ARTICLE IN PRESS

American Journal of Infection Control 000 (2021) 1−7

Contents lists available at ScienceDirect

American Journal of Infection Control

journal homepage: www.ajicjournal.org

Major Article

Duration or technique to improve the effectiveness of children' hand

hygiene: A randomized controlled trial
€ u
Emine Onc € *, Su
€ mbu
€ le Ko
€ksoy Vayısog
lu
Community Health Nursing Department, Faculty of Nursing, Mersin University, Mersin, Turkey

Key Words: Background: How to wash hands is as important as when and how often to wash hands for acquiring proper
Handwashing effectiveness hand hygiene habits.
Primary school students Methods: The study aimed to compare the effect of education based on technique or duration for developing
Handwashing procedure children's handwashing skills. The double-blind randomized controlled study was conducted in a primary
Hand hygiene
school between the 10th and 28th of December, 2018 with 155 children who were divided into Group-I,
Group-II, and Control groups. One group was taught by a multi-stage technique, the other was by duration-
based teaching, and the control group was provided with usual training. Handwashing efficacy was assessed
by variance analysis on fluorescent residue after using glo-germ.
Results: The students' mean age was 9.74 § 0.69 years, 53.6% of them were girls. Effective handwashing was
highest in the Group-I. There was a difference between Group-I and Group-II, and Group-I and Control group
in terms of hand cleanness. The frequently missed areas when cleaning hands were palmar surface, dorsal
metacarpal area, and fingertips.
Conclusions: Teaching hand hygiene to children by multi-step technique may increase the handwashing
effectiveness. Conducting comparative studies with new techniques including fewer stages is recom-
mended.
© 2021 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier
Inc. All rights reserved.

Severe acute respiratory syndrome, Middle East respiratory syn-
drome coronavirus, and coronavirus disease 2019 (COVID 19) infec-
tions which shook the world in the last 2 decades affected children
less than adults. Since the children overcome illnesses with asymp-
tomatic or milder symptoms, the debate continues as to whether
children are super-spreaders or not.1−3 While the contact and trans-
mission among child, school, and family can contribute to the spread-
ing potential of pandemic influenza, families also have increased
concerns about protecting their children from pandemics within this
period.3,4 Handwashing, which is at the center of all infection control
measures, is presented as the most effective application for reducing
disease spread in recent pandemics.5,6
Handwashing is a procedure that should be executed automati-
cally without activating the brain's decision-making processes when
needed. Therefore, it is important to make a habit of handwashing to
internalize.7,8 However, it is observed that the importance of hand-
washing in school-age children is not understood as well just like in
* Address correspondence to Emine Onc € u € , Community Health Nursing Department,
€y Campus, Yenişehir/ Mersin, Turkey.
Faculty of Nursing, Mersin University, Çiftlikko
E-mail address: eeoncu@gmail.com (E. Onc € u € ).
Conflicts of interests: The authors have no conflicts of interest to declare.
adults globally.9 In a systematic review involving handwashing stud-
ies through direct observation, the prevalence of handwashing is lim-
ited to 5%-25% in low and middle-income regions and 48%-72% in
high-income countries, even after contact with feces.10 Among chil-
dren, the frequency of handwashing after the toilet ranges between
22%-65%.11-14
For the proper removal of microorganisms from the hands, how
the hands are washed is as important as when and how often. While
emphasizing the importance of developing handwashing knowledge
and behavior in children, it is seen that the information on how to
wash hands is limited.15 World Health Organization has a hand
hygiene procedure for healthcare workers, has no recommendations
for children. Centers for Disease Control and Prevention (CDC)
emphasizes the handwashing duration of 20 seconds with a proce-
dure consisting of ''foam, rub, rinse, dry'' steps.5,16 Amin stated that
the complex handwashing directive may negatively affect compli-
ance with hand hygiene.17 It remains unclear whether handwashing
technique affects the handwashing effectiveness. The current study
aimed to evaluate the effects of 2 teaching programs, namely the
World Health Organization’s multi-stage hand hygiene procedure
and CDC's duration-based recommendation on teaching hand-
hygiene to children.

