Effect of Hand Hygiene Program Among School Children in Bangladesh

Effect of Hand Hygiene Program Among School Children in Bangladesh | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of Hand Hygiene Program Among School Children in Bangladesh Ferdushi Akhter, Shanzida Khatun, Happy Bandana Biswas This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7358688/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Dec, 2025 Read the published version in BMC Public Health → Version 1 posted 4 You are reading this latest preprint version Abstract Purpose: School children are silent carrier and higher risk to acquire infectious diseases. Good hand hygiene can be an effective preventive measure to protect transmissions of infections. This study was aim to examine the effect of hand hygiene program among school aged children at city corporation Adarsha high school in Dhaka, Bangladesh. Design and Methods: A quasi experimental one group pre-test post-test study was conducted among 40 students conveniently. Hand hygiene education intervention was given for two weeks. This study was guided by the KAP survey model which is influence behavior change begins with knowledge, shapes attitude and results in improved practice. Data were collected by using structured self-administered questionnaires including (1) Demographic Questionnaire, (2) Hand Hygiene Knowledge Questionnaire, (3) Hand Hygiene Attitude Questionnaire, and (4) Hand Hygiene Practice Questionnaire. Data were analyzed using both descriptive statistics and inferential statistics. Results: The results of the present study showed that the average age of school students was 11.62±1.44 years. There was a statistically significant mean difference between pre- and post-test scores of knowledges (t=-5.605, p<.001), attitude (t=-3.839, p=<.001) and practice (t=-8.273, p=<.001) of hand hygiene among school children’s. Conclusion: The findings of this study provide baseline information to the policymaker to implement hand hygiene program using KAP model effective for school students. Further intervention study is needed on diverse setting and population. Implications for Practice: In order to improve hand hygiene knowledge, attitude and practice among school children can be integrating in school curriculum play an effective role in preventing the spread of infectious disease. Nurse and Health educators can get the guideline for developing school-based hygiene promotion intervention particularly in Low middle income countries. Hand Hygiene School Children Knowledge Attitude Practice Bangladesh Introduction Hand hygiene is generally accepted as the primary preventive measure for the reduction of infectious diseases (Klar et al., 2022). Hand hygiene is the process of cleansing dirt with water in order to suppress or kill bacteria that have built up on the skin of the hands from interaction with the environment, preventing diseases from being transmitted through the hands (Hidayah & Ramadhani, 2019 ). Around 2.3 billion people do not have access to basic sanitation, and 892 million people do not have access to indoor sanitation. (Chattopadhyay et al., 2019). According to the World Health Organization (2012), roughly 35% of the world's population lacks basic sanitation, and unclean and poor sanitation conditions cause 7% of global disease burden (Wang et al., 2019 ), which primarily include respiratory and diarrheal illnesses (Mbakaya et al., 2017). In Bangladesh children may not wash their hands for a variety of reasons, including a lack of resources like soap and water and poor sanitary conditions. In addition to having the right tools and facilities, students' attitudes and understanding about cleanliness have a big impact on how they practice it (Sharifa Nasreen & Amin, 2023 ). Several researches have been carried out to look into the problems with hand washing and overall hygiene in school children. Hand washing, especially after using the restroom, significantly reduces the transmission of parasite illnesses, which are more prevalent among school children in many nations (Lopez-Quintero et al., 2009 ; Sharma et al., 2021 ). School-age is an important period for the formation of clean and healthy living habits in children, who in the future are expected to become agents of change who can encourage healthy living in schools, communities, and the home environment (Nuraida, 2015 ). One of the strategic places in promoting health is Educational Institutions. Habits carried out by a child at school will also be carried out at home which is expected to influence the behavior of other family members (Solehati et al., 2018 ). In low- and middle-income countries improvements are essential to promoting children's health. The enormous burden of preventable children’s ailments, like intestinal worms and dental cavities, is considerably exacerbated by a shortage of water, restricted access to improved sanitation, and poor personal hygiene at home and at school (Walker et al., 2013; Bethony et al., 2006; Benzian et al., 2022 ). Through their negative effects on children's school attendance, educational performance, and production, these hygiene-related ailments contribute to a vicious cycle of poverty and disease (Duijster et al., 2017). Previous studies the implementation of hand hygiene interventions has shown that hand hygiene compliance can increase by 34% (Randle et al., 2013). Studies of HH in preschools have been conducted in various countries such as Netherlands (Zomer et al., 2013), Israel (Rosen et al., 2011 ), Thailand (Pandejpong et al., 2012 ), India (Nicholson et al., 2014), New Zealand (Priest et al., 2014 ), Spain (Azor-Martinez et al., 2018) and Iceland (Gudnason et al., 2012) focusing on the reduction of diseases through hand hygiene interventions. These studies have not been conclusive in determining a specific intervention, which will work in all areas and all scenarios, as each study made use of different interventions and measured various outcomes, such as reduction of disease or reduced absenteeism. Many of these interventions included the provision of hand sanitizer or soap or both by the researchers, as part of the intervention (Randle et al., 2013, Zomer et al., 2013, Pandejpong et al., 2012 , Nicholson et al., 2014, Priest et al., 2014 ; Azor-Martinez et al., 2018; Gudnason et al., 2012). Although the studies showed decreases in school absenteeism and hand hygiene-related diseases. However, studies which have shown an increased hand hygiene knowledge, attitude and practice change that resulted in behavior change as well as decreased absenteeism based on interventions which did not incur additional costs after the completion of the intervention (Croghan, 2008 ), These interventions made use of health education sessions and interactive learning regarding hand washing and increase hand hygiene knowledge, attitude and practice. However, a weak and complicated budgetary allocation and procurement process in Bangladeshi schools fails to ensure an operating budget for basic supplies, including soap (Ara et al., 2019). A major problem of health issues in our country is unhygienic environment particularly lack of hand washing that leads thorough health hazard of public specially children in the school. School children have not realized that clean living behaviors such as the habit of washing hands in daily life, both in the school environment and in the playground, can improve their health. Children often eat food using unwashed hands. This habit is one of the factors that contribute to the incidence of diarrheal diseases and other infectious diseases. Based on the above phenomenon, the researcher is interested in conducting research will use Glow gel technique to educate and involve children in hand washing intervention. Glow gel glows in ultra violet light and children can visualize bacteria and their location on hands physically. This study will help to improve hand hygiene knowledge, attitude and practice among school going children through health education intervention. In Bangladesh, it has been observed that very a smaller number of researches on Hand Hygiene has been done on school going children. Even in nursing sector, there is not so much information about doing research on hand hygiene. In other countries, there is few histories of doing research on hand hygiene. The hand hygiene program of school children in the daily life, both in the school environment and in the playground, can improve their health. Based on the above phenomenon, the authors are interested in conducting hand hygiene program to understand the level of school going children’s knowledge, attitude and practice. Therefore, this study aimed to assess knowledge; attitude and practice level can be increased in school going children. That’s why researchers think that it is very important to study on Hand Hygiene. Method The study was conducted among school children at City corporation Adorsho high school. This chapter described the study design, participants, instruments, ethical consideration, data collection methods, and data analysis. A quasi experimental one group pre and post-test study was used to identify the effect of hand hygiene program among school children in Bangladesh. This study period began from July 2022 to June 2023. This study was carried out on City Corporation Adorsho High School, Dholpur, Dhaka. This school was selected for the research setting because it is located in Dhaka and is considered as the renowned school of the Dhaka city. There was total 1200 students in City Corporation Adorsho High School who were studying in different classes. The participants of this study were 5th and 6th grade school children. Sample of this study was school children who were 10 to 12 years old and studied in City Corporation Adorsho High School, Dhaka, Bangladesh. Convenience sampling technique was applied to select the eligible sample for the study. Generally, most of the school children were busy with their schedule class. Therefore, the research works were done to intend to give hand hygiene intervention and collect data from students who were available and willing to participate. The sample size of this study was estimated by using G* power analysis software. The sample size was calculated for an accepted minimum significance level (α) 0.05, an expected power of 0.80, and an estimated population effect size of 0.25 as the medium effect size used in the nursing studies. Sample size was (34). In considering 10% attrition the final sample size was (40). The inclusion criteria of the participants were: (1) children between 10 to 12 years old enrolled at city corporation adorsho high school, (2) school attendance for at least 25 hours per week, (3) whose parents and/or guardians was signed an informed consent document. Data was collected by using Structured Self-administered questionnaire. The Instrument consists of five sections. Section I is related to participants Demographic Data Questionnaire (DDQ), Section II is related to Hand Hygiene Knowledge Questionnaire (HHKQ), Section III is related to Hand Hygiene Attitude Questionnaire (HHAQ), Section IV is related to Hand Hygiene Practice Questionnaire (HHPQ). Based on cultural context of our country the instruments were validated by three panel experts that is three PhD faculties of National