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Impact of health education on knowledge, attitude and practices regarding hand-hygiene amongst school children aged 10-12 years in Pune: An interventional study

1 MBBS, Sr Manager, Plum Health, Pune, Maharashtra, India
2 GSO1 Med (ESM), Army HQ, New Delhi, India
3 Professor, Department of Community Medicine, AFMC, Pune, Maharashtra, India
4 Scientist 'E', ICMR, New Delhi, India

Date of Submission17-May-2022
Date of Decision20-Jul-2022
Date of Acceptance10-Aug-2022
Date of Web Publication30-Nov-2022

Correspondence Address:
Swati Bajaj,
Department of Community Medicine, AFMC, Pune - 411040, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_81_22


Background: Hand hygiene in school children is a widely recognized low-cost effective intervention for the prevention and control of many infectious diseases. Health and hygiene education in schools is now a part of the “Swachh Bharat Abhiyan” and is being implemented across most schools in India. Objectives: This study was carried out to assess the impact of intervention in the form of a health education package on change in knowledge, attitude, and practices (KAP) regarding hand hygiene among school children. Methodology: A prepost interventional study was carried out in a school located in an urban area of Pune, Maharashtra, to evaluate the effectiveness of health education intervention on KAP regarding hand hygiene among school children. A total of 115 children in the age group 10–12 years were included in the study. The baseline KAP was measured using a pretested validated questionnaire followed by intervention in the form of health education through health talks, interactive sessions, videos, and demonstrations. Postintervention assessment of KAP was done using the same questionnaire. Results: The mean age (± Standard Deviation) of the study participants was 11.2 (±-0.712) years. Boys comprised 65.2% of the study population and the remaining 34.8% were girls. The baseline survey showed that only 3.5% of school children were aware of the correct method of handwashing which improved significantly to 91% postintervention. None of the children knew the names of the diseases prevented by handwashing preintervention. This changed postintervention, where 27.8% said it prevents diarrheal diseases, 20.0% said it prevents common cold, and 52.2% said it prevents both. The practices regarding handwashing before eating meals at home, after using toilet facility, after coughing/sneezing, and after playing outside improved significantly postintervention. Conclusion: Health education is an effective intervention to improve hand-washing practices among school children and bring about behavioral change for disease prevention.

Keywords: Behavioral change, disease prevention, handwashing practices, health education

How to cite this URL:
Kothari A, Phutane VS, Bajaj S, Mukherjee R, Tawar S. Impact of health education on knowledge, attitude and practices regarding hand-hygiene amongst school children aged 10-12 years in Pune: An interventional study. J Mar Med Soc [Epub ahead of print] [cited 2023 Mar 24]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=361396

  Introduction Top

The health and hygiene of children are closely linked to both scholastic performance and school attendance.[1],[2] Schools in the low- and middle-income group countries have poor cleanliness and sanitation. Children spending a significant amount of time each day in such surroundings may fall ill from water, sanitation, and hygiene (WASH)-related illnesses. Not only can they transmit these infections to each other, but it is estimated that they further infect at least half of their household contacts. School-going children are most affected by diarrhea, respiratory tract infections, and worm infestations. It has been estimated that 88% of all diarrheal diseases in children are caused by unsafe water and inadequate sanitation practices.[1] Washing hands with soap after toilet use and before meals has been cited as one of the most cost-effective public health interventions toward reducing the incidence of diarrhea. Another strategy in situations where adequate water and soap facilities are not available or feasible is the use of alcohol-based hand sanitizers which are proven to be as effective. Proper handwashing can reduce the risk of diarrhea by 42%–48%.[3] Similarly, a study comparing the results from different countries found that handwashing in children can cut the risk of respiratory infections by 16% and significantly reduce worm infestation.[2],[4],[5] A systematic review and meta-analysis on the effectiveness of hand hygiene interventions in reducing illness among children in educational settings reported a reduction in the incidence of infections, especially respiratory tract infections among school children.[2],[6]

Frequent absenteeism due to illness is known to affect both academic development and the keenness to learn in children.[1],[7] Children who are frequently absent find it challenging to learn the concepts taught in school and subsequently develop an aversion to schooling, thus leading to early school dropout. It is also well acknowledged that most forms of adult health-related behaviors are developed and molded during childhood and adolescence. Thus, children imbibing healthy habits and behaviors ensure a “life course” approach to health.[8]