https://doi.org/10.1016/j.ajic.2021.03.012
0196-6553/© 2021 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
 ARTICLE IN PRESS
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Fig 1. Flow diagram of the study population.
METHODS
This study was conducted at a primary school located in a low
socio-economic region of Turkey as a randomized controlled double-
blind study between the 10th and 28th of December 2018. The target
population of the study was 2128 students in this school. 155 fourth-
grade students within the 8-11 age group, who showed similar devel-
opmental characteristics in terms of progression and learning, were
included in the study. The 5 students who did not meet the study cri-
teria, 1 student who declined to participate in the research, along
with 93 students who could not receive parental approval were
excluded from the study. It was completed with 151 students
(Figure 1).
Participants
Based on the work of Lee and Lee,18 it was determined that 30
people should be recruited for each group with an effect size of
0.635, 0.80 power, and a= 0.05 (G*Power 3.1.9.2 statistical soft-
ware). Randomization was applied according to classes when
forming the G-I, G-II and C groups to prevent students from being
affected by each other (Figure 1). Since each class consists of 35-
42 people on average, it was decided to take 2 classes into each
group considering the possible losses. Six classes were deter-
mined by the simple random sampling method among 14 classes,
and their group assignment was created based on the randomiza-
tion table formed by the computer programme. The determined
groups were not explained to the students and their families, and
it is stated that a hand-hygiene study will be carried out. At the
end of the study, all children were provided with multi-stage
hygiene training.
Instrumentation
The data were collected through a “demographic information
form” created by reviewing the literature and consisting of 15
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questions to evaluate children's sociodemographic characteristics,
and general hygiene habits.19−21 The form was filled in by the stu-
dents in the classroom environment in 15 minutes.
The training set used in the application consisted of glo-germ gel
and Semmelweis Hand in Scan (SHS) device, soap, paper towel. The
glo-germ gel was prepared by adding 1 drop of phosphoric substance
to a 75 ml hydroalcoholic solution and can be used safely for evalua-
tion of handwashing efficacy in various age groups and observed in
the light under UV lamp due to its fluorescent substance. The amount
of gel to be applied to the participants was approximately 1 ml,
enough to cover the surface of their hands.18,19 Semmelweis Hand in
Scan is a digital imaging and recording system under UV lighting. It
provides instant visual and percentage feedback about the suitability
of hand hygiene.
Procedure
In the research, firstly, all groups were provided with 15 minutes
of training in the classroom environment, which included the sub-
jects of ''what is a microbe, its types, the ways microbes enter our
body, the importance of handwashing in protection from microbes,
when and how often to wash hands.'' Banners on the importance of
handwashing were hung on the classroom boards.
Handwashing procedure applied to Group- I: After the training,
the WHO's multi-staged handwashing technique which consists of
eleven steps was shown.16 Under the supervision of the researchers,
the children washed their hands in the sinks as shown. At the end of
the demonstration, children were given pictorial cards with the
WHO's directive and asked to stick them near their sink at home and
repeat the application.
Secondly, on the 15th day after training, it was carried out in the
school laboratory. Students were taken to the laboratory in groups of
5. The children were given fluorescent solutions and asked to rub
them and waited for the gel to dry for 15-20 seconds. Students were
told that their hands' images were captured. The hands' images were
recorded by the SHS device. The children were then asked to wash
their hands as taught. Handwashing was performed in student basins
without the supervision of researchers; soap and paper towels were
provided. Hand-imaging was repeated after handwashing.
Handwashing procedure applied to the Group- II: After the train-
ing, as per the recommendation of the CDC, handwashing by singing
“happy birthday (own name)'' song twice was demonstrated. Hand-
washing was repeated in the sinks under the supervision of the
researchers. Pictorial cards reminding them to wash hands accompa-
nied by songs were asked to stick near sinks at home and repeat the
application. The second stage of the research was carried out simi-