Institute of Advanced Nursing Education and Research. The instruments are described as below. Demographic Data Questionnaire (DQ): The Demographic Data Questionnaire of the study was developed by the researcher based on the literature reviewed. It consisted of 12 items including age, religion, class, gender, family size, housing status, fathers’ education, source of water, type of toilet, nails status, nails length, illness diagnosed. Hand Hygiene Knowledge Questionnaire (HHKQ): Hand Hygiene Knowledge Questionnaire was developed by the researcher based on the literature reviewed. It was used to measure the knowledge of school children regarding hand hygiene. It consisted of 13 items and the response format was 1 = yes, 0 = no, and 2 = don’t know. During summing don’t know was 0. Therefore, the total score was 0–13. Higher score indicates higher knowledge regarding hand hygiene. Hand Hygiene Attitude Questionnaire (HHAQ): Hand Hygiene Attitude Questionnaire was developed by the researcher based on the literature reviewed. Hand hygiene attitude of children was assessed by using 16 items 5-point Likert scale strongly disagree = 1, Disagree = 2, Neutral = 3, Agree = 4, strongly agree = 5. The total score was 16–80. Higher score indicates higher attitude regarding hand hygiene. Hand Hygiene Practice Questionnaire (HHPQ): Hand Hygiene Practice Questionnaire was developed by the researcher based on the literature reviewed. Hand hygiene practice of children was assessed by using 14 items 3-point Likert scale Never = 0, Sometimes = 1and always = 2.The total score was 14–28. Higher score indicates that good hand hygiene practice among school children. The original version of the instruments was developed in the English language. After that the English version instruments were translated into the Bengali language. The method of translation was the back translation technique (Brislin, 1970). It is a translation process which ensures accuracy and the culturally equivalence of the instruments when translated to another language (Brislin). Three bilingual translators who were fluent in both English and Bengali translated the instruments (e.g., they were Nursing faculty and one English editor). The process of back translation was conducted as follows. The first bilingual translator translated the English version of instruments into the Bengali language. The second bilingual translator back translated the instruments from the Bengali versions into the English language. The third bilingual translator clarified and identified the differences in all items of two English versions. After completing the back translation process, the researcher reviewed and compared both English versions. The researcher analyzed each item in details and revised based on the two translations. Then, the researcher modified the words of the instruments as needed in order to establish the same meaning within acceptable limits. This study was approved by the Institutional of Review Board, National Institute of Advanced Nursing Education and Research and Bangabandhu Sheikh Mujib Medical University. All school children were received sufficient information about the purpose of the study, the methods and the instruments used for collecting data, and how their rights will be protected. Before using the informed consent from (Appendix B) the researcher was explained the process of data collection to the participants and assured them that the information they were give that would be keep private and confidential. The confidentiality of subject’s responses was assured throughout the study by using sample coding and the assurance that was used for research purposes only. However, the participants were assured that they have the right to refuse to participate in the study at any time. Data collection process consists of two phases including the preparation phase and implementation phase. In the preparation phase, researcher completed the following procedures: Approval of the research proposal was given by the Institutional Review Board at National Institute of Advanced Nursing Education and Research, Bangabandhu Sheikh Mujib Medical University. The researcher was taking permission from authority of City Corporation Adorsho High School in Dholpur, Dhaka, Bangladesh through written order issue by the Director of NIANER. During Data collection phase, the researcher explained the study objectives, benefits, confidentiality and methods or process of data collection to the authority and study participants. All participants are ensured that their participation would be voluntary. In the implementation phase, data was collected by using Demographic questionnaire, Hand Hygiene Knowledge Questionnaire, Hand Hygiene Attitude Questionnaire, Hand Hygiene Practice Questionnaire from January 2023 to February 2023. Data collection and Hand hygiene program was conducted by the researcher with the help of the respective school teacher. Before collecting data, the researcher approached the children who was meet the inclusion criteria and introduced themselves. The day before baseline data collection, the researcher was communicating with students over telephone to come to city corporation Adorsho high school. On the day of pre-test, the researcher was explained study purpose, benefit and ethical consideration of the study. The researcher was informed the participants regarding signing the consent form. The participants were informed by the researcher that they have full right to withdraw from this study at any time without any obligation. All participants’ confidentiality and anonymity were strictly maintained with code numbers. Participants were also informed that the findings of the study were submitted to a scientific journal for publication and presentation at conferences, code sheets were secured in a locked file up to five years and the data was accessible only to the researcher, all necessary information collected from the participants was kept confidential. After obtaining verbal permission from the participants, researcher was collecting written consent from the participating students. The researcher explained the questionnaire to the participants. Each student was be given a code number and were divided into five groups (A-D) based on the age of them. Each group was consisting of ten members. The participants were instructed to answer the questionnaires spontaneously within 20–30 minutes. The pretest was done through structured questionnaires by the researcher. After that, the researcher was checked that the questionnaires would be completed. After the researcher performed three days face –to-face group session of hand hygiene education intervention, post –test data was obtained from participants after two weeks of intervention by the same researcher. Collected data was monitored and checked for completeness and consistency during data collection and at the end of each day. Hand Hygiene Program Hand Hygiene program modules were developed based on World Health Organization Hand washing technique guidelines. The module was designed over three sessions (40 minutes/session). The content validity of the hand hygiene education intervention module was tested at expert faculties from Child Health Nursing department of National Institute of Advanced Nursing Education and Research. The module was prepared in English and translated by three bilingual experts according to translation process. Hand hygiene program was conducted for two weeks, commencing the day after baseline data collection. All sessions were face to face group session and were conducted at the school children’s convenience time at City Corporation Adorsho High School dividing the participants into five groups: (A-D), each group consisting ten members. The day before intervention, the researcher was invited with school children via class teacher or over telephone to come to school health center (City Corporation Adorsho High School) according to group. Group A-D was instructed to come sequentially. Total three sessions were consecutively provided to each participant/group. One group was participated in one session daily. All sessions were face to face group session and were conducted at the participant’s convenience time in local language Bangla. Initially, the researchers were introduced themselves and participants were informing about the purpose and procedures of the intervention. After obtaining verbal permission from the participants, the researchers were implemented hand hygiene intervention program. The hand hygiene intervention was conducted using theoretical session, discussion, and poster, and leaflet, video and practical demonstration. Result After completion of data collection, raw data was entered in the data sheet against each question. Then the data was checked, verified and edited for consistency to minimize error. The statistical analysis was performed by using IBM SPSS (Version 23.0). Both descriptive and inferential statistics was used to analysis the data. The demographic characteristics of children were measured by the descriptive statistics such as frequency, percentage, mean, standard deviation. Hand hygiene knowledge, attitude and practice was measured using descriptive frequency. Inferential statistics such as Paired t-test was used to compare hand hygiene knowledge, attitude and practice score of students both before and after intervention. Independent sample t test, Pearson product correlation and one way ANOVA was used to test homogeneity for socio-demographic characteristics of students. Finally, the result was summarized using frequency, mean, standard deviation and percentage. The findings of this study are presented under the following headings of subject’s characteristics. The result is represented by descriptive and inferential statistics as frequency, percentage, mean, standard deviation, correlation, t-test and ANOVA. The average age of the respondents was 11.62 years. About 80% of the respondent lived in nuclear family and 20% of the respondent lived in joint family. In this study about 65% of the respondent’s housing status was Building and 35% was shed and semi building. The most of the respondent’s fathers and mothers’ education level was secondary and above (60% and 50%) respectively. The majority of the participants (77.50%) were using tape well water and 80% of them using sanitary latrine. About 52.50% participants had grown nails and 47.50% had trimmed nails. The 60% of the participants had dirty nails and 40% of the participants had clean nails. Hand hygiene knowledge level of school children’s (n = 40) before and after intervention. The mean knowledge score of school children before and after intervention was 14.70 ± 4.0 & 22.35 ± 4.26 respectively. Result shows, in the baseline data, only (20%) children know about the item I knows properly how to wash hands with soap. About 65% children answered No the item of unclean hands are a way of spreading diseases. The 55% of the participants knows about the item if I fail to wash my hands, I cannot be affected with diseases. Only 20% of the children knows the correct technique of hand washing. The majority (67.5%) of the participants answered “No” for the item of must wash hands before sneezing and coughing. Only 25% of the respondent answered “Yes” for the item of Bacteria may