An observational study of handwashing compliance in a child care facility


      • Handwashing compliance is low among personnel in early childhood centers.
      • Surveillance cameras were used to verify handwashing compliance in an early childhood center.
      • Overall compliance among all personnel for handwashing was 22%.
      • Parents had the lowest compliance rate at 4%.
      • Caregivers had the highest compliance at 30%.


      Handwashing (HW) compliance, although an effective means of limiting childhood illness, remains low among personnel in early childhood centers (ECCs). Our study determined HW compliance and efficacy of ECC personnel.


      Surveillance cameras were used to determine HW opportunities, compliance, occurrences, and effectiveness based on child-care oriented criteria.


      We observed 349 HW triggering events, with 14 events per hour; a median of 2 personnel (caregivers, paraprofessional aides, or parents) were present at any given time period. Compliance was 30% (caregivers), 11% (paraprofessional aides), and 4% (parents), with an overall compliance of 22%. Between-room and between-age groups of children being cared for and compliance of caregivers and paraprofessional aides were not found to be significantly different (P < .05). For all personnel between the 10 different rooms, the median compliance was 20.2% (95% confidence interval, 8%-35%). Only 7% of personnel taking care of 2- to 3-year-old children washed their hands, the lowest compliance per age group. Of all steps in HW, paper towel usage had the highest compliance, with a 97% adherence, whereas turning off the faucet with a paper towel was the lowest at 17%.


      Methods and strategies need to be developed to increase compliance. Current technology provides an effective means of gathering data for determining HW compliance in ECCs.