larly to the G-I.
Handwashing procedure applied to the Group- C: After the train-
ing, the students washed their hands as usual, with reminders about
the importance of handwashing under the supervision of researchers.
The students were reminded about the cards showing the impor-
tance of hand cleaning and to stick them near the sinks at home and
wash their hands frequently. The second stage of the research was
carried out similar to the G-I, and students were asked to perform
handwashing as usual.
Using digital records of the SHS device, the percentage difference
obtained by subtracting fluorescent covered area on the hands before
and after handwashing was evaluated as “handwashing efficacy.” To
localize the site of the unwashed areas, the hand was divided into
regions. The hand surface was calculated as follows: regions where
distal phalanges, intermediate phalanges, proximal phalanges, meta-
carpal and carpal bones are located were measured using a tape mea-
sure for determining the palmar and dorsal surface areas of the right
and left hands.19 The remaining fluorescent residues in these sections
were graded on a 4 point scale. “3 points- all fluorescent residuals
3
remained in the examined part of the hand; 2 points-less than half of
the examined part was cleared of fluorescent material; 1 point- more
than half of the examined part was cleared of fluorescent material; 0
points- all of the fluorescent residues were removed from the hands.”
As the score increased, hand hygiene is decreased.
Data analysis
The data were summarized by number, percentage, mean, stan-
dard deviation, and median using a statistical package program. Nor-
mality of data was assessed using the skewness and kurtosis. ANOVA
analysis was employed for those showed normal distribution, and
LSD from Post-hoc Tests applied to determine the group causing dif-
ference since the equality of variances was ensured. Kruskal Wallis
and Mann-Whitney U test were used to compare data without nor-
mal distribution, p≤0.05 was accepted as statistically significant.
Ethical considerations
Approval was obtained from the Mersin University Clinical
Research Ethical Committee (17th October.2018 and 2018/412). Insti-
tution permission was obtained from the Directorate of National Edu-
cation. School administrators and teachers were informed. Informed
written consent was taken from all students and their parents at the
beginning of the study.
RESULTS
Except for 4 students in groups, other students completed the
study. 55.1% of the students were female, the mean age was 9.74 §
0.68 years, and the groups had similar sociodemographic characteris-
tics (Table 1). 13 of the students (8.6%) are left-handed. While 99.7%
of the children had a toilet inside their home, in 7 children's houses
(4.6%), toilet paper was not present. Eight students stated that they
were not cleaning after urination, 1 student that she/he was not
cleaning after defecation, 50 students (33.1%) that they cleaned peri-
neum only with water without toilet paper after defecation (Table 1).
According to the interventional results of the research, when both
dorsal and palmar surfaces of the 2 hands' washing effectiveness are
evaluated, the difference of fluorescent area before and after the
intervention was 154.47 (85.34-194.53) of the G-I, 100.32 (78.12-
165.26) of the G-II, 99.00 (70.00-150.50) of the C group, there was a
difference between the G-I and G-II, and G-I and C groups (P = .05)
(Table 2).
The amount of residual fluorescence left on the hands after hand-
washing was lower in the G-I's ''all fingers'' and ''metacarpal and car-
pal areas'' than the G-II and C group (Table 3). In the C group,
fingertips on the left and right dorsal surface, almost all hand in the
left and palmar surface; in the G-II, the right dorsal surface fingertips
and most of the hand in the left palmar surface, while in the G-I, the
carpal area close to the wrist on the right and left palmar surface
were the least cleaned areas (Figure 2).
Hand washing effectiveness according to dominant hand, on the
right hand palmar surface for left-handed children was 20.85
(11.66-35.31), for right-handed 13.41 (10.90-29.15); on the left
hand palmar surface for lefty was 21.86 (10.00-32.93), for right-
handed 16.89 (9.48-28.15); on the right hand dorsal surface for lefty
was 32.93 (19.53-58.55), for right-handed 46.00 (28.86-56.45); left
hand dorsal surface for lefty was 41.64 (26.08-61.24), for right-
handed 46.91 (21.66-56.50). There was no difference between right
and left hand for handwashing effectiveness according to the domi-
nance hand (P > .05).
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Table 1
Socio-demographic characteristics of groups and hand washing habit characteristics