spread from hands to the nose and mouth. Almost 62.5% of the participants answered “yes” for the item of To Prevent Corona virus, hand should be cleaned with soap. After intervention, almost (97.5%) participants answered “Yes” for the item I knows properly how to wash hands with soap. The majority 92.5% of the respondent answered “Yes’’ for the item Unclean hands are a way of spreading diseases. About (50%) answered “No” for the item if I fail to wash my hands, I cannot be affected with diseases. Majority (90%) of the children’s answered for the item I know the correct techniques of how to wash hands. Almost 90% of the children’s answered “Yes” for the item of must wash hands before sneezing and coughing and Bacteria may spread from hands to the nose and mouth. Most of the children’s (87.5) answered “yes” for the item To Prevent Corona virus, hand should be cleaned with soap. hand hygiene attitude of school children’s before and after hand hygiene intervention. The total item was 16. Before intervention, 40% of school children were strongly agreed with the statement “I believe that dirty hands cannot make illness”. Majority of children’s 62.5% agreed on “I believe that I should wash my hands when they become dirty”. About 35% children’s believe that on “I believe that I should Wash my hands before touching my foods” Majority of children’s (52.5%) strongly agreed on “I don’t think that while helping other’s cooking in home, I need to wash my hand”. About 42.5% of the respondents were disagreed on the statement of “I believe that I should Wash My Hands, when I visited someone in the hospital”. Only 2.5% of children were strongly agreed on “I believe that I should Wash My Hands after sniffing or blowing the nose”. About 47.5% children were disagreed on “I believe I should cover my nose by elbow while sneezing”. Majority of children’s (42.5%) were strongly agreed on “I don’t believe that every step of washing hand is important. Majority of the children’s (45%) were strongly disagreed on “I don’t think that washing hands with only water can reduce germs”. “Only 2.5% of the respondents strongly agreed on “I can wash my hands with soap and water properly”. Majority of the children were strongly agreed on “I don't believe that humans have germs on their hands. After intervention 45% of school children were strongly disagreed with the statement “I believe that dirty hands cannot make illness”. Majority of children’s 65% agreed on “I believe that I should wash my hands when they become dirty”. Majority 47.5% children believe that on “I believe that I should Wash my hands before touching my foods”. Only (7.5%) strongly agreed on “I don’t think that while helping other’s cooking in home, I need to wash my hand”. About 37.5% of the respondents were agreed on the statement of “I believe that I should Wash My Hands, when I visited someone in the hospital”. Majority of the children’s (65%) were agreed on “I believe that I should Wash My Hands after sniffing or blowing the nose”. About 55% children were agreed on “I believe I should cover my nose by elbow while sneezing”. Majority of children’s (60%) were strongly disagreed on “I don’t believe that every step of washing hand is important. Only (7.5%) children were strongly disagreed on “I don’t think that washing hands with only water can reduce germs”. Majority of the respondents (57.5) were strongly agreed on “I can wash my hands with soap and water properly”. About 55% of children were strongly disagreed on “I don't believe that humans have germs on their hands. hand hygiene practice of school children’s before and after hand hygiene intervention. The total item was 14. Before intervention, only 10% of the children were answered “always” for the item of I use soap while washing hands in school before eating tiffin. Majority 87.5% of the participants were answered for the item of I use soap to wash hands after toilet. Only 15% of the respondent answered “always” for the item of I wash my hands with soap before preparing food. Majority 65% of the participants answered “Never” for the item of I wash my hands 30 seconds to 1 minute at a time. Mostly 62.5% of the children are answered “Always” for the item of I don’t wash my hands in school because soap is not available. Only 20% of the children’s answered “Always” for the item of I wash my hands with soap before meal. About 55% of the respondent answered “Never” for the item of I Wash my Hands after touching any animals. Only 20% of the children were answered for the item of I wash my hands after sneezing or coughing. Majority 55% of the respondents were answered “Sometimes” for the item of I keep my nails shorter and clean. Majority 62.5% of the respondents were answered “Never” for the item when soap and water are not available, I use alcohol spray or hand sanitizer. After intervention, about 52.5% of the children were answered “always” for the item of I use soap while washing hands in school before eating tiffin. Mostly 87.5% of the participants were answered for the item of I use soap to wash hands after toilet. Majority 70% of the respondent answered “always” for the item of I wash my hands with soap before preparing food. Mostly 90% of the participants answered “Always” for the item of I wash my hands 30 seconds to 1 minute at a time. About 37.5% of the children are answered “Always” for the item of I don’t wash my hands in school because soap is not available. Only 75% of the children’s answered “Always” for the item of I wash my hands with soap before meal. Only 15% of the respondent answered “Never” for the item of I Wash my Hands after touching any animals. Mostly 82.5% of the children were answered “Always” for the item of I wash my hands after sneezing or coughing. About 35% of the respondents were answered “Sometimes” for the item of I keep my nails shorter and clean. Only 10% of the respondents were answered “Never” for the item when soap and water are not available, I use alcohol spray or hand sanitizer. represents the relationship between demographic characteristics of school children. There was no significant difference among variable except religion, housing status, domestic source of water, nails length and status. Table shows religion of the children’s was significantly related with the children’s practice (t = 2.063, P = .05), Children’s practice was significantly related with housing status (F = 2.105, P = .042), Children’s knowledge was significantly related with domestic source of water (F = 2.29, P = .027), children’s attitude was significantly related with nails length (t = 2.090, P = .043) and children’s practice was significantly related with nails status(t = 3.273, P = .003) The differences between pre and posttest knowledge, attitude & practice scores of children’s. the mean pre-test knowledge, attitude & practice score of children’s was 14.70 ± 4.0, 50.65 ± 8.15 ,17.00 ± 5.22 and post-test knowledge, attitude & practice score of children’s was 22.35 ± 4.26, 56.60 ± 5.35, 23.33 ± 3.63 respectively. The mean difference of knowledge attitude & practice was − 5.35 ± 6.04, -5.95 ± 9.80, -8.62 ± 6.59 respectively which is indicates significant difference between pre and post-test score. In matched paired t-test analysis, it was found that there was a significant mean difference between pre and post-test knowledge, attitude & practice among children’s (t= -5.605, p < 0.001), (t=-3.839, p < 0.001), (t=-8.273, p < 0.001). Therefore, children’s knowledge, attitude & practice level statistically significantly increased after two weeks hand hygiene intervention. The hand hygiene program was significantly effective to increase knowledge, attitude & practice among school children’s Data analysis The findings of the study showed that the average age of the children was about 11 years. Based on the result, this finding is in agreement with the previous study (Eshetu et al., 2020 ). The finding is incongruent with the (Sultana et al., 2022,). The study findings revealed that the hand hygiene knowledge of children increased at the end of intervention. Hand hygiene knowledge increased from 17.00 to 22.35 after intervention. It is possible that the significant change in children’s knowledge could have been ascribed to the hand hygiene education message provided. Hand hygiene program improved children’s knowledge regarding properly how to wash hands with soap, unclean hands are a way of spreading disease, important of wash hands with soap water to prevent disease. This finding is consistent with previous several studies (Potdar, P. A., More, T. A., Wagh, A., Desai, M. M., & Raja. (2019). knowledge regarding use of soap for hand washing showed improvement from 70–85% after the active health education program. Similar results were found in research done by Grag which showed improvement from 81.1–99.3% in their study (Garg et al., 2013 ). In this study knowledge regarding hand washing after visiting toilets to remove germs increased from 85–95% with the effective hand hygiene program and another study conducted by shrestha showed similar improvement from 55.2–89.6% (Shrestha & Angolkar, 2014 ). Similar observation was given by Damayanthi where they showed improvement in knowledge from 77.3–94.6%. in this study revealed that only 20% of students knew correct hand washing technique before intervention which improved to 90% afterwards which is similar results were found in research done by potadar which showed improvement from 7.5–33.12% in their study (Potdar, P. A., More, T. A., Wagh, A., Desai, M. M., & Raja. (2019). The study done by Garg noted higher level of knowledge compared to their study participants I e. 32.4% knew the correct technique which was raised to 68% with significant (p < 0.001) (Garg, Taneja, Badhan, & Ingle, 2013 ) that is similar in this current study and shows the statistically significant (p < 0.001).Findings of this study indicate that attitude of children towards hand hygiene increased significantly after hand hygiene education intervention. The attitude level of children on hand hygiene was increased significantly from 50.65 to 56.60. In other words, the hand hygiene education gave a positive effect to the children’s attitude in the effort to provide good hand hygiene practice. This shows that there is a tendency to change attitudes in a positive direction. This was achieved through the use of posters to display the benefits of appropriate hand hygiene practice. It was stated that people will not have change in behavior unless they see the benefits (USAID, 2011). This shows that change in attitude among the children in the intervention group was based on the information receiving during the hand hygiene education. This finding was almost comparable with the studies conducted in other parts of Ethiopia: 59.4% in Hosanna (Vivas et al., 2010 ) and 61.7% in northern Ethiopia (Assefa & Kumie, 2014 ). However, it was lower than one conducted in south Africa, (Sibiya & Gumbo, 2013 ) in which 91.4% of school children had positive attitudes towards hand washing. A large number of students from different schools in South Africa participated, while children from a single school were included in the current study, and this might be a good reason for the variation. The study indicates that hand hygiene practice level of children increased significantly after two