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        • United States Census Bureau
        How do we know? Child care an important part of American life.
        (Available from) (Accessed June 29, 2015)
        • Peate I.
        • Gormley-Fleming E.
        Fundamentals of children's anatomy and physiology: a textbook for nursing and healthcare students.
        John Wiley & Sons, New York (NY)2014
        • Herold B.C.
        • Immergluck L.C.
        • Maranan M.C.
        • Lauderdale D.S.
        • Gaskin R.E.
        • Boyle-Vavra S.
        • et al.
        Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk.
        JAMA. 1998; 279: 593-598
        • Nesti M.M.
        • Goldbaum M.
        Infectious diseases and daycare and preschool education.
        J Pediatr (Rio J). 2007; 83: 299-312
        • Barros A.J.
        Child-care attendance and common morbidity: evidence of association in the literature and questions of design.
        Rev Saude Publica. 1999; 33: 98-106
        • Pittet D.
        • Boyce J.M.
        Hand hygiene and patient care: pursuing the Semmelweis legacy.
        Lancet Infect Dis. 2001; : 9-20
        • Centers for Disease Control and Prevention
        (Available from) (Accessed August 4, 2016)
        • Soto J.C.
        • Guy M.
        • Deshaies D.
        • Durand L.
        • Gratton J.
        • Belanger L.
        A community health approach for infection control in day-care centers.
        Pediatrics. 1994; 94: 1027
        • Huskins W.C.
        Transmission and control of infections in out-of-home child care.
        Pediatr Infect Dis J. 2000; 19 (S106-10)
        • Roberts L.
        • Smith W.
        • Jorm L.
        • Patel M.
        • Douglas R.M.
        • McGilchrist C.
        Effect of infection control measures on the frequency of upper respiratory infection in child care: a randomized, controlled trial.
        Pediatrics. 2000; 105: 738-742
        • Black R.E.
        • Dykes A.C.
        • Anderson K.E.
        • Wells J.G.
        • Sinclair S.P.
        • Gary G.W.
        • et al.
        Handwashing to prevent diarrhea in day-care centers.
        Am J Epidemiol. 1981; 113: 445-451
        • Pittet D.
        • Sax H.
        • Hugonnet S.
        • Harbarth S.
        Cost implications of successful hand hygiene promotion.
        Infect Control Hosp Epidemiol. 2004; 25: 264-266
        • Ejemot-Nwadiaro R.I.
        • Ehiri J.E.
        • Meremikwu M.M.
        • Critchley J.A.
        Hand washing for preventing diarrhoea.
        Cochrane Library. 2012; (CD004265)
        • Roberts L.
        • Jorm L.
        • Patel M.
        • Smith W.
        • Douglas R.M.
        • McGilchrist C.
        Effect of infection control measures on the frequency of diarrheal episodes in child care: a randomized, controlled trial.
        Pediatrics. 2000; 105: 743-746
        • Pearson M.L.
        Guideline for hand hygiene in healthcare settings.
        J Am Coll Surg. 2004; 198: 121-127
        • Zomer T.P.
        • Erasmus V.
        • Van Beeck E.F.
        • Tjon-A-Tsien A.
        • Richardus J.H.
        • Voeten H.A.
        Hand hygiene compliance and environmental determinants in child day care centers: an observational study.
        Am J Infect Control. 2013; 41: 497-502
        • Strohbehn C.
        • Sneed J.
        • Paez P.
        • Meyer J.
        Hand washing frequencies and procedures used in retail food services.
        J Food Prot. 2008; 71: 1641-1650
        • Lee G.M.
        • Salomon J.A.
        • Friedman J.F.
        • Hibberd P.L.
        • Ross-Degnan D.
        • Zasloff E.
        • et al.
        Illness transmission in the home: a possible role for alcohol-based hand gels.
        Pediatrics. 2005; 115: 852-860
        • Judah G.
        • Aunger R.
        • Schmidt W.P.
        • Michie S.
        • Granger S.
        • Curtis V.
        Experimental pretesting of hand-washing interventions in a natural setting.
        Am J Public Health. 2009; 99: 405-411
        • Carabin H.
        • Gyorkos T.W.
        • Soto J.C.
        • Joseph L.
        • Payment P.
        • Collet J.P.
        Effectiveness of a training program in reducing infections in toddlers attending day care centers.
        Epidemiology. 1999; 10: 219-227
        • Spano R.
        Observer behavior as a potential source of reactivity: describing and quantifying observer effects in a large-scale observational study of police.
        Sociol Methods Res. 2006; 34: 521-553
        • Shah R.
        • Patel D.
        • Shah K.
        • Phatak A.
        • Nimbalkar S.
        Video surveillance audit of hand-washing practices in a neonatal intensive care unit.
        Indian Pediatr. 2015; 52: 409-411
        • Diller T.
        • Kelly J.W.
        • Blackhurst D.
        • Steed C.
        • Boeker S.
        • McElveen D.C.
        Estimation of hand hygiene opportunities on an adult medical ward using 24-hour camera surveillance: validation of the HOW2 benchmark study.
        Am J Infect Control. 2014; 42: 602-607
        • Anderson M.E.
        • Sargeant J.M.
        • Weese J.S.
        Video observation of hand hygiene practices during routine companion animal appointments and the effect of a poster intervention on hand hygiene compliance.