Group I Group II Control Group Total P

n % n % n % n %

Gender Girl 33 58.9 29 57.4 22 48.9 84 55.1 0.552

Boy 23 41.1 21 42.6 23 51.1 67 44.9
X § Sd
Age 9.70§0.71 9.64§0.63 9.89§0.68 9.74§0.68 0.174
n (%)
Total 56 (100.0%) 50 (100.0%) 45 (100.0%) 151 (100.0%)

Hand washing frequency among students, n (%)

Always Sometimes Never

After contact with sick people 86 (57.0) 39 (25.8) 18 (11.9)

When getting back to school 102 (67.5) 38 (25.2) 6 (4)
After playing on the street 104 (68.9) 39 (25.8) 3 (2)
After throwing out the trash 108 (71.5) 28 (18.5) 8 (5.3)
After meals 83 (55.0) 56 (37.1) 7 (4.6)
Before meals 124 (82.1) 18 (11.9) 4 (2.6)
Clean the nose 124 (82.1) 22 (14.6) 0 (0)
After going to toilet 134 (88.7) 9 (6) 3 (2)

DISCUSSION
In the study, the effectiveness of conducted 2 teaching programs,
WHO's multi-stage hand hygiene procedure and CDC's duration-
based recommendation were tested. While the majority of children
associate visible dirt in hands with germs, they cannot associate the
probability of unhealthiness with invisible dirt in the hands. It has
been observed that the use of glo-germ gel in education embodies
the hand cleaning in a way to highlight the invisible microbes,
increases the compliance with hand hygiene with easy application,
and draws the attention of the students as similar to literature and
provides active participation in education.14,19,22
When the general hand hygiene habits of the children were evalu-
ated in the study, the majority had washed their hands after the playing
outside, taking the garbage out, before the meal, similar to the other
study conducted by the researchers19, it was observed that few children
didn't wash their hands after toilet. The findings show that these chil-
dren become susceptible to infection in the area where fecal-oral trans-
mission is highest.23 Perineum cleaning by only water may increase the
risk in children who do not have toilet paper in their homes.

Table 2
The fluorescent covered area on the hands before and after the intervention based on the groups (%)

Dorsal right Dorsal left Palmar right Palmar left Total

Median (25%-75%)

Group I (n = 56) Before HW 80.16 81.47 81.19 79.71 315.17

(72.61-85.86) (74.14-86.48) (73.34-86.20) (72.41-86.34) (303.87-338.08)
After HW 32.23y 23.88y 52.27y 49.29y 159.92y
(17.63-61.00) (11.57-39.56) (33.63-68.43) (37.07-67.30) (114.38-223.93)
HW effectiveness* 40.34 56.59 24.08 22.60 154.47
(19.91-60.43) (31.88-68.25) (12.45-41.42) (14.95-40.29) (85.34-194.53)
Group II (n = 50) Before HW 78.32 75.09 78.55 74.53 301.33
(72.88-85.43) (64.51-84.72) (70.54-84.32) (70.46-81.37) (285.39-331.02)
After HW 45.46y 34.79y 56.73y 54.67y 190.16y
(24.31-60.95) (14.45-51.76) (42.78-68.66) (39.80-64.04) (134.10-235.85)
HW effectiveness 29.83 37.36 18.46 20.68 100.32
(20.09-50.54) (24.22-51.82) (10.36-31.06) (09.27-30.15) (78.12-165.26)
Control Before HW 84.00 83.00 81.00 78.00 325.00
Group (77.00-90.48) (74.50-87.00) (76.50-88.05) (73.00-81.50) (309.50-336.00)
(n = 45) After HW 46.03y 43.00y 64.00y 65.00y 219.83y
(29.50-67.00) (21.00-56.45) (50.93-73.00) (48.00-73.00) (173.00-254.05)
HW effectiveness 33.00 38.00 15.00 15.00 99.00
(21.00-48.50) (27.00-56.00) (09.39-27.50) (07.00-28.50) (70.00-150.50)

Between the groups comparisons 0.371 0.006 0.069 0.033 0.020

GI-GII GI-GII GI-GII GI-GII GI-GII
(0.172) (0.002) (0.112) (0.127) (0.015)
GI-Control GI-Control GI-Control GI-Control GI-Control
(0.393) (0.034) (0.026) (0.011) (0.019)
GII-Control GII-Control GII-Control GII-Control GII-Control
(0.591) (0.488) (0.541) (0.259) (0.788)