weeks hand hygiene education intervention. The score of children’s practicing appropriate hand washing technique was improved from 14.70 to 23.33 at the end of the study. This illustrates that a hand hygiene education intervention is able to improve hand washing practice of children’s. Regarded barriers of hand washing at school and home, the present study revealed that there were barriers of washing hands at schools before and after the program implementation. McDonald, Cunningham et al., supported these findings that show that one of most important barriers of hand washing in schools is lack of soap, since schools have neither soap nor proper hand washing facilities. This could be possible for increased knowledge & positive attitude during hand hygiene education intervention. The similar findings were given by shrestha which showed improvement from 41.43–60.87% (Shrestha & Angolkar, 2014 ). The significant improvement of knowledge attitude and practice of hand hygiene program increasing hand hygiene intervention program of school children’s. The improvement might also be explained by the improvement of children’s hand washing knowledge during hand hygiene education intervention. This suggests that hand hygiene education intervention had the power to change the existing poor hand hygiene knowledge and attitude, simultaneously improving hand washing practice of school children’s. There were some limitations of present study. Firstly, the study design was quasi experiment; secondly, study used only one setting which did not reflect generalization of the findings to other settings; and finally, the instruments of the study were developed based on the literature reviewed. Conclusion A quasi experiment one group pretest post-test study carried out from July 2022 to June 2023 at City Corporation Adorsho High School, Dhaka, Bangladesh. The objective of the study was to examine the effect of hand hygiene program among school children in Bangladesh. Total 40 number of children participated to the study. Hand hygiene education intervention given for two weeks. Hand hygiene education intervention significantly improved hand hygiene knowledge, attitude and practice of school children’s. This illustrates that a hand hygiene education intervention is able to improve hand washing practice of school children’s. Recommendations Based on the limitation of the study following recommendations are suggested- Curriculum should be revised taking the hand hygiene into consideration for good health of the school children. The training of teachers and parents, their motivation, both are needed for their role in improving hand washing practice. Further studies are needed to understand how hand hygiene is practiced at home and in school while relating this practice to infectious disease transmission and risk factors. Furthermore, extensive controlled studies are required to address other potential factors that contribute to knowledge, attitudes and practices of hand hygiene. Declarations Ethics Statement Ethical approval for this study was obtained from the Ethical Review Committee of National Institute of Advanced Nursing Education and Research, Dhaka, Bangladesh (Approval No: IRB No Expo NIA-S-172. Informed consent was obtained from all participants and, where applicable, their guardians. Participation was voluntary, and confidentiality was maintained throughout the study. Conflict of Interests The author declares no competing interests. References Ara, L., Trisha, M. D., Haque Tamal, Md. E., Siddiquee, N. K. A., Mowla, S. N., Hossain, F., Rahman, T., Alam Sarker, Md. S., & Haque Alam, Md. N. (2019). Implementation of a Multimodal Multicentre Hand Hygiene Study: Evidence From Bangladesh Hospitals. Global Journal of Health Science, 11(11), 73. https://doi.org/10.5539/gjhs.v11n11p73 Assefa, M., & Kumie, A. (2014). Assessment of factors influencing hygiene behaviour among school children in Mereb-Leke District, Northern Ethiopia: a cross-sectional study. BMC Public Health , 14 (1). https://doi.org/10.1186/1471-2458-14-1000 Azor-Martinez, E., Yui-Hifume, R., Muñoz-Vico, F. J., Jimenez-Noguera, E., Strizzi, J. M., Martinez-Martinez, I., Garcia-Fernandez, L., Seijas-Vazquez, M. L., Torres-Alegre, P., Fernández-Campos, M. A., & Gimenez-Sanchez, F. (2018). 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Impact of a school-based hand washing promotion program on knowledge and hand washing behavior of girl students in a middle school of Delhi. Indian Journal of Public Health, 57(2), 109. https://doi.org/10.4103/0019-557x.115009 Hidayah, N., & Ramadhani, N. F. (2019). Kepatuhan Tenaga Kesehatan Terhadap Implementasi Hand Hygiene Di Rumah Sakit Umum Daerah Haji Kota Makassar. Jurnal Manajemen Kesehatan Yayasan RS.Dr. Soetomo, 5(2), 182. https://doi.org/10.29241/jmk.v5i2.236 Klar, K., Knaack, D., Kampmeier, S., Hein, A. K., Görlich, D., Steltenkamp, S., Weyland, U., & Becker, K. (2022). Knowledge about hand hygiene and related infectious disease awareness among primary school children in Germany. Children, 9 , 190. https://doi.org/10.3390/children9020190 Lopez-Quintero, C., Freeman, P., & Neumark, Y. (2009). Hand Washing Among School Children in Bogotá, Colombia. American Journal of Public Health, 99(1), 94–101. https://doi.org/10.2105/ajph.2007.129759 Nicholson, J. A., Naeeni, M., Hoptroff, M., Matheson, J. R., Roberts, A. J., Taylor, D., Sidibe, M., Weir, A. J., Damle, S. G., & Wright, R. L. (2014). An investigation of the effects of a hand washing intervention on health outcomes and school absence using a randomised trial in Indian urban communities. Tropical Medicine & International Health, 19 , 284-292. https://doi.org/10.1111/tmi.12254 Nuraida, L. (2015). A review: Health promoting lactic acid bacteria in traditional Indonesian fermented foods. Food Science and Human Wellness, 4 , 47-55. https://doi.org/10.1016/j.fshw.2015.06.001 Pandejpong, D., Danchaivijitr, S., Vanprapa, N., Pandejpong, T., & Cook, E. F. (2012). Appropriate time-interval application of alcohol hand gel on reducing influenza-like illness among preschool children: A randomized, controlled trial. American Journal of Infection Control, 40 , 507-511. https://doi.org/10.1016/j.ajic.2011.08.020 Potdar, P. A., More, T. A., Wagh, A., Desai, M. M., & Raja. (2019). Impact of hand Washing intervention program on knowledge, attitude and practices about hand hygiene among school children in urban area of Kolhapur city. International Journal of Community Medicine and Public Health, 6, 2955. https://doi.org/10.18203/2394-6040.ijcmph20192832 Priest, P., McKenzie, J. E., Audas, R., Poore, M., Brunton, C., & Reeves, L. (2014). Hand Sanitiser Provision for Reducing Illness Absences in Primary School Children: A Cluster Randomised Trial. PLoS Medicine, 11 , e1001700. https://doi.org/10.1371/journal.pmed.1001700 Randle, J., Metcalfe, J., Webb, H., Luckett, J. C. A., Nerlich, B., Vaughan, N., Segal, J. I., & Hardie, K. R. (2013). Impact of an educational intervention upon the hand hygiene compliance of children. Journal of Hospital Infection, 85 , 220–225. https://doi.org/10.1016/j.jhin.2013.07.013 Rosen, L., Zucker, D., Brody, D., Engelhard, D., Meir, M., & Manor, O. (2011). Enabling Hygienic Behavior among Preschoolers: Improving Environmental Conditions through a Multifaceted Intervention. American Journal of Health Promotion, 25 , 248–256. https://doi.org/10.4278/ajhp.081104-QUAN-265 Sibiya, J. E., & Gumbo, J. R. (2013). Knowledge, Attitude and Practices (KAP) Survey on Water, Sanitation and Hygiene in Selected Schools in Vhembe District, Limpopo, South Africa. International Journal of Environmental Research and Public Health, 10 , 2282–2295. https://doi.org/10.3390/ijerph10062282 Sharifa Nasreen, & Amin, N. (2023). Effects of handwashing with soap on acute respiratory infections in low-resource settings: challenges and ways forward . 401 (10389), 1634–1635. https://doi.org/10.1016/s0140-6736(23)00266-0 Sharma, M. K., Khanal, S. P., Acharya, D., & Acharya, J. (2021). Association between Handwashing Knowledge and Practices among the Students in Nepal. Prithvi Academic Journal, 4, 7–17. https://doi.org/10.3126/paj.v4i0.37005 Solehati, T., Rahmat, A., Kosasih, C. E., & Hidayati, N. O. (2018). The impact of clean lifestyle health promotion on the attitude, motivation, and behaviour of village health cadres. Masyarakat, Kebudayaan Dan Politik, 31, 310. https://doi.org/10.20473/mkp.v31i32018.310-317 Shrestha, A., & Angolkar, M. (2014). Impact of Health Education on the Knowledge and Practice Regarding Personal Hygiene among Primary School Children in Urban Area of Karnataka, India. IOSR Journal of Dental and Medical Sciences, 13(4), 86–89. https://doi.org/10.9790/0853-13478689 Sultana, F., Nizame, F. A., Southern, D. L., Unicomb, L., Winch, P. J., & Luby, S. P. (2017). Pilot of an Elementary School Cough Etiquette Intervention: Acceptability, Feasibility, and Potential for Sustainability. The American journal of tropical medicine and hygiene, 97, 1876–1885. https://doi.org/10.4269/ajtmh.16-0914 Vivas, A. P., B Gelaye, N Aboset, A Kumie, Berhane, Y., & Williams, M. A. (2010). Knowledge, attitudes and practices (KAP) of hygiene among school children in Angolela, Ethiopia. PMID: 21155409 PMCID: PMC3075961 Walker, C. L. F., Rudan, I., Liu, L., Nair, H., Theodoratou, E., Bhutta, Z. A., O’Brien, K. L., Campbell, H., & Black, R. E. (2013). Global burden of childhood pneumonia and diarrhoea. The Lancet, 381 , 1405–1416. https://doi.org/10.1016/S0140-6736(13)60222-6 Wang, C., Pan, J., Yaya, S., Yadav, R. B., & Yao, D. (2019). Geographic Inequalities in Accessing Improved Water and Sanitation Facilities in Nepal. International Journal of Environmental Research and Public Health , 16, 1269. https://doi.org/10.3390/ijerph16071269 Zomer, T. P., Erasmus, V., Vlaar, N., van Beeck, E. F., Tjon-A-Tsien, A., Richardus, J. H., & Voeten, H. A. (2013). A hand hygiene intervention to decrease infections among children attending day care centers: design of a cluster randomized controlled trial. BMC Infectious Diseases , 13(1). https://doi.org/10.1186/1471-2334-13-259 Additional Declarations No competing interests reported. Supplementary Files TrendChecklistHandHygiene.docx Cite Share Download PDF Status: Published Journal Publication published 12 Dec, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 18 Aug, 2025 Editor assigned by journal 14 Aug, 2025 Submission checks completed at journal 14 Aug, 2025 First submitted to journal 12 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7358688","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":500118126,"identity":"be811bf1-6835-4c60-a944-d0b260c24809","order_by":0,"name":"Ferdushi Akhter","email":"data:image/png;base64,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","orcid":"","institution":"Juntendo University","correspondingAuthor":true,"prefix":"","firstName":"Ferdushi","middleName":"","lastName":"Akhter","suffix":""},{"id":500118127,"identity":"b2a25398-3c47-4f04-b209-261e58d4d395","order_by":1,"name":"Shanzida Khatun","email":"","orcid":"","institution":"National Institute of Advanced Nursing Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Shanzida","middleName":"","lastName":"Khatun","suffix":""},{"id":500118128,"identity":"8a29fde3-03fb-4455-a996-2b7b43964ceb","order_by":2,"name":"Happy Bandana