
ance, continuous monitoring and real-time feedback of every
hand wash. From this, we were able to look at the progress of
hand washing scores and percentage of steps performed.
Since the monitoring ran for a period of eight weeks, the
tablets help to save human resource as long-term physical
guidance and monitoring would require a lot of time and
manpower.11
Results from this study revealed that more than 6000 hand
wash were performed. The number of hand wash was low at
the first week, increased to the highest at week 3, but decrease
by the end of the study period. The low number of hand wash
in the first week might be attributed to lack of confidence and
understanding in using the application. The total number of
hand wash by the end of the study reduced to below than
10% which was deduced due to the decreased in the number
of children attending the pre-school since it was nearing to
the year-end school break, that started a week after the study
finished. Besides that, we postulated that the decline may also
be due to the decrease in interest towards the hand hygiene
application. As time goes by, the children got used to the
presence of the tablet and towards the end of the study
period, they do not comply with the hand washing instruc-
tions provided by the application.
Effective hand washing requires appropriate contact time
(duration) and coverage of skin surfaces. Our data showed
that the prototype able to guide children to perform hand
washing for at least 20 seconds as recommended by the
Centre of Disease Control. For hand hygiene steps, the pro-
totype managed to capture percentage of correct steps
according to the WHO guideline. In congruence with a pre-
vious study on health care workers, we found that the most
performed hand washing steps among these pre-school chil-
dren was washing hands palm to palm.9 The least common
steps were scrubbing the fingernails and the wrist. This is
similar to other study where children showed poor compli-
ance to washing the base of their thumbs, back of fingers,
fingernails and wrists, even with visual guidance.22
Essentially, this application only provides visual aids with-
out human involvement to prompt and guide them to wash
their hands. Nonetheless, with repeated visual aid for proper
hand hygiene, their knowledge regarding proper hand
hygiene might have improved; however, they still do not
practice it on a regular basis. Large evidence has shown
that education alone is inadequate to elicit a behaviour
change.23 Poor adherence to hand washing steps may be
due to absence of good role modelling and self-efficacy
from their educators.24 Furthermore, in order to instil
habits, repeated handwashing practices are needed. Lally et
al. concluded that in order for a habit to be successful, rep-
etition is needed on a daily basis.25 The duration required is
about eight to 254 days. In our study, we were only able to
provide five continuous days per week since the children did
not attend school during weekends. There was also a one-
week holiday break in the middle of the study.
Automated monitoring devices proved to be cost-effec-
tive26 compared to direct observation which required
employment of study personnel for monitoring. The ability
to upload data to a password-protected dedicated internet
website with data collection capabilities substantially reduced
the amount of time researchers had to spend to collect and
export the data to analysis software.
This study had number of limitations. Firstly, the devices
were not equipped with any identification software to tag and
recognise the subjects individually. This allowed repeated
result if the subjects wash their hands multiple times.
Secondly, the use of device needs full cooperation from
teachers in terms of maintaining of the device and encourag-
ing children to use it. Thirdly, unavailability of backup device
to replace malfunction device.
Conclusion
As a conclusion, the hand hygiene application and android
tablet are a good prototype to be used for education, stimu-
lating and monitoring hand hygiene quality among pre-
school children. Combining electronic monitoring with
observational methods may provide the best information as
part of a multimodal strategy to improve and sustain hand
hygiene quality and compliance rates among pre-school chil-
dren. For future study, it is recommended to perform quasi-
experimental study to look for the differences of hand
hygiene performance with and without the application.
Further improvements towards the prototype’s technology
and performance are required in order to make sure that
there is no failure of the system in capturing the information
required.
Author’s Contribution
“Conceptualization, N.A.M. and I.I.; Methodology, M.D.M.R and
H.F.; Data Collection, F.N.A.S., A.R.A. and A.A.C.A. Formal
Analysis, S.R., Z.I.; Writing – Original Draft Preparation, A.R.A.
and F.N.A.S.; Writing – Review & Editing, N.A.M., T.Z.M.T.J.
and I.I.; Funding Acquisition, N.A.M.” All authors have read
and approved the manuscript.
Ethics Approval and Consent to Participate
Ethics approval was obtained from the Medical Human Ethics
Committee of Universiti Sains Islam Malaysia (USIM) (USIM/
JKEP/2017-20). Written informed consent for participation in the
study was obtained from their parent or guardian.
Data Accessibility Statement
Data and materials are available upon request.
Mohd Rani et al.