*HW effectiveness: (Hands covered with fluorescent before washing the hands)-(Hands covered with fluorescent after washing the hands).
y
There were statistically significant differences with the before hand washing, P < .01
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Table 3
Distribution of remained fluorescent substances related to the examined parts of the hands based on the groups*

Groups Dorsal right Dorsal left Palmar right Palmar left

Phalanges x § ss

Group I 1.50§0.89 1.37§0.81 1.28§0.90 1.48§0.88

Group II 1.39§0.76 1.63§0.92 1.37§0.82 1.76§0.75
Control 1.76§0.82 1.76§0.91 1.89§0.85y 1.90§0.86

Group I 1.12§0.91 1.08§1.02 1.52§0.82 1.25§0.72

Group II 1.82§0.79y 1.83§0.84y 1.86§0.85 1.69§0.63
Control 1.65§1.04y 1.83§1.04y 2.02§0.89y 1.99§0.79y

Group I 1.39§0.96 1.20§0.89 1.59§0.69 1.69§0.67

Group II 1.83§0.90 1.65§0.96 1.91§0.77 2.09§0.65
Control 1.82§0.98 1.73§0.94y 2.12§0.78y 2.16§0.70y

Group I 1.35§0.94 0.99§0.96 1.42§0.76 1.69§0.68

Group II 1.76§0.98 1.42§1.06 1.73§0.82 1.97§0.68
Control 1.81§1.05 1.57§0.94y 1.93§0.81y 2.03§0.73

Group I 1.51§1.07 0.94§0.92 1.52§0.77 1.79§0.80

Group II 1.87§1.10 1.44§1.05 1.89§0.81 2.00§0.75
Control 2.10§1.08 1.74§1.08y 1.94§0.86y 2.09§0.76

Group I 1.37§0.81 1.12§0.79 1.47§0.63 1.58§0.66

Group II 1.73§0.74 1.59§0.82 1.76§0.70 1.90§0.53
Control 1.82§0.84y 1.73§0.86y 1.98§0.72y 2.03§0.71y

Group I 1.06§0.90 0.99§0.99 1.72§0.58 1.73§0.62

Group II 1.41§0.89 1.34§0.79 2.01§0.63 2.03§0.60
Control 1.45§0.98 1.20§0.87 2.36§0.51y 2.28§0.74y

*The evaluation was made on students who covered 75% of their hands with fluorescent material.
y
There was a difference with G-I.

The results regarding the technique teaching for effective hand-
washing show that this teaching method is more successful. Since
palmar surfaces and fingertips are less cleaned areas in the “teaching
with duration application” and control group, it showed that these
areas should be cleaned with special movements, as in “multi-stage
teaching.”
Amin (2019), compared the simple technique consisting of “wet-
ting the hands with water, soap foaming and rinsing” and the 9 step
complex technique that includes “rubbing of hand surfaces, between
the fingers and the under the nails” in terms of memorization. In
groups, the difference in memorization of all stages is expected, but
the quality of handwashing should be evaluated with these results as
well.17 It is stated that in the group applying complex handwashing
instruction, the scrubbing of the fingers, the cleaning of the beneath
the nails, and the hand drying are increased. It is stated that the time
allocated for hand cleaning is 22 seconds in the simple technique and
31 seconds in the complex group.17 For effective handwashing, the
spared time is also important. In the previous study conducted by
researchers, it was observed that little time was allocated for hand-
washing in children19. In the current study, the fact that the fluores-
cent residuals remaining in the “group with duration-based
teaching” were less than the group receiving classical education indi-
cates the importance of the duration. In observational studies, the
time allocated for handwashing is limited to 5-10 seconds. Fuls et al.
stated that washing for a longer time is effective to eliminate bacteria,
and by increasing the washing time from 15 to 30 seconds, the anti-
microbial effect was increased.24
In the study in which the relationship between handwashing
duration and skipped areas in hand was evaluated, in their study
with healthcare professionals Pan et al. stated that the duration was
over 30 seconds of 2/3 of the participants, and there was no relation-
ship between handwashing time and unwashed hand areas. How-
ever, the fact that the study was carried out with healthcare workers,
who had more training in handwashing, may have caused this differ-
ence, to be observed due to the appropriate duration of the hand-
washing of the majority of the participants.22 The findings of the
study are that “increase in the time allocated for handwashing” is
important for effective handwashing both in technical or duration-
based handwashing.
When the areas that are frequently forgotten in handwashing are
evaluated, the distal areas of the fingers are cleaned less, and the
missed areas are reduced from distal to proximal, but problematic
areas are concentrated in the area near the wrists.19,21,22,25 In another
study conducted among adults in Hong Kong, the fingertips (48.1%),
medial area (30.5%), and back of the hand (28%) palm (%22.1) were
the most commonly missed areas in terms of washing.6 When hand
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Fig 2. Areas of the hands covered with fluorescent after washing the hands (The evaluation was made on students who covered 75% of their hands with fluorescent material).
Red colored number: It points to the mean score of all regions on the finger.
Purple: Most often missed areas Yellow: Often missed areas Skin color: Less often missed areas (colour version of figure is available online).

