Research Article: A multimodal intervention to improve hand hygiene compliance via social cognitive influences among kindergarten teachers in China

Date Published: May 14, 2019

Publisher: Public Library of Science

Author(s): Xiaona Liu, Zhiguang Zhao, Wanli Hou, Suzanne Polinder, Ed F. van Beeck, Zhen Zhang, Yan Zhou, Gang Liu, Xu Xie, Jinquan Cheng, Jan Hendrik Richardus, Vicki Erasmus, Eric HY Lau.


Children attending kindergarten are at high risk for contracting infections, for which hand hygiene (HH) has been recognized as the most cost-effective prevention measure globally. Kindergarten teachers’ HH behavior plays a vital role in encouraging favorable hygiene techniques and environment. This study aims to evaluate the effectiveness of a multimodal intervention at changing kindergarten teachers’ HH behavior and social cognitive factors that influences HH behavior in China. The intervention named “Clean Hands, Happy Life” includes HH products with refills, reminders and cues for action, a kick-off event with awards, and training programs. We evaluated the intervention using a self-administrative questionnaire with a stratified random sample of 12 kindergartens. Two surveys was completed by 176 teachers at baseline and 185 after the 6-month intervention. Compared with the baseline scores, there was a significant improvement in the overall self-reported HH compliance of teachers (9.38 vs. 9.68 out of 10, p = 0.006), as well as teachers’ perceived disease susceptibility, disease severity and behavioral control after the intervention (p<0.05). We found that teachers’ HH compliance was likely to be higher among those who have better HH guideline awareness (β = 0.48, p<0.01) and perceived behavioral control (β = 0.26, p = 0.01), which explained 24.2% of the variance of self-reported compliance of teachers at baseline. The assessed intervention may provide Chinese kindergarten teachers with behavioral skills and cognitions that associated with the compliance of HH behavior. We thus recommend future intervention studies consider our HH behavior change techniques, address multiple social cognitive determinants of HH behavior and include the change of targeted influences in the impact evaluation.

Partial Text

Children attending kindergartens or child care centers are more susceptible to infectious diseases than children who are cared for in their own homes [1]. Children cared for at kindergartens have a 2–3 times greater risk of acquiring infections [2]. A recent study in Taiwan suggests that there were 136 laboratory-confirmed respiratory viral infections per 100 person years in the 2007 academic year among kindergarten attendees aged 2–5 years [3]. In addition, children attending kindergartens in China generally fall into the range of age between 3 and 6 years old–an age group that is highly susceptible to hand, foot and mouth disease (HFMD). A Chinese national surveillance registry documented over seven million probable HFMD cases between 2008 to 2012, of which 3.7% were laboratory confirmed and 0.03% were fatal [4].

A total of 361 teachers completed the survey, with 176 during the baseline period (response rate: 92.6%) and 185 in the post-intervention period after implementing 6 months of the intervention (response rate: 94.9%). Table 2 shows the comparison of baseline respondents’ characteristics and post-intervention respondents and demonstrates that with regard to the social demographics and HH-related illness history of respondents, there was no significant difference between before the intervention and after the intervention (p>0.05).

This study reveals that there were significant improvements in self-reported HH compliance and in the cognitive determinants–namely, perceived disease susceptibility, severity and behavioral control–for kindergarten teachers after 6-month implementation of the intervention “Clean Hands, Happy Life” at their workplace.