Biswas","email":"","orcid":"","institution":"National Institute of Advanced Nursing Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Happy","middleName":"Bandana","lastName":"Biswas","suffix":""}],"badges":[],"createdAt":"2025-08-12 19:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7358688/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7358688/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-25592-x","type":"published","date":"2025-12-12T15:59:41+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":98245349,"identity":"1af98272-f6a7-4d6f-b831-d31bea8b2dc9","added_by":"auto","created_at":"2025-12-15 16:17:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":402009,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7358688/v1/623b7034-443b-43ad-913f-a7c3b6f9bdf7.pdf"},{"id":89067294,"identity":"b035e775-cb8f-4414-893e-284458b56521","added_by":"auto","created_at":"2025-08-14 10:44:56","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":19357,"visible":true,"origin":"","legend":"","description":"","filename":"TrendChecklistHandHygiene.docx","url":"https://assets-eu.researchsquare.com/files/rs-7358688/v1/b192febb5c74e49ed8639c0e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of Hand Hygiene Program Among School Children in Bangladesh","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHand hygiene is generally accepted as the primary preventive measure for the reduction of infectious diseases (Klar et al., 2022). Hand hygiene is the process of cleansing dirt with water in order to suppress or kill bacteria that have built up on the skin of the hands from interaction with the environment, preventing diseases from being transmitted through the hands (Hidayah \u0026amp; Ramadhani, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Around 2.3\u0026nbsp;billion people do not have access to basic sanitation, and 892\u0026nbsp;million people do not have access to indoor sanitation. (Chattopadhyay et al., 2019). According to the World Health Organization (2012), roughly 35% of the world's population lacks basic sanitation, and unclean and poor sanitation conditions cause 7% of global disease burden (Wang et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), which primarily include respiratory and diarrheal illnesses (Mbakaya et al., 2017). In Bangladesh children may not wash their hands for a variety of reasons, including a lack of resources like soap and water and poor sanitary conditions. In addition to having the right tools and facilities, students' attitudes and understanding about cleanliness have a big impact on how they practice it (Sharifa Nasreen \u0026amp; Amin, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Several researches have been carried out to look into the problems with hand washing and overall hygiene in school children. Hand washing, especially after using the restroom, significantly reduces the transmission of parasite illnesses, which are more prevalent among school children in many nations (Lopez-Quintero et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Sharma et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSchool-age is an important period for the formation of clean and healthy living habits in children, who in the future are expected to become agents of change who can encourage healthy living in schools, communities, and the home environment (Nuraida, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). One of the strategic places in promoting health is Educational Institutions. Habits carried out by a child at school will also be carried out at home which is expected to influence the behavior of other family members (Solehati et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). In low- and middle-income countries improvements are essential to promoting children's health. The enormous burden of preventable children\u0026rsquo;s ailments, like intestinal worms and dental cavities, is considerably exacerbated by a shortage of water, restricted access to improved sanitation, and poor personal hygiene at home and at school (Walker et al., 2013; Bethony et al., 2006; Benzian et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Through their negative effects on children's school attendance, educational performance, and production, these hygiene-related ailments contribute to a vicious cycle of poverty and disease (Duijster et al., 2017).\u003c/p\u003e\u003cp\u003ePrevious studies the implementation of hand hygiene interventions has shown that hand hygiene compliance can increase by 34% (Randle et al., 2013). Studies of HH in preschools have been conducted in various countries such as Netherlands (Zomer et al., 2013), Israel (Rosen et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2011\u003c/span\u003e), Thailand (Pandejpong et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2012\u003c/span\u003e), India (Nicholson et al., 2014), New Zealand (Priest et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), Spain (Azor-Martinez et al., 2018) and Iceland (Gudnason et al., 2012) focusing on the reduction of diseases through hand hygiene interventions. These studies have not been conclusive in determining a specific intervention, which will work in all areas and all scenarios, as each study made use of different interventions and measured various outcomes, such as reduction of disease or reduced absenteeism. Many of these interventions included the provision of hand sanitizer or soap or both by the researchers, as part of the intervention (Randle et al., 2013, Zomer et al., 2013, Pandejpong et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2012\u003c/span\u003e, Nicholson et al., 2014, Priest et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Azor-Martinez et al., 2018; Gudnason et al., 2012). Although the studies showed decreases in school absenteeism and hand hygiene-related diseases. However, studies which have shown an increased hand hygiene knowledge, attitude and practice change that resulted in behavior change as well as decreased absenteeism based on interventions which did not incur additional costs after the completion of the intervention (Croghan, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2008\u003c/span\u003e), These interventions made use of health education sessions and interactive learning regarding hand washing and increase hand hygiene knowledge, attitude and practice.\u003c/p\u003e\u003cp\u003eHowever, a weak and complicated budgetary allocation and procurement process in Bangladeshi schools fails to ensure an operating budget for basic supplies, including soap (Ara et al., 2019). A major problem of health issues in our country is unhygienic environment particularly lack of hand washing that leads thorough health hazard of public specially children in the school. School children have not realized that clean living behaviors such as the habit of washing hands in daily life, both in the school environment and in the playground, can improve their health. Children often eat food using unwashed hands. This habit is one of the factors that contribute to the incidence of diarrheal diseases and other infectious diseases. Based on the above phenomenon, the researcher is interested in conducting research will use Glow gel technique to educate and involve children in hand washing intervention. Glow gel glows in ultra violet light and children can visualize bacteria and their location on hands physically. This study will help to improve hand hygiene knowledge, attitude and practice among school going children through health education intervention.\u003c/p\u003e\u003cp\u003eIn Bangladesh, it has been observed that very a smaller number of researches on Hand Hygiene has been done on school going children. Even in nursing sector, there is not so much information about doing research on hand hygiene. In other countries, there is few histories of doing research on hand hygiene. The hand hygiene program of school children in the daily life, both in the school environment and in the playground, can improve their health. Based on the above phenomenon, the authors are interested in conducting hand hygiene program to understand the level of school going children\u0026rsquo;s knowledge, attitude and practice. Therefore, this study aimed to assess knowledge; attitude and practice level can be increased in school going children. That\u0026rsquo;s why researchers think that it is very important to study on Hand Hygiene.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eThe study was conducted among school children at City corporation Adorsho high school. This chapter described the study design, participants, instruments, ethical consideration, data collection methods, and data analysis.\u003c/p\u003e\u003cp\u003eA quasi experimental one group pre and post-test study was used to identify the effect of hand hygiene program among school children in Bangladesh. This study period began from July 2022 to June 2023. This study was carried out on City Corporation Adorsho High School, Dholpur, Dhaka. This school was selected for the research setting because it is located in Dhaka and is considered as the renowned school of the Dhaka city. There was total 1200 students in City Corporation Adorsho High School who were studying in different classes.\u003c/p\u003e\u003cp\u003eThe participants of this study were 5th and 6th grade school children. Sample of this study was school children who were 10 to 12 years old and studied in City Corporation Adorsho High School, Dhaka, Bangladesh. Convenience sampling technique was applied to select the eligible sample for the study. Generally, most of the school children were busy with their schedule class. Therefore, the research works were done to intend to give hand hygiene intervention and collect data from students who were available and willing to participate.\u003c/p\u003e\u003cp\u003eThe sample size of this study was estimated by using G* power analysis software. The sample size was calculated for an accepted minimum significance level (α) 0.05, an expected power of 0.80, and an estimated population effect size of 0.25 as the medium effect size used in the nursing studies. Sample size was (34). In considering 10% attrition the final sample size was (40). The inclusion criteria of the participants were: (1) children between 10 to 12 years old enrolled at city corporation adorsho high school, (2) school attendance for at least 25 hours per week, (3) whose parents and/or guardians was signed an informed consent document.\u003c/p\u003e\u003cp\u003eData was collected by using Structured Self-administered questionnaire. The Instrument consists of five sections. Section I is related to participants Demographic Data Questionnaire (DDQ), Section II is related to Hand Hygiene Knowledge Questionnaire (HHKQ), Section III is related to Hand Hygiene Attitude Questionnaire (HHAQ), Section IV is related to Hand Hygiene Practice Questionnaire (HHPQ). Based on cultural context of our country the instruments were validated by three panel experts that is three PhD faculties of National Institute of Advanced Nursing Education and Research. The instruments are described as below.