hygiene is not sufficient, the pathogens left in the hands of children
can act as a reservoir, and the rubbing, as clasping the fingers and the
palm as stated in the WHO stage model can provide more effective
cleaning of these areas.
The most missed areas when washing hands in children were fin-
gertips and palmar surfaces. The human palm has been described as
1 of the richest habitats for microbial presence, and this makes hand
hygiene indispensable for primary prevention of infection.7 At the
same time, it is seen that dorsal surfaces are cleaned more effectively
than palmar. Unlike the research findings, in a study by Pan et al., it
was found that the areas missed in the dorsal area were more than
palmar. In this study, the areas missed are marked by the observer,
since the fluorescent coated area before handwashing, is not evalu-
ated, it is not clear how much of these areas are cleaned.22 Vanyolos
et al. on the other hand, stated that the most frequently missed area
in medical students was the proximal part of the palm after the meta-
carpal regions.25
In this study, there was no statistical difference in handwashing
effectiveness for dominated hand. Vanyolos stated that the students
who used their right hand made fewer mistakes on both the dorsal
and palmar surface of their non-dominant left hands.25 To make pas-
sive hand cleaning more effective, teaching with technique, can be
more effective for ensuring these areas are washed without skipping.
CONCLUSIONS
Although it is globally accepted that correct handwashing is an
important habit to be acquired in childhood, the absence of a com-
monly accepted teaching procedure indicates that researches are
needed for developing the appropriate method. As the CDC recom-
mends, increasing the time allocated for handwashing over 20 sec-
onds by singing the “Happy Birthday song” has provided
improvement for the effectiveness of handwashing and the reduction
of frequently missed areas in the hands. However, the most effective
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method of increasing handwashing effectiveness in children is the
multi-stage technique as WHO recommends for healthcare professio-
nals. School nurses and teachers can increase handwashing effective-
ness by teaching children to wash their hands with the multi-stage
technique. Teaching the multi-stage handwashing technique through
embodying by using glo-germ in children can help to hand wash to
turn into a habit with the right technique as well as increasing the
motivation of handwashing. In multi-step teaching, repeating the
movement at least 5 times in each area can increase the effectiveness
of the area, which is cleaned by rubbing and can reduce the difference
between individuals. Starting from the children, extending handwash-
ing habits and appropriate technic use throughout society is the most
cost-effective practice that would control pandemics in the world.
In future studies, it is recommended to compare the multi-stage
technique of WHO with the new technique, which will have fewer
stages and include all areas of the hands and to evaluate the long-
term results.
Limitations
Although ''direct observation'' is considered as the gold standard
in compliance with hand hygiene, in the current study, observation
has not been applied to avoid Hawthorne effect. According to the stu-
dents' angle of putting their hands on the device, the differences
observed in the evaluation as 1%-3% are among the limitations of the
material used. Due to the partial support provided for using the hand
scan device, compliance with the handwashing procedure was evalu-
ated with a 2-week recall and the long-term results of the study
could not be examined.
Acknowledgments
The Sysmex Turkey Company supported the study by allowing the
use of Semmelweis Hand in Scan device. We would like to thank the
company for their device support. The Company had no role in study
design, data collection and analysis, interpretation of data, writing of
the report decision to publish, or preparation of the manuscript.
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