Acknowledgement
We are immensely grateful to Majlis Agama Islam Wilayah
Persekutuan (MAIWP) for their participation and cooperation in
this study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: The
financial support for the provision of tablets was given by
Mundipharma Pharmaceutical Sdn. Bhd. (USIM/MUNDI/FPSK/
052002/42817).
ORCID iD
Nurul Azmawati Mohamed https://orcid.org/0000-0003-2751-
5402
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Author Biographies
Mohd Dzulkhairi Mohd Rani is an Associate Professor and
Public Health Physician in the Faculty of Medicine and
6 International Quarterly of Community Health Education 0(0)
Health Sciences, Universiti Sains Islam Malaysia. He
obtained his medical degree from the International Islamic
University, Malaysia and his specialist training in Public
Health Medicine from the Universiti Sains Malaysia. His
research interest is on the health issues of the marginalised
community. He is one of the mentors for UNESCO
Community Based Participatory Research and currently
working on projects with the indigenous population.
Nurul Azmawati Mohamed is an associate professor &
Clinical Microbiologist at the Faculty of Medicine and
Health Sciences, Universiti Sains Islam Malaysia. She grad-
uated in 2002 from the University of Sheffield’s Medical
School. Ten years later, she obtained a master degree in
pathology (MPath) majoring in medical microbiology from
Universiti Kebangsaan Malaysia. Her research interests are
infection control in the community and antimicrobial- resis-
tant organisms.
Tengku Zetty Maztura Tengku Jamaluddin is a medical lec-
turer at the Department of Medical Microbiology, Faculty of
Medicine and Health Sciences, Universiti Putra Malaysia.
She received her MBChB in medicine from the University
of Sheffield, United Kingdom in 2002, and PhD in
Infection Control Science from Juntendo University, Japan
in 2008. She is Head of Infection Control Section,
Department of Medical Microbiology, Hospital Pengajar
UPM. She sits on the Antimicrobial Stewardship
Committee and COVID-19 Advisory Committee, HPUPM.
Her research interests are infection prevention and control of
infectious diseases both in the healthcare setting and the
community.
Zarini Ismail is a lecturer at the Faculty of Medicine and
Health Sciences, Universiti Sains Islam Malaysia. She
obtained her medical degree in 2003 from Universiti Sains
Malaysia. She acquired her Master in Science from Liverpool
School of Tropical Medicine and subsequently gained her
Doctor of Philosophy from the University of Liverpool in
2014. Her research interest is in clinical infection particularly
latent tuberculosis infection and also in molecular biology.
Shalinawati Ramli is a Public Health lecturer at the Faculty
of Medicine and Health Sciences, Universiti Sains Islam
Malaysia (USIM).She attained her Bsc. Nursing from
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Universiti Kebangsaan Malaysia. She obtained her
Master’s Degree in Nursing with specialty in Women’s
Health. She completed her PhD in Public Health from
Universiti Kebangsaan Malaysia in 2020. Her research inter-
est are child health in the community.
Habibah Faroque is a PhD candidate in Biomedical Science
(Pathology) in the Faculty of Health Sciences, Universiti
Sultan Zainal Abidin. She is an active member of the
European Association for Cancer Research. She completed
her master’s degree in Biotechnology (MSc) in 2018 from
Universiti Putra Malaysia. Her research interests are cancer
immunology, molecular biology, and genetic engineering.
Aisyah Ar-Redha is a Medical Officer currently serving in the
Emergency and Trauma Department of Hospital Kuala
Lumpur. She obtained MBBS degree from MAHSA
University in 2017, and her research interests include
Pathology and Microbiology.
Farishah Nur Abd Samad is a general dental surgeon in pri-
vate practice. She is a member of the Malaysian Dental
Association. She obtained her Bachelor of Dental Surgery
(BDS) in 2017 from University of Malaya. Her research
interests include orthodontics and infection control in
dentistry.
Abdul Rasyid Ariffien is an Emergency Medicine Trainee at
the Faculty of Medicine and Health Sciences, Universiti
Sains Islam Malaysia. He graduated with MBBS in 2017
from Universiti Teknokogi MARA (UiTM). His research
interest is in emergency medicine.
Ilina Isahak is graduated with M.B.B.S (Universiti Malaya)
and M.Sc.(Universiti London). She had been teaching
Medical Virology to under graduate and Masters students
at Universiti Kebangsaan Malaysia (UKM) for more than
30 years, She was managing Diagnostic Virology Laboratory
and held the post of Infection Control Doctor in Hospital
UKM. Since 2011 she moved to Universiti Sains Islam
Malaysia. Her research interests are Respiratory viruses
Vaccinology and Infection control. She has worked in
many infectious disease programmes with Ministry of
Health Malaysia and pharmaceutical companies.