The School Sanitation and Hygiene Education (SSHE) program was started in India in 1999, under the flagship program of the Total Sanitation Campaign. The priority areas of SSHE were to provide water, sanitation, and handwashing facilities in the schools and promote behavioral change through hygiene education and linking the same to home and community.[1],[9],[10] In 2009, the Right to Education Act also incorporated hygiene education in schools, and extensive work was done on WASH promotion in schools by many Indian States. In 2014, the “Swachh Bharat Abhiyan” was launched by our Honorable Prime Minister, placing the issue of sanitation at the center of the government's developmental agenda. Information, education, and communication (IEC) activities are being conducted in schools under this project emphasizing on clean drinking water, promoting handwashing as a habit, basic sanitation and hygiene facilities, separate toilets for boys and girls, and Swachh Vidyalaya Puraskar honoring Swachh Bharat Abhiyan. Against this backdrop, we planned this interventional study to measure the impact of health education on knowledge, attitude, and practices (KAP) of handwashing among school children in an urban community in Maharashtra, India.

  Methodology Top

Study design and setting

A pre- and postinterventional study were carried out in a school located in the urban field practice area of the health training center of a Government Medical College in Pune, Maharashtra.

Sampling technique

The school meeting the study criteria was selected by lottery method. As the study population was school children in the age group 10–12 years, students of Class VI were selected for the study. There were eight sections in Class VI and out of these four sections were chosen by lottery method. All the children (n = 126) in these four sections were included in the study. However, 11 students were absent during the interventions and they were excluded from the study making the final sample size as 115 students [Figure 1].
Figure 1: Methodology and timeline of the pre- and postinterventional study

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Sample size determination

The sample size was estimated assuming a 30% awareness level of handwashing practices in school children before the intervention based on pilot study findings. With a confidence interval (CI) of 95% and the desired absolute precision of 20%, the minimum sample size calculated was 95. However, we finally included 115 children in the study.

Educational intervention

Intervention in the form of health education through health talks, interactive sessions, audiovisual aids using videos and material from the WHO and CDC websites and live demonstrations of the WHO 7 steps of handwashing was given to the students. The first phase of intervention included health talks on the importance of handwashing and interactive session for clearing the doubts and queries of the students. After 1 week, the second phase of intervention was given in the form of audiovisual videos and live demonstrations on the right method of handwashing. Students were assessed 4 weeks postintervention to study the change in their knowledge, attitude, and practices (KAP) regarding handwashing. Students absent on the days of intervention were excluded from the study but were given IEC regarding handwashing practices.

Data collection tool

Data were collected by a self-administered pretested, structured questionnaire designed to elicit responses on the knowledge, attitude, and handwashing practices and techniques, sanitation facilities available in school, and behavior of students on personal hygiene and sanitation after explaining the questionnaire verbally to the children. The questionnaire was in the English language as all the children expressed their ability to understand English. The questionnaire was explained to the children and any doubts regarding the questions were clarified. Pilot testing was done to validate the questionnaire and required changes based on the pilot study were incorporated. Observations were made by researchers to collect information regarding personal hygiene, use of hand sanitizers, and other handwashing facilities in the school such as washbasins, water supply, and soaps. Postintervention assessment of KAP was done using the same questionnaire.

Ethical considerations

The study was approved by the institutional ethics committee. Written informed consent was taken from the parents of the children participating in the study, and we also took verbal assent from all the children.

Data analysis

Data were analyzed using the SPSS software version 22.0 (IBM Corp., Armonk, NY, USA). Data are summarized in absolute numbers and percentages. McNemar's test for difference in percentage change pre- and postintervention was carried out as the appropriate test. P < 0.05 were considered statistically significant.

  Results Top

The study was carried out in 115 school children in the age group 10–12 years, to assess their KAP regarding handwashing. The mean age (±standard deviation) of the study participants was 11.2 (±0.712) years with a range of 10–12 years. Boys comprised 65.2% of the study population and the remaining 34.8% were girls. The results of the baseline knowledge about handwashing showed that 67 (58.3%) children learned about hand hygiene from their parents and 32 (27.8%) learned it from school teachers [Figure 2]. Postintervention, the main source of knowledge was the health education package administered to the children during the study. Nails were stated to have the maximum germs by 80 (69.6%) respondents and 21 (18.3%) said that palms have the maximum germs. When asked about handwashing facilities on the school premises, 69 (60.9%) said that while water was available, soap was not available for handwashing. However, on physically verifying this fact, it was seen that soap cake was present in some washrooms only. The school authorities were advised to keep liquid handwash in the washrooms for encouraging the children to wash their hands properly. This was incorporated by the school authorities. In preintervention, 97 (84.3%) children believed that using hand sanitizers removes all the dirt and germs from their hands.
Figure 2: Source of knowledge regarding handwashing practices in the study population

