Comparative efficacy of a simplified handwashing program for improvement in hand hygiene and reduction of school absenteeism among children with intellectual disability


      • Evidence-based simplified handwashing program to prevent infectious diseases.
      • Social learning factors contribute to the improvement of handwashing quality.
      • Multimedia promotes handwashing techniques for children with special needs.
      • Efficacy of primary health care is shown through a simplified handwashing program.
      • Fluorescent stain rating test is used to assess handwashing quality.


      Infectious diseases are common among schoolchildren as a result of their poor hand hygiene, especially in those who have developmental disabilities.


      A quasi-experimental study using a pre- to post-test design with a control group was used to test the feasibility and sustainability of simplified 5-step handwashing techniques to measure the hand hygiene outcome for students with mild intellectual disability. Sickness-related school absenteeism was compared.


      The intervention group experienced a significant increase in the rating of their handwashing quality in both hands from pre- to post-test: left dorsum (+1.05, P < .001); right dorsum (+1.00, P < .001); left palm (+0.98, P < .001); and right palm (+1.09, P < .001). The pre- to post-test difference in the intervention group (+1.03, P < .001) was significantly greater than the difference in the control group (+0.34, P = .001). There were no differences between the post-test and the sustainability assessment in the intervention group. The intervention school experienced a significantly lower absenteeism rate (0.0167) than the control group in the same year (0.028, P = .04).Students in this study showed better performance in simplified handwashing techniques and experienced lower absenteeism than those using usual practice in special education school settings.


      The simplified 5-step hand hygiene technique has been proven effective in reducing the spread of infectious diseases.

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        • Frieden T.R.
        • Damon I.
        • Bell B.P.
        • Kenyon T.
        • Nichol S.
        Ebola 2014--new challenges, new global response and responsibility.
        N Engl J Med. 2014; 371: 1177-1180
      1. Centre for Health Protection. 2013 year in review. Communicable diseases watch. 2014. Available from: Accessed April 23, 2015.

        • Stehlé J.
        • Voirin N.
        • Barrat A.
        • Cattuto C.
        • Isella L.
        • Pinton J.F.
        • et al.
        High-resolution measurements of face-to-face contact patterns in a primary school.
        PLoS One. 2011; 6: e23176
      2. Centre for Health Protection. Proper hand hygiene. Available from: Accessed November 9, 2014.

        • Wu J.T.
        • Ma E.S.
        • Lee C.K.
        • Chu D.K.
        • Ho P.L.
        • Shen A.L.
        • et al.
        The infection attack rate and severity of 2009 pandemic H1N1 influenza in Hong Kong.
        Clin Infect Dis. 2010; 51: 1184-1191
        • Wong V.W.
        • Cowling B.J.
        • Aiello A.E.
        Hand hygiene and risk of influenza virus infections in the community: a systematic review and meta-analysis.
        Epidemiol Infect. 2014; 142: 922-932
        • Lee M.B.
        • Greig J.D.
        A review of gastrointestinal outbreaks in schools: effective infection control interventions.
        J Sch Health. 2010; 80: 588-598
        • Bloomfield S.F.
        • Aiello A.E.
        • Cookson B.
        • O'Boyle C.
        • Larson E.L.
        The effectiveness of hand hygiene procedures in reducing the risks of infections in home and community settings including handwashing and alcohol-based hand sanitizers.
        Am J Infect Control. 2007; 35: S27-S64
        • Godoy P.
        • Castilla J.
        • Delgado-Rodríguez M.
        • Martín V.
        • Soldevila N.
        • Alonso J.
        • et al.
        Effectiveness of hand hygiene and provision of information in preventing influenza cases requiring hospitalization.
        Prevent Med. 2012; 54: 434-439
        • Choi K.S.
        • Wong P.K.
        • Chung W.Y.
        Using computer-assisted method to teach children with intellectual disabilities handwashing skills.
        Disabil Rehabil Assist Technol. 2012; 7: 507-516
      3. Centre for Health Protection. CHP advises special school with influenza A outbreak to suspend classes. Available from: Accessed November 9, 2014.

        • Bylinsky G.
        The new fight against killer microbes.
        Fortune. 1994; 130: 74-80
        • Bandura A.
        Social learning theory.
        Prentice-Hall, Englewood Cliffs [NY]1977
        • Bandura A.
        Self-efficacy: the exercise of control.
        W.H. Freeman, New York [NY]1997
        • Walmsley C.
        • Mahoney A.
        • Durgin A.
        • Poling A.
        Fostering hand washing before lunch by students attending a special needs young adults program.
        Res Dev Disabil. 2013; 34: 95-101
        • Lee R.L.
        • Lee P.H.
        To evaluate the effects of a simplified hand washing improvement program in schoolchildren with mild intellectual disability: a pilot study.
        Res Dev Disabil. 2014; 35: 3014-3025
      4. World Health Organization. WHO guidelines on hand hygiene in health care. 2009. Available from: Accessed February 4, 2014.

        • Decker M.M.
        • Buggey T.
        Using video self- and peer modeling to facilitate reading fluency in children with learning disabilities.
        J Learn Disabil. 2014; 47: 167-177
        • Cannella-Malone H.I.
        • Fleming C.
        • Chung Y.C.
        • Wheeler G.M.
        • Basbagill A.R.
        • Singh A.H.
        Teaching daily living skills to seven individuals with severe intellectual disabilities: a comparison of video prompting to video modeling.
        J Posit Behav Interv. 2011; 13: 144-153
      5. Centre for Health Protection. Scientific Committee on Infection Control. Available from: Accessed April 23, 2015.