Implementing an Effective Handwashing Program in Schools

Once upon a time, encouraging school children to wash their hands before eating and after using the bathroom was seen as a way to instill good manners in young people. Now, however, proper handwashing can be a matter of life and death for students and educators. Approximately one-fifth of the U.S. population attends or works in school on a full- or part-time basis. This means that it is essential for the health of the public, as well as students and educators, that proper hygiene is practiced and the risk of communicable epidemics is minimized ("Seasonal Flu Information for Schools & Childcare Providers, CDC). It is also important for the mission as well as the health of the school. Sick children have poor attendance, which impacts their education. Sick educators cannot educate children, resulting in poor school performance. Sick students and school employees bring their illnesses home to their loved ones and friends, as well.

Schools are meeting-places of many wonderful ideas and people from diverse circumstances and backgrounds, but they are also often the meeting-grounds and thus breeding-grounds of many new varieties of germs, many of which are antibiotic-resistant. The need for handwashing promotional campaigns at schools is proclaimed by every news headline that blares yet another epidemic breaking out in a nearby school. Today, "drug-resistant bacteria are considered a major health threat by public health experts. Some strains, including S. aureus (staph), have alarmed experts with increased levels of resistance to multiple antibiotics. Ruth M. Parker, MD, an associate professor of medicine at Emory University in Atlanta and a member of the panel, called the potential for more antibacterial resistance absolutely terrifying" (Zwillich 2005). Also, because students, especially younger students, often lack practical basic knowledge of hygienic practices, or fail to put their knowledge in action (much as they run through the halls, or talk out of turn unless they are reminded or reprimanded) students and people who work with students are at greater risk for contracting severe and common as well as severe and relatively uncommon communicable ailments. They can then pass these ailments onto the larger population outside of the school.

The fact that there has been an increased incidence of antibiotic-resistant bacteria in hospitals and many other public locations, but particularly in schools means that parents and maybe even some students are scared enough to take action, thus beginning a handwashing campaign at this juncture is an excellent idea for any school district. One well-publicized examples of this is MRSA, a kind of Staphylococcus aureus ("staph") bacterium that is resistant to most common antibiotics, including methicillin, oxacillin, penicillin, and amoxicillin. It in particular is becoming more common in community settings, including schools. All staph bacteria-borne illnesses are spread by direct contact and school settings and there are many opportunities for direct contact among students, especially when students do not wash their hands, or merely rinse their hands quickly. "Factors that have been associated with the spread of MRSA skin infections include close skin-to-skin contact" (De Maria)

While MRSA is one of the more recent extreme public health threats, influenza is a long-standing problem that affects young children more severely than other populations. Even when children have gotten flu shots, no shot can protect students against all forms of the ailment. And viruses are rampant in schools. Some viruses and bacteria can live from 20 minutes or up to 2 hours or more on surfaces like cafeteria tables, doorknobs, and desks. Handwashing can protect against the flu, as well as colds and other illnesses that can cause absences and raise the risk of weakening young children's already fragile immune symptoms to further infections. Nearly 22 million school days are lost annually due to the common cold alone, which indicates that poor hygiene is a priority because it can impact the educational environment ("Seasonal Flu Information for Schools & Childcare Providers, CDC). Lost school days mean it is difficult for absent students to catch up with their classmates. Gaps in the class roster can slow down the other, healthy student's learning as the teacher must modify the lesson plan accordingly, so the absent students can catch up. Teachers who are absent because of illnesses they contract from students leave the entire classroom prey to substitutes unfamiliar with student learning habits.

However, persuading parents of the dangers of MRSA and the flu, even the common cold is unlikely to be the problem, although sending home flyers reminding parents of the importance of handwashing at home and at school, as well as the school board's acknowledgement of the problem is a good idea. The problem is encouraging children to wash their hands properly, a challenge even for many well-meaning parents who find it difficult to make sure that their children are washing their hands before mealtimes! "Wash your hands. When you're a kid, it's just one more thing you're being told you must do" ("Healthy Schools, Healthy People: How one school put clean hands into the spotlight." SDA: Soap and Detergent Association. 2003, p.1). Making handwashing fun, not an adult-imposed chore is essential for school-wide behavioral compliance, given that there is no feasible strategy by which adults can ensure that every child washes his other hands through supervision, at every moment of the day.