        BMC Vet Res. 2014; 10: 106
        • Pickering A.J.
        • Blum A.G.
        • Breiman R.F.
        • Ram P.K.
        • Davis J.
        Video surveillance captures student hand hygiene behavior, reactivity to observation, and peer influence in Kenyan primary schools.
        PLoS ONE. 2014; 9: 1-8
        • American Academy of Pediatrics
        Caring for our children: national health and safety performance standards; guidelines for early care and education programs.
        3rd ed. National Resource Center for Health and Safety in Child Care and Early Education, Aurora (CO)2011
        • Boyce J.M.
        • Pittet D.
        • Healthcare Infection Control Practices Advisory Committee
        • HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force
        Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America.
        MMWR Recomm Rep. 2002; 51: 1-45
        • Morvai J.
        • Szabó R.
        The role of mobile communication devices in the spread of infections. A systematic review.
        Antimicrob Resist Infect Control. 2015; 4: P39
        • Green L.R.
        • Selman C.A.
        • Radke V.
        • Ripley D.
        • Mack J.C.
        • Reimann D.W.
        • et al.
        Food worker hand washing practices: An observation study.
        J Food Prot. 2006; 69: 2417-2423
        • Hallgren K.A.
        Computing inter-rater reliability for observational data: an overview and tutorial.
        Tutor Quant Methods Psychol. 2012; 8: 23-24
        • Borchgrevink C.P.
        • Cha J.
        • Kim S.
        Hand washing practices in a college town environment.
        J Environ Health. 2013; 75: 18-24
        • Krippendorff K.
        Estimating the reliability, systematic error and random error of interval data.
        Educ Psychol Meas. 1970; 30: 61-70
        • De S.K.
        Calculating inter-coder reliability in media content analysis using Krippendorf's alpha.
        (Available from) (Accessed August 4, 2016)
        • World Health Organization
        Hand hygiene technical reference manual.
        (Available from) (Accessed August 4, 2016)
        • Tromp M.
        • Huis A.
        • De Guchteneire I.
        • Van Der Meer J.
        • Van Achterberg T.
        • Hulscher M.
        • et al.
        The short-term and long-term effectiveness of a multidisciplinary hand hygiene improvement program.
        Am J Infect Control. 2012; 40: 732-736
        • Monk-Turner E.
        • Edwards D.
        • Broadstone J.
        • Hummel R.
        • Lewis S.
        • Wilson D.
        Another look at hand-washing behavior.
        Soc Behav Pers. 2005; 33: 629-634
        • Drankiewicz D.
        • Dundes L.
        Handwashing among female college students.
        Am J Infect Control. 2003; 31: 67-71
        • Meengs M.R.
        • Giles B.K.
        • Chisholm C.D.
        • Cordell W.H.
        • Nelson D.R.
        Hand washing frequency in an emergency department.
        Ann Emerg Med. 1994; 23: 1307-1312
        • Quraishi Z.A.
        • McGuckin M.
        • Blals F.X.
        Duration of handwashing in intensive care units: a descriptive study.
        Am J Infect Control. 1984; 12: 83-87
        • Shanks C.R.
        • Peteroy-Kelly M.A.
        Analysis of antimicrobial resistance in bacteria found at various sites on surfaces in an urban university.
        Bios. 2009; 80: 105-113
        • Pan S.C.
        • Tien K.L.
        • Hung I.C.
        • Lin Y.J.
        • Sheng W.H.
        • Wang M.J.
        • et al.
        Compliance of health care workers with hand hygiene practices: independent advantages of overt and covert observers.
        PLoS ONE. 2013; 8: 1-8
        • Hagel S.
        • Reischke J.
        • Kesselmeier M.
        • Math D.
        • Winning J.
        • Gastmeier P.
        • et al.
        Quantifying the Hawthorne effect in hand hygiene compliance through comparing direct observation with automated hand hygiene monitoring.
        Infect Control Hosp Epidemiol. 2015; 36: 957-962
        • Srigley J.A.
        • Furness C.D.
        • Baker G.R.
        • Gardam M.
        Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study.
        BMJ Qual Saf. 2014; 23: 974-980
        • Parsons H.M.
        What happened at Hawthorne?: new evidence suggests the Hawthorne effect resulted from operant reinforcement contingencies.
        Science. 1974; 183: 922-932
        • Yin J.M.
        • Reisinger H.S.P.
        • Weg M.V.P.
        • Schweizer M.L.P.
        • Jesson A.
        • Morgan D.J.
        • et al.
        Establishing evidence-based criteria for directly observed hand hygiene compliance monitoring programs: a prospective, multicenter cohort study.
        Infect Control Hosp Epidemiol. 2014; 35: 1163-1168
        • Arkansas Department of Human Services
        Arkansas healthy children handbook.
        6th ed. 2013 (Available from) (Accessed August 4, 2016)
        • Fraser A.
        • Arbogast J.W.
        • Jaykus L.-A.
        • Linton R.
        • Pittet D.
        Rethinking hand hygiene in the retail and food service industries: are recommended procedures based on the best science and practical under real-world conditions?.
        Food Protect Trends. 2012; : 750-759