\u003c/p\u003e\u003cp\u003eDemographic Data Questionnaire (DQ): The Demographic Data Questionnaire of the study was developed by the researcher based on the literature reviewed. It consisted of 12 items including age, religion, class, gender, family size, housing status, fathers\u0026rsquo; education, source of water, type of toilet, nails status, nails length, illness diagnosed.\u003c/p\u003e\u003cp\u003eHand Hygiene Knowledge Questionnaire (HHKQ): Hand Hygiene Knowledge Questionnaire was developed by the researcher based on the literature reviewed. It was used to measure the knowledge of school children regarding hand hygiene. It consisted of 13 items and the response format was 1\u0026thinsp;=\u0026thinsp;yes, 0\u0026thinsp;=\u0026thinsp;no, and 2\u0026thinsp;=\u0026thinsp;don\u0026rsquo;t know. During summing don\u0026rsquo;t know was 0. Therefore, the total score was 0\u0026ndash;13. Higher score indicates higher knowledge regarding hand hygiene.\u003c/p\u003e\u003cp\u003eHand Hygiene Attitude Questionnaire (HHAQ): Hand Hygiene Attitude Questionnaire was developed by the researcher based on the literature reviewed. Hand hygiene attitude of children was assessed by using 16 items 5-point Likert scale strongly disagree\u0026thinsp;=\u0026thinsp;1, Disagree\u0026thinsp;=\u0026thinsp;2, Neutral\u0026thinsp;=\u0026thinsp;3, Agree\u0026thinsp;=\u0026thinsp;4, strongly agree\u0026thinsp;=\u0026thinsp;5. The total score was 16\u0026ndash;80. Higher score indicates higher attitude regarding hand hygiene.\u003c/p\u003e\u003cp\u003eHand Hygiene Practice Questionnaire (HHPQ): Hand Hygiene Practice Questionnaire was developed by the researcher based on the literature reviewed. Hand hygiene practice of children was assessed by using 14 items 3-point Likert scale Never\u0026thinsp;=\u0026thinsp;0, Sometimes\u0026thinsp;=\u0026thinsp;1and always\u0026thinsp;=\u0026thinsp;2.The total score was 14\u0026ndash;28. Higher score indicates that good hand hygiene practice among school children.\u003c/p\u003e\u003cp\u003eThe original version of the instruments was developed in the English language. After that the English version instruments were translated into the Bengali language. The method of translation was the back translation technique (Brislin, 1970). It is a translation process which ensures accuracy and the culturally equivalence of the instruments when translated to another language (Brislin). Three bilingual translators who were fluent in both English and Bengali translated the instruments (e.g., they were Nursing faculty and one English editor). The process of back translation was conducted as follows.\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe first bilingual translator translated the English version of instruments into the Bengali language.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe second bilingual translator back translated the instruments from the Bengali versions into the English language.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe third bilingual translator clarified and identified the differences in all items of two English versions.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eAfter completing the back translation process, the researcher reviewed and compared both English versions. The researcher analyzed each item in details and revised based on the two translations. Then, the researcher modified the words of the instruments as needed in order to establish the same meaning within acceptable limits.\u003c/p\u003e\u003cp\u003e This study was approved by the Institutional of Review Board, National Institute of Advanced Nursing Education and Research and Bangabandhu Sheikh Mujib Medical University. All school children were received sufficient information about the purpose of the study, the methods and the instruments used for collecting data, and how their rights will be protected. Before using the informed consent from (Appendix B) the researcher was explained the process of data collection to the participants and assured them that the information they were give that would be keep private and confidential. The confidentiality of subject\u0026rsquo;s responses was assured throughout the study by using sample coding and the assurance that was used for research purposes only. However, the participants were assured that they have the right to refuse to participate in the study at any time.\u003c/p\u003e\u003cp\u003eData collection process consists of two phases including the preparation phase and implementation phase. In the preparation phase, researcher completed the following procedures: Approval of the research proposal was given by the Institutional Review Board at National Institute of Advanced Nursing Education and Research, Bangabandhu Sheikh Mujib Medical University. The researcher was taking permission from authority of City Corporation Adorsho High School in Dholpur, Dhaka, Bangladesh through written order issue by the Director of NIANER. During Data collection phase, the researcher explained the study objectives, benefits, confidentiality and methods or process of data collection to the authority and study participants. All participants are ensured that their participation would be voluntary.\u003c/p\u003e\u003cp\u003eIn the implementation phase, data was collected by using Demographic questionnaire, Hand Hygiene Knowledge Questionnaire, Hand Hygiene Attitude Questionnaire, Hand Hygiene Practice Questionnaire from January 2023 to February 2023. Data collection and Hand hygiene program was conducted by the researcher with the help of the respective school teacher. Before collecting data, the researcher approached the children who was meet the inclusion criteria and introduced themselves.\u003c/p\u003e\u003cp\u003eThe day before baseline data collection, the researcher was communicating with students over telephone to come to city corporation Adorsho high school. On the day of pre-test, the researcher was explained study purpose, benefit and ethical consideration of the study. The researcher was informed the participants regarding signing the consent form. The participants were informed by the researcher that they have full right to withdraw from this study at any time without any obligation. All participants\u0026rsquo; confidentiality and anonymity were strictly maintained with code numbers. Participants were also informed that the findings of the study were submitted to a scientific journal for publication and presentation at conferences, code sheets were secured in a locked file up to five years and the data was accessible only to the researcher, all necessary information collected from the participants was kept confidential. After obtaining verbal permission from the participants, researcher was collecting written consent from the participating students. The researcher explained the questionnaire to the participants. Each student was be given a code number and were divided into five groups (A-D) based on the age of them. Each group was consisting of ten members. The participants were instructed to answer the questionnaires spontaneously within 20\u0026ndash;30 minutes. The pretest was done through structured questionnaires by the researcher. After that, the researcher was checked that the questionnaires would be completed. After the researcher performed three days face \u0026ndash;to-face group session of hand hygiene education intervention, post \u0026ndash;test data was obtained from participants after two weeks of intervention by the same researcher. Collected data was monitored and checked for completeness and consistency during data collection and at the end of each day.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eHand Hygiene Program\u003c/h2\u003e\u003cp\u003e Hand Hygiene program modules were developed based on World Health Organization Hand washing technique guidelines. The module was designed over three sessions (40 minutes/session). The content validity of the hand hygiene education intervention module was tested at expert faculties from Child Health Nursing department of National Institute of Advanced Nursing Education and Research. The module was prepared in English and translated by three bilingual experts according to translation process.\u003c/p\u003e\u003cp\u003eHand hygiene program was conducted for two weeks, commencing the day after baseline data collection. All sessions were face to face group session and were conducted at the school children\u0026rsquo;s convenience time at City Corporation Adorsho High School dividing the participants into five groups: (A-D), each group consisting ten members. The day before intervention, the researcher was invited with school children via class teacher or over telephone to come to school health center (City Corporation Adorsho High School) according to group. Group A-D was instructed to come sequentially. Total three sessions were consecutively provided to each participant/group. One group was participated in one session daily. All sessions were face to face group session and were conducted at the participant\u0026rsquo;s convenience time in local language Bangla. Initially, the researchers were introduced themselves and participants were informing about the purpose and procedures of the intervention. After obtaining verbal permission from the participants, the researchers were implemented hand hygiene intervention program. The hand hygiene intervention was conducted using theoretical session, discussion, and poster, and leaflet, video and practical demonstration.\u003c/p\u003e\u003c/div\u003e"},{"header":"Result","content":"\u003cp\u003eAfter completion of data collection, raw data was entered in the data sheet against each question. Then the data was checked, verified and edited for consistency to minimize error. The statistical analysis was performed by using IBM SPSS (Version 23.0). Both descriptive and inferential statistics was used to analysis the data. The demographic characteristics of children were measured by the descriptive statistics such as frequency, percentage, mean, standard deviation. Hand hygiene knowledge, attitude and practice was measured using descriptive frequency. Inferential statistics such as Paired t-test was used to compare hand hygiene knowledge, attitude and practice score of students both before and after intervention. Independent sample t test, Pearson product correlation and one way ANOVA was used to test homogeneity for socio-demographic characteristics of students. Finally, the result was summarized using frequency, mean, standard deviation and percentage.\u003c/p\u003e\u003cp\u003eThe findings of this study are presented under the following headings of subject\u0026rsquo;s characteristics. The result is represented by descriptive and inferential statistics as frequency, percentage, mean, standard deviation, correlation, t-test and ANOVA.\u003c/p\u003e\u003cp\u003eThe average age of the respondents was 11.62 years. About 80% of the respondent lived in nuclear family and 20% of the respondent lived in joint family. In this study about 65% of the respondent\u0026rsquo;s housing status was Building and 35% was shed and semi building. The most of the respondent\u0026rsquo;s fathers and mothers\u0026rsquo; education level was secondary and above (60% and 50%) respectively. The majority of the participants (77.50%) were using tape well water and 80% of them using sanitary latrine. About 52.50% participants had grown nails and 47.50% had trimmed nails. The 60% of the participants had dirty nails and 40% of the participants had clean nails.