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The proportion of children with knowledge about different aspects of handwashing before and after health education is presented in [Table 1]. While preintervention 44.3% of children knew that handwashing prevents the spread of diseases, postintervention, the proportion increased significantly to 93%. There was a significant improvement in the proportion of children with knowledge regarding the correct technique and duration of effective handwashing. During preintervention, only 3.5% of school children were aware of the correct method of handwashing, which improved significantly to about 91% postintervention. Similarly, in preintervention, 60 (52.2%) respondents answered correctly that hands should be washed for 20 s for it to be effective against disease transmission, which increased to 75 (65.2%) postintervention. While a large proportion of children knew the reasons for handwashing even preintervention, none could name the diseases prevented by handwashing. This changed postintervention, where 32 (27.8%) said it prevents diarrheal diseases, 23 (20.0%) said it prevents common cold, and 60 (52.2%) said it prevents both.
Table 1: Distribution of school children as per their knowledge about hand hygiene

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Although all children were aware that handwashing is important pre- and postintervention; however, there was a significant change in the knowledge regarding why it is important pre- and postintervention. Postintervention, a significantly higher proportion of children felt that washing hands removes germs (87%) as compared to preintervention (75.7%) (P = 0.016) [Figure 3]. Preintervention to postintervention, a significant change was noted in attitude and behaviors of the study population [Table 2]. A higher proportion scrubbed under their nails while washing hands (53.9% versus 75.7%), washed hands before eating meals at home (93% versus 99.1%); after using the toilet facility (87% versus 100%); after coughing or sneezing (60.9% versus 82.6%); and after playing outside (69.6% versus 87%).
Figure 3: Distribution of school children as per their attitude about handwashing

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Table 2: Distribution of school children as per their practices about hand hygiene

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  Discussion Top

The purpose of this study was to assess the KAP of school children about hand hygiene and to measure the impact of health education intervention. An encouraging finding from our study is that a large number of children were already washing their hands before eating food, after coughing or sneezing, and after use of the toilet. Health education and demonstration led to further improvement in these numbers. A study from Bangladesh reported higher odds of handwashing in students above classes 5th and also in children who had been taught about hand hygiene.[11] Two studies, one among school children of rural population of Pune District, Maharashtra and another from municipal schools of Mumbai, India also reported good knowledge, attitude and practices regarding hand hygiene among school children. However, though the percentage of children washing hands before meals was high (73% & 75%), but the practice of washing hands after use of toilet facility was low (22% & 13%). [12,13] This is probably due to the different study settings, ours being in an urban field practice area of a medical college. We found that intervention in the form of health education is effective in improving the KAP regarding hand hygiene. Similar findings have been reported from Panipat, India, by Siwach[14] and Shrestha and Angolkar from Belgaum, Karnataka, India.[15] Both these studies demonstrated an improvement in the knowledge and behavior scores of children who underwent a health education intervention to improve hand hygiene practices. Similar findings have been reported from other countries as well.[3],[16],[17] A systematic review of hand hygiene intervention strategies to reduce diarrheal diseases and respiratory infections among school children in developing countries found that training was one of the most commonly used intervention strategies to improve hand hygiene in children.[1],[3],[6],[17],[18]

Although a large proportion (92.2%) of children reported using soap while washing hands, on observation by researchers it was seen that the actual number was lesser (77.4%). The reason behind this could be the nonavailability of soap in the school washrooms at certain times.

  Conclusion Top

The effectiveness of handwashing in reducing the incidence of respiratory and intestinal infections is well documented; hence, it is essential to inculcate this habit in school children by regularly reinforcing the message of handwashing. The preexisting knowledge about handwashing in school children was encouraging and pointed toward higher awareness in the urban community about this important practice. However, children should be constantly reminded and motivated to follow correct hand hygiene by both parents and school teachers. The availability of soap and handwashing facilities should be provided in the school premises to ensure proper hand hygiene practices among the school children.