The Los Angeles Department of Health suggests that school districts pepper the walls with posters advising children to wash their hands. One poster created by the health department is entitled "Why do we wash our hands? When do we wash our hands? How do we wash our hands?" The text of the poster, which shows happy, healthy cartoon drawings of students engaged in a variety of activities, advises readers that "we" wash our hands before eating, touching wounds, using the toilet, etcetera. The reminder not to touch wounds and touch another person before washing one's hands is especially important when preventing the spread of ailments such as MRSA, as MRSA is particularly apt to be passed on through open sores and cuts. A student with a scab may not realize that he or she is more in danger of contracting the ailment, or passing the bacteria onto others.

Interestingly, the poster also lists some situations not specific to the school environment such as caring for children or pets, which may be wise given that a student who picks up an illness in these situations could still spread the disease after he or she comes to school. The poster also lists situations that seem more common in the life of an adult, like helping someone to use the toilet. Regardless, all adults can use such reminders and the non-specific school reminders are important because a child that practices healthy habits at home is more likely to practice those healthy habits in school, and simply to stay healthy in general. Health campaigns at schools are at least partially designed to foster good habits as well as to protect other students from frequent absences, and healthcare workers.

However, rather than simply using pre-made posters on the walls, having a poster contest, with a reward for the first, second and third place contestants in every grade might be a better way for students to have a 'hands-on' (no pun intended) sense in the campaign, especially if they saw their award-winning design, or the design of their friends, throughout the school reminding students to wash their hands, and the best ways to prevent the spread of illnesses. Also, students may know better what slogans are likely to be motivational for their peers.

The "Why do we wash our hands?" poster also proclaims, "When we wash our hands we . . . make bubbles by rubbing our hands together, sing our ABC's, or other favorite songs we know, use warm water to rinse the germs and the soap off." The 'singing' component of handwashing ("Happy Birthday" is another common song used to encourage children to wash their hands for longer periods of time) is an excellent way to encourage children to become part of the effort-for the first weeks, allowing the children to sing loudly, and to come up with new, short, silly songs that encourage them to wash their hands for the duration of the period needed to kill all of the bacteria on their hands and beneath their fingers will be something all students thoroughly enjoy! In fact, they may wash their hands for a long time simply for the pleasure of singing or annoying their fellow students and adults! The difficulty may be to get them to stop, or to turn the volume of their voices down after the full-throttled phase of the campaign is over. Hanging signs in the bathroom reminding students to sing while they wash their hands, and not to stop washing until they finish, and perhaps providing the lyrics of silly songs, might be a possible element of the handwashing campaign.

Having enough soap on hand may be a problem in some school districts, or obtaining soap that smells good, and encourages children to wash. Getting liquid soap rather than bar soap (which tends to grow crusty and uninviting on sinks, as well as laden with bacteria) is another point to keep in mind. Using antibacterial soap may be less of a priority than using soap, period, so long as the soap encourages the children to wash in a proper fashion (Zwillich 2005). In fact, "In an 11 to 1 vote, advisory panel members" to the FDA "concluded that mass-marketed antiseptics have shown no evidence of preventing infections more effectively than hand washing with regular soap," and "experts said it may not be worth the risk of spawning resistant bacteria" (Zwillich, 2005). Although many classrooms stock hand sanitizers that can be used in the absence of water, the efficacy of these products is also in dispute, although for classrooms without access to sink, teachers often use them as the 'next best thing.'

If soap shortages are a concern because of budgeting at the school, parents can be asked to volunteer to bring in liquid soap to stock the classroom and school, preferably in colorful, attractively smelling varieties. If the teachers desire, they can allow the students to test and compare different types, scents, and prices, to see which wins a 'competition' for the 'best soap' and the best price. Students can read the labels of different types of soaps, solvents, shampoos, and anti-bacterial hand sanitizers to understand why the products are (or are not) effective, on a chemical basis.