\u003c/p\u003e\u003cp\u003eHand hygiene knowledge level of school children\u0026rsquo;s (n\u0026thinsp;=\u0026thinsp;40) before and after intervention. The mean knowledge score of school children before and after intervention was 14.70\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0 \u0026amp; 22.35\u0026thinsp;\u0026plusmn;\u0026thinsp;4.26 respectively. Result shows, in the baseline data, only (20%) children know about the item I knows properly how to wash hands with soap. About 65% children answered No the item of unclean hands are a way of spreading diseases. The 55% of the participants knows about the item if I fail to wash my hands, I cannot be affected with diseases. Only 20% of the children knows the correct technique of hand washing. The majority (67.5%) of the participants answered \u0026ldquo;No\u0026rdquo; for the item of must wash hands before sneezing and coughing. Only 25% of the respondent answered \u0026ldquo;Yes\u0026rdquo; for the item of Bacteria may spread from hands to the nose and mouth. Almost 62.5% of the participants answered \u0026ldquo;yes\u0026rdquo; for the item of To Prevent Corona virus, hand should be cleaned with soap. After intervention, almost (97.5%) participants answered \u0026ldquo;Yes\u0026rdquo; for the item I knows properly how to wash hands with soap. The majority 92.5% of the respondent answered \u0026ldquo;Yes\u0026rsquo;\u0026rsquo; for the item Unclean hands are a way of spreading diseases. About (50%) answered \u0026ldquo;No\u0026rdquo; for the item if I fail to wash my hands, I cannot be affected with diseases. Majority (90%) of the children\u0026rsquo;s answered for the item I know the correct techniques of how to wash hands. Almost 90% of the children\u0026rsquo;s answered \u0026ldquo;Yes\u0026rdquo; for the item of must wash hands before sneezing and coughing and Bacteria may spread from hands to the nose and mouth. Most of the children\u0026rsquo;s (87.5) answered \u0026ldquo;yes\u0026rdquo; for the item To Prevent Corona virus, hand should be cleaned with soap.\u003c/p\u003e\u003cp\u003ehand hygiene attitude of school children\u0026rsquo;s before and after hand hygiene intervention. The total item was 16. Before intervention, 40% of school children were strongly agreed with the statement \u0026ldquo;I believe that dirty hands cannot make illness\u0026rdquo;. Majority of children\u0026rsquo;s 62.5% agreed on \u0026ldquo;I believe that I should wash my hands when they become dirty\u0026rdquo;. About 35% children\u0026rsquo;s believe that on \u0026ldquo;I believe that I should Wash my hands before touching my foods\u0026rdquo; Majority of children\u0026rsquo;s (52.5%) strongly agreed on \u0026ldquo;I don\u0026rsquo;t think that while helping other\u0026rsquo;s cooking in home, I need to wash my hand\u0026rdquo;. About 42.5% of the respondents were disagreed on the statement of \u0026ldquo;I believe that I should Wash My Hands, when I visited someone in the hospital\u0026rdquo;. Only 2.5% of children were strongly agreed on \u0026ldquo;I believe that I should Wash My Hands after sniffing or blowing the nose\u0026rdquo;. About 47.5% children were disagreed on \u0026ldquo;I believe I should cover my nose by elbow while sneezing\u0026rdquo;. Majority of children\u0026rsquo;s (42.5%) were strongly agreed on \u0026ldquo;I don\u0026rsquo;t believe that every step of washing hand is important. Majority of the children\u0026rsquo;s (45%) were strongly disagreed on \u0026ldquo;I don\u0026rsquo;t think that washing hands with only water can reduce germs\u0026rdquo;. \u0026ldquo;Only 2.5% of the respondents strongly agreed on \u0026ldquo;I can wash my hands with soap and water properly\u0026rdquo;. Majority of the children were strongly agreed on \u0026ldquo;I don't believe that humans have germs on their hands.\u003c/p\u003e\u003cp\u003eAfter intervention 45% of school children were strongly disagreed with the statement \u0026ldquo;I believe that dirty hands cannot make illness\u0026rdquo;. Majority of children\u0026rsquo;s 65% agreed on \u0026ldquo;I believe that I should wash my hands when they become dirty\u0026rdquo;. Majority 47.5% children believe that on \u0026ldquo;I believe that I should Wash my hands before touching my foods\u0026rdquo;. Only (7.5%) strongly agreed on \u0026ldquo;I don\u0026rsquo;t think that while helping other\u0026rsquo;s cooking in home, I need to wash my hand\u0026rdquo;. About 37.5% of the respondents were agreed on the statement of \u0026ldquo;I believe that I should Wash My Hands, when I visited someone in the hospital\u0026rdquo;. Majority of the children\u0026rsquo;s (65%) were agreed on \u0026ldquo;I believe that I should Wash My Hands after sniffing or blowing the nose\u0026rdquo;. About 55% children were agreed on \u0026ldquo;I believe I should cover my nose by elbow while sneezing\u0026rdquo;. Majority of children\u0026rsquo;s (60%) were strongly disagreed on \u0026ldquo;I don\u0026rsquo;t believe that every step of washing hand is important. Only (7.5%) children were strongly disagreed on \u0026ldquo;I don\u0026rsquo;t think that washing hands with only water can reduce germs\u0026rdquo;. Majority of the respondents (57.5) were strongly agreed on \u0026ldquo;I can wash my hands with soap and water properly\u0026rdquo;. About 55% of children were strongly disagreed on \u0026ldquo;I don't believe that humans have germs on their hands.\u003c/p\u003e\u003cp\u003ehand hygiene practice of school children\u0026rsquo;s before and after hand hygiene intervention. The total item was 14. Before intervention, only 10% of the children were answered \u0026ldquo;always\u0026rdquo; for the item of I use soap while washing hands in school before eating tiffin. Majority 87.5% of the participants were answered for the item of I use soap to wash hands after toilet. Only 15% of the respondent answered \u0026ldquo;always\u0026rdquo; for the item of I wash my hands with soap before preparing food. Majority 65% of the participants answered \u0026ldquo;Never\u0026rdquo; for the item of I wash my hands 30 seconds to 1 minute at a time. Mostly 62.5% of the children are answered \u0026ldquo;Always\u0026rdquo; for the item of I don\u0026rsquo;t wash my hands in school because soap is not available. Only 20% of the children\u0026rsquo;s answered \u0026ldquo;Always\u0026rdquo; for the item of I wash my hands with soap before meal. About 55% of the respondent answered \u0026ldquo;Never\u0026rdquo; for the item of I Wash my Hands after touching any animals. Only 20% of the children were answered for the item of I wash my hands after sneezing or coughing. Majority 55% of the respondents were answered \u0026ldquo;Sometimes\u0026rdquo; for the item of I keep my nails shorter and clean. Majority 62.5% of the respondents were answered \u0026ldquo;Never\u0026rdquo; for the item when soap and water are not available, I use alcohol spray or hand sanitizer.\u003c/p\u003e\u003cp\u003eAfter intervention, about 52.5% of the children were answered \u0026ldquo;always\u0026rdquo; for the item of I use soap while washing hands in school before eating tiffin. Mostly 87.5% of the participants were answered for the item of I use soap to wash hands after toilet. Majority 70% of the respondent answered \u0026ldquo;always\u0026rdquo; for the item of I wash my hands with soap before preparing food. Mostly 90% of the participants answered \u0026ldquo;Always\u0026rdquo; for the item of I wash my hands 30 seconds to 1 minute at a time. About 37.5% of the children are answered \u0026ldquo;Always\u0026rdquo; for the item of I don\u0026rsquo;t wash my hands in school because soap is not available. Only 75% of the children\u0026rsquo;s answered \u0026ldquo;Always\u0026rdquo; for the item of I wash my hands with soap before meal. Only 15% of the respondent answered \u0026ldquo;Never\u0026rdquo; for the item of I Wash my Hands after touching any animals. Mostly 82.5% of the children were answered \u0026ldquo;Always\u0026rdquo; for the item of I wash my hands after sneezing or coughing. About 35% of the respondents were answered \u0026ldquo;Sometimes\u0026rdquo; for the item of I keep my nails shorter and clean. Only 10% of the respondents were answered \u0026ldquo;Never\u0026rdquo; for the item when soap and water are not available, I use alcohol spray or hand sanitizer.\u003c/p\u003e\u003cp\u003erepresents the relationship between demographic characteristics of school children. There was no significant difference among variable except religion, housing status, domestic source of water, nails length and status. Table shows religion of the children\u0026rsquo;s was significantly related with the children\u0026rsquo;s practice (t\u0026thinsp;=\u0026thinsp;2.063, P\u0026thinsp;=\u0026thinsp;.05), Children\u0026rsquo;s practice was significantly related with housing status (F\u0026thinsp;=\u0026thinsp;2.105, P\u0026thinsp;=\u0026thinsp;.042), Children\u0026rsquo;s knowledge was significantly related with domestic source of water (F\u0026thinsp;=\u0026thinsp;2.29, P\u0026thinsp;=\u0026thinsp;.027), children\u0026rsquo;s attitude was significantly related with nails length (t\u0026thinsp;=\u0026thinsp;2.090, P\u0026thinsp;=\u0026thinsp;.043) and children\u0026rsquo;s practice was significantly related with nails status(t\u0026thinsp;=\u0026thinsp;3.273, P\u0026thinsp;=\u0026thinsp;.003)\u003c/p\u003e\u003cp\u003eThe differences between pre and posttest knowledge, attitude \u0026amp; practice scores of children\u0026rsquo;s. the mean pre-test knowledge, attitude \u0026amp; practice score of children\u0026rsquo;s was 14.70\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0, 50.65\u0026thinsp;\u0026plusmn;\u0026thinsp;8.15 ,17.00\u0026thinsp;\u0026plusmn;\u0026thinsp;5.22 and post-test knowledge, attitude \u0026amp; practice score of children\u0026rsquo;s was 22.35\u0026thinsp;\u0026plusmn;\u0026thinsp;4.26, 56.60\u0026thinsp;\u0026plusmn;\u0026thinsp;5.35, 23.33\u0026thinsp;\u0026plusmn;\u0026thinsp;3.63 respectively. The mean difference of knowledge attitude \u0026amp; practice was \u0026minus;\u0026thinsp;5.35\u0026thinsp;\u0026plusmn;\u0026thinsp;6.04, -5.95\u0026thinsp;\u0026plusmn;\u0026thinsp;9.80, -8.62\u0026thinsp;\u0026plusmn;\u0026thinsp;6.59 respectively which is indicates significant difference between pre and post-test score. In matched paired t-test analysis, it was found that there was a significant mean difference between pre and post-test knowledge, attitude \u0026amp; practice among children\u0026rsquo;s (t= -5.605, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), (t=-3.839, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), (t=-8.273, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Therefore, children\u0026rsquo;s knowledge, attitude \u0026amp; practice level statistically significantly increased after two weeks hand hygiene intervention. The hand hygiene program was significantly effective to increase knowledge, attitude \u0026amp; practice among school children\u0026rsquo;s\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eThe findings of the study showed that the average age of the children was about 11 years. Based on the result, this finding is in agreement with the previous study (Eshetu et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The finding is incongruent with the (Sultana et al., 2022,).