Factors influencing hand washing behaviour in primary schools

Good hand hygiene is an important infection control measure as person-to-person contact, including via hands, is a common mode of transmission for gastrointestinal and respiratory infections. Half of all general practitioner consultations, and 12% of all hospitalizations among children aged 0–14 years are for infections.

Respiratory infections and infectious intestinal disease are responsible for 48 and 29% of primary care consultations among this age group, respectively. In primary schools in England, 5 days are lost due to sickness per teacher per year, and pupils are absent due to illness for 3.7% of the sessions that they should attend, although it is not known how many of these are due to infections. Hand hygiene is important in primary schools to prevent the spread of infectious illnesses, and is a key infection control measure recommended during pandemic influenza. 

Improving hand hygiene to lower the transmission of infections could reduce absenteeism of teachers and pupils in schools, and could also potentially prevent secondary infections in the wider community, reduce health service costs and lower the burden on families, some of whom may need to take time off work to care for children.

Meta-analyses have shown that hand hygiene educational interventions, particularly the use of non-antibacterial soap with education, can be effective in preventing gastrointestinal and respiratory illness, although this review was not focused specifically on primary school settings. However, this review, and two others focussing on developing countries, have drawn attention to the lack of rigorously conducted randomized controlled trials (RCTs) to evaluate the effectiveness of hand washing interventions in preventing the spread of respiratory and gastrointestinal infections.

Educational interventions to promote hand washing in school settings aim to improve knowledge and awareness about healthy hand hygiene to reduce the spread of infections and have been associated with reduced absenteeism and gastrointestinal infections, and increased compliance with hand washing. An individual, or agent, may be more likely to wash their hands when they understand why and how to do it. Patterns of health-promoting behaviour, however, are not merely products of independent individuals.

Individual choices about healthy lifestyles fit into a structural scheme grounded in group behaviour and social interaction and are not always rational or autonomous. Individuals may have control over their choices, but not over the conditions, or structures, in which these choices are made. These structural factors determine what choices are realistically most likely to be operationalized and made routine.

Awareness and knowledge

Knowledge of the importance of washing hands to reduce the spread of germs was high among pupils, with this being mentioned in all focus groups.

If you get any germs it’ll get rid of them by washing your hands. (ID127, Control upper KS2 focus group)

If you don’t wash your hands and then you eat something then you might get all the germs and all the bugs. (ID303, Intervention KS1 focus group)

Understanding that hand washing was important to prevent people getting ill was also evident in most focus groups (six control, all intervention).

When you wash your hands it’s getting rid of germs that can make you ill (ID324, Control lower KS2 focus group)

If you wash your hands you get to do more learning in school, you get to join in a lot more things, 'cause if you are not well you can’t go outside. (ID104, Intervention upper KS2 focus group)