Even young students can 'get involved' and direct the nature of the handwashing campaign, rather than merely be 'told' what to do by adults. A suggested health class lesson plan designed for elementary and middle school children may ask the students to "think about how many things we touch on our way between the classroom and the lunchroom. How many things did you touch with your hands before you used your hands to put food into your mouth? ...What are some of the ways that germs are spread from one person to another...What are some of the things we can do to prevent the spread of germs?" (Ferrin).

Incorporating the hygiene campaign into science and health classes is a more sophisticated way to increase student education and empowerment. For example, students in Mrs. Kiser's 7th grade science class at Goodrich Middle School in Lincoln, Nebraska were first introduced to the topic by examining common bacteria on their hands and in the classroom through a microscope. Now they "know that clean hands are important to their health and the health of their classmates. They've seen live cultures of hand-borne yuck." ("Healthy Schools, Healthy People: How one school put clean hands into the spotlight," SDA: Soap and Detergent Association. 2003, p.2). The students were sufficiently motivated by what they saw that they decided to conduct some more experiments of their own. They went on to swabbed school surfaces and cultivated bacteria on agar plates to find the top germ breeding grounds in the school ("Healthy Schools, Healthy People: How one school put clean hands into the spotlight." SDA: Soap and Detergent Association. 2003, p.3). The most germ-dense places in the school were the surfaces in the cafeteria, student phone booth, computer center, and the library.

The point of the exercise was not merely to excite disgust, but to identify potential sites for hand-cleaning stations and to show how not washing their hands left a very clear and visible trace. While every school is likely to have a bathroom and perhaps a sink in the locker room or art room, the presence of sinks is itself a reminder to wash one's hands. Installing more sinks, having hands-free soap and paper towel dispensers, hand dryers, and other sanitary methods of handwashing is helpful, although this requires adults to 'get on board' with the child-lead effort. To garner other suggestions, and to find the best places to put handwashing stations to suit the needs of the school, allowing the students to submit suggestions would further facilitate compliance.

In short, the best strategies to encourage handwashing are not prescriptive-i.e., the suggestions that 'tell' students how they should behave. Students must understand why they should wash their hands, and the scientific reasons behind handwashing. Although scare and shock tactics do not work, seeing bacteria under the microscope is a wonderful way to educate students and to encourage them to feel a healthy disgust for dirt, grit and grime. This shows them that their parents are not simply nagging them to wash their hands to be irritating, but are acting out of real concern for their health. For older students, understanding the reasons and the danger for the spread of antibiotic-resistant bacteria or new forms of the influenza virus is a way of teaching current events and science, as well as to reinforce the visual impact of seeing what lies invisible on different common school surfaces. For all ages, creativity and understanding the how's and why's behind common household products inspires students to feel as if they are participating in making the school a better place. Every student likes to know more about what sorts of ingredients are in every day products, and comparing the efficacy of certain products that they use every day, like soaps and shampoos.

No student likes to be sick. Washing hands is a health-promoting habit. The reason that students and some adults do not wash their hands may partly be due to laziness, partly because they find it irritating to do what 'mother told them to do,' and also because they do not understand the risks of noncompliance. By making handwashing seem like less of a chore and helping the school better understand why handwashing is so important, a school district can become healthier and cleaner. The students with the help of the teachers must direct the effort, because they have the most to gain and lose from the results of the program.

Bibliography

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Parets, Robyn Taylor. "Marketing to Gay Community Can Pay Dividends to Hotels." Hotel & Motel Management. 7 May 2005.

Poria, Yaniv. "Assessing Gay Men and Lesbian Women's Hotel Experiences: An Exploratory Study of Sexual Orientation in the Travel Industry." Journal of Travel Research, Vol 44, 83567, No. 3, 327-334 (2006).

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