Limitation of the study

Our study has the limitation of including children belonging to a specific age group in an urban area; hence, the findings of the study may not be generalizable in other settings. However, this is one of the few studies that assessed the impact of an intervention in a school setting in India and may generate interest for other extensive studies in the same direction with a larger sample size.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

UNICEF_WASH_for_School_Children_South_Asia_Report.pdf.Available from: https://www.Unicef.org/Wash/Schools/files/UNICEF_WASH_for_School_Children_South_Asia_Report.pdf. [Last accessed on 2020 Dec 7].  Back to cited text no. 1
Willmott M, Nicholson A, Busse H, MacArthur GJ, Brookes S, Campbell R. Effectiveness of hand hygiene interventions in reducing illness absence among children in educational settings: A systematic review and meta-analysis. Arch Dis Child 2016;101:42-50.  Back to cited text no. 2
Mbakaya BC, Lee PH, Lee RL. Hand hygiene intervention strategies to reduce diarrhoea and respiratory infections among schoolchildren in developing countries: A systematic review. Int J Environ Res Public Health 2017;14:371.  Back to cited text no. 3
Rabie T, Curtis V. Handwashing and risk of respiratory infections: a quantitative systematic review. Trop Med Int Health 2006;11:258-67.  Back to cited text no. 4
Mahmud MA, Spigt M, Bezabih AM, Dinant GJ, Velasco RB. Associations between intestinal parasitic infections, anaemia, and diarrhoea among school aged children, and the impact of hand-washing and nail clipping. BMC Res Notes 2020;13:1.  Back to cited text no. 5
Lin A, Ercumen A, Benjamin-Chung J, Arnold BF, Das S, Haque R, et al. Effects of water, sanitation, handwashing, and nutritional interventions on child enteric protozoan infections in rural bangladesh: A cluster-randomized controlled trial. Clin Infect Dis 2018;67:1515-22.  Back to cited text no. 6
Mbakaya BC, Lee P, Lee RL. Effect of a school-based hand hygiene program for Malawian children: A cluster randomized controlled trial. Am J Infect Control 2019;47:1460-4.  Back to cited text no. 7
Available from: https://www.who.int/ageing/publications/lifecourse/alc_lifecourse_training_en.pdf. [Last accessed on 2020 Dec 09].  Back to cited text no. 8
WHO | Long-Term Impact of a Community-led Sanitation Campaign in India, 2005-2016. WHO. World Health Organization. Available from: http://www.who.int/bulletin/volumes/97/8/18-221572/en/. [Last accessed on 2020 Dec 09].  Back to cited text no. 9
School Sanitation and Hygiene Education Program (SSHE). Available from: http://www.indiasanitationportal.org/full-view-page.php?title=MTQ0. [Last accessed on 2020 Dec 09].  Back to cited text no. 10
Alam SS, Haque A, Shipu TA, Ghosh S, Kabir RK, Rahman MN. Assessment of hand washing knowledge and practice among primary school children in Noakhali district, Bangladesh. Am J Public Health Res 2020;8:197-201.  Back to cited text no. 11
Pratinidhi SA, Haribhakta SV, Ambike DA, Bhole O, Kankariya B. Study of knowledge and practices related to handwashing in school going children of a rural community. International Journal of Contemporary Pediatrics 2019;7:24-9.  Back to cited text no. 12
Gawai PP, Taware SA, Chatterjee AS, Thakur HP. A cross-sectional descriptive study of hand washing knowledge and practices among primary school children in Mumbai, Maharashtra, India. Int J Community Med Public Health 2016;3:2958-66.  Back to cited text no. 13
Siwach M. Impact of health education programme on the knowledge and practices of school children regarding personal hygiene in rural panipat. Int J Educ Sci 2009;1:115-8.  Back to cited text no. 14
Shrestha A, Angolkar M. Improving handwashing among schoolchildren: an educational intervention in South India. Al Ameen J Med Sci 2015;8:81-5.  Back to cited text no. 15
Randle J, Metcalfe J, Webb H, Luckett JC, Nerlich B, Vaughan N, et al. Impact of an educational intervention upon the hand hygiene compliance of children. J Hosp Infect 2013;85:220-5.  Back to cited text no. 16
Duijster D, Buxton H, Benzian H, Dimaisip-Nabuab J, Monse B, Volgenant C, et al. Impact of a school-based water, sanitation and hygiene programme on children's independent handwashing and toothbrushing habits: A cluster-randomized trial. Int J Public Health 2020;65:1699-709.  Back to cited text no. 17
Sarkar M. Personal hygiene among primary school children living in a slum of Kolkata, India. J Prev Med Hyg 2013;54:153-8.  Back to cited text no. 18


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