\u003c/p\u003e\u003cp\u003eThe study findings revealed that the hand hygiene knowledge of children increased at the end of intervention. Hand hygiene knowledge increased from 17.00 to 22.35 after intervention. It is possible that the significant change in children\u0026rsquo;s knowledge could have been ascribed to the hand hygiene education message provided. Hand hygiene program improved children\u0026rsquo;s knowledge regarding properly how to wash hands with soap, unclean hands are a way of spreading disease, important of wash hands with soap water to prevent disease. This finding is consistent with previous several studies (Potdar, P. A., More, T. A., Wagh, A., Desai, M. M., \u0026amp; Raja. (2019). knowledge regarding use of soap for hand washing showed improvement from 70\u0026ndash;85% after the active health education program. Similar results were found in research done by Grag which showed improvement from 81.1\u0026ndash;99.3% in their study (Garg et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). In this study knowledge regarding hand washing after visiting toilets to remove germs increased from 85\u0026ndash;95% with the effective hand hygiene program and another study conducted by shrestha showed similar improvement from 55.2\u0026ndash;89.6% (Shrestha \u0026amp; Angolkar, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Similar observation was given by Damayanthi where they showed improvement in knowledge from 77.3\u0026ndash;94.6%. in this study revealed that only 20% of students knew correct hand washing technique before intervention which improved to 90% afterwards which is similar results were found in research done by potadar which showed improvement from 7.5\u0026ndash;33.12% in their study (Potdar, P. A., More, T. A., Wagh, A., Desai, M. M., \u0026amp; Raja. (2019). The study done by Garg noted higher level of knowledge compared to their study participants I e. 32.4% knew the correct technique which was raised to 68% with significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Garg, Taneja, Badhan, \u0026amp; Ingle, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) that is similar in this current study and shows the statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).Findings of this study indicate that attitude of children towards hand hygiene increased significantly after hand hygiene education intervention. The attitude level of children on hand hygiene was increased significantly from 50.65 to 56.60. In other words, the hand hygiene education gave a positive effect to the children\u0026rsquo;s attitude in the effort to provide good hand hygiene practice. This shows that there is a tendency to change attitudes in a positive direction. This was achieved through the use of posters to display the benefits of appropriate hand hygiene practice. It was stated that people will not have change in behavior unless they see the benefits (USAID, 2011). This shows that change in attitude among the children in the intervention group was based on the information receiving during the hand hygiene education. This finding was almost comparable with the studies conducted in other parts of Ethiopia: 59.4% in Hosanna (Vivas et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) and 61.7% in northern Ethiopia (Assefa \u0026amp; Kumie, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). However, it was lower than one conducted in south Africa, (Sibiya \u0026amp; Gumbo, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) in which 91.4% of school children had positive attitudes towards hand washing. A large number of students from different schools in South Africa participated, while children from a single school were included in the current study, and this might be a good reason for the variation.\u003c/p\u003e\u003cp\u003eThe study indicates that hand hygiene practice level of children increased significantly after two weeks hand hygiene education intervention. The score of children\u0026rsquo;s practicing appropriate hand washing technique was improved from 14.70 to 23.33 at the end of the study. This illustrates that a hand hygiene education intervention is able to improve hand washing practice of children\u0026rsquo;s. Regarded barriers of hand washing at school and home, the present study revealed that there were barriers of washing hands at schools before and after the program implementation. McDonald, Cunningham et al., supported these findings that show that one of most important barriers of hand washing in schools is lack of soap, since schools have neither soap nor proper hand washing facilities.\u003c/p\u003e\u003cp\u003eThis could be possible for increased knowledge \u0026amp; positive attitude during hand hygiene education intervention. The similar findings were given by shrestha which showed improvement from 41.43\u0026ndash;60.87% (Shrestha \u0026amp; Angolkar, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe significant improvement of knowledge attitude and practice of hand hygiene program increasing hand hygiene intervention program of school children\u0026rsquo;s. The improvement might also be explained by the improvement of children\u0026rsquo;s hand washing knowledge during hand hygiene education intervention. This suggests that hand hygiene education intervention had the power to change the existing poor hand hygiene knowledge and attitude, simultaneously improving hand washing practice of school children\u0026rsquo;s.\u003c/p\u003e\u003cp\u003eThere were some limitations of present study. Firstly, the study design was quasi experiment; secondly, study used only one setting which did not reflect generalization of the findings to other settings; and finally, the instruments of the study were developed based on the literature reviewed.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eA quasi experiment one group pretest post-test study carried out from July 2022 to June 2023 at City Corporation Adorsho High School, Dhaka, Bangladesh. The objective of the study was to examine the effect of hand hygiene program among school children in Bangladesh. Total 40 number of children participated to the study. Hand hygiene education intervention given for two weeks. Hand hygiene education intervention significantly improved hand hygiene knowledge, attitude and practice of school children\u0026rsquo;s. This illustrates that a hand hygiene education intervention is able to improve hand washing practice of school children\u0026rsquo;s.\u003c/p\u003e\n\u003ch3\u003eRecommendations\u003c/h3\u003e\n\u003cp\u003eBased on the limitation of the study following recommendations are suggested-\u003c/p\u003e\u003cp\u003eCurriculum should be revised taking the hand hygiene into consideration for good health of the school children. The training of teachers and parents, their motivation, both are needed for their role in improving hand washing practice. Further studies are needed to understand how hand hygiene is practiced at home and in school while relating this practice to infectious disease transmission and risk factors. Furthermore, extensive controlled studies are required to address other potential factors that contribute to knowledge, attitudes and practices of hand hygiene.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Statement\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Ethical approval for this study was obtained from the Ethical Review Committee of National Institute of Advanced Nursing Education and Research, Dhaka, Bangladesh (Approval No: IRB No Expo NIA-S-172. Informed consent was obtained from all participants and, where applicable, their guardians. Participation was voluntary, and confidentiality was maintained throughout the study.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eConflict of Interests\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe author declares no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAra, L., Trisha, M. D., Haque Tamal, Md. E., Siddiquee, N. K. A., Mowla, S. N., Hossain, F., Rahman, T., Alam Sarker, Md. S., \u0026amp; Haque Alam, Md. N. (2019). Implementation of a Multimodal Multicentre Hand Hygiene Study: Evidence From Bangladesh Hospitals. Global Journal of Health Science, 11(11), 73. \u0026nbsp;https://doi.org/10.5539/gjhs.v11n11p73\u003c/li\u003e\n \u003cli\u003eAssefa, M., \u0026amp; Kumie, A. (2014). Assessment of factors influencing hygiene behaviour among school children in Mereb-Leke District, Northern Ethiopia: a cross-sectional study. \u003cem\u003eBMC Public Health\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(1). https://doi.org/10.1186/1471-2458-14-1000 \u0026nbsp; \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAzor-Martinez, E., Yui-Hifume, R., Mu\u0026ntilde;oz-Vico, F. J., Jimenez-Noguera, E., Strizzi, J. M., Martinez-Martinez, I., Garcia-Fernandez, L., Seijas-Vazquez, M. L., Torres-Alegre, P., Fern\u0026aacute;ndez-Campos, M. A., \u0026amp; Gimenez-Sanchez, F. (2018). 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(2012). Appropriate time-interval application of alcohol hand gel on reducing influenza-like illness among preschool children: A randomized, controlled trial. \u003cem\u003eAmerican Journal of Infection Control, 40\u003c/em\u003e, 507-511. https://doi.org/10.1016/j.ajic.2011.08.020 \u0026nbsp;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePotdar, P. A., More, T. A., Wagh, A., Desai, M. M., \u0026amp; Raja. (2019). Impact of hand Washing intervention program on knowledge, attitude and practices about hand hygiene among school children in urban area of Kolhapur city. \u003cem\u003eInternational Journal of Community Medicine and Public Health, 6,\u0026nbsp;\u003c/em\u003e2955. https://doi.org/10.18203/2394-6040.ijcmph20192832\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePriest, P., McKenzie, J. E., Audas, R., Poore, M., Brunton, C., \u0026amp; Reeves, L. (2014). 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(2023). \u003cem\u003eEffects of handwashing with soap on acute respiratory\u0026nbsp;\u003c/em\u003e\u003cem\u003einfections in low-resource settings: challenges and ways forward\u003c/em\u003e. \u003cem\u003e401\u003c/em\u003e(10389), 1634\u0026ndash;1635. https://doi.org/10.1016/s0140-6736(23)00266-0\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSharma, M. K., Khanal, S. P., Acharya, D., \u0026amp; Acharya, J. (2021). Association between Handwashing Knowledge and Practices among the Students in Nepal. Prithvi Academic Journal, 4, 7\u0026ndash;17. https://doi.org/10.3126/paj.v4i0.37005\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSolehati, T., Rahmat, A., Kosasih, C. E., \u0026amp; Hidayati, N. O. (2018). 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Pilot of an Elementary School Cough Etiquette Intervention: Acceptability, Feasibility, and Potential for Sustainability. \u003cem\u003eThe American journal of tropical medicine and hygiene, 97,\u003c/em\u003e 1876\u0026ndash;1885. https://doi.org/10.4269/ajtmh.16-0914 \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eVivas, A. P., B Gelaye, N Aboset, A Kumie, Berhane, Y., \u0026amp; Williams, M. A. (2010). Knowledge, attitudes and practices (KAP) of hygiene among school children in Angolela, Ethiopia. PMID: 21155409 PMCID: PMC3075961\u003c/li\u003e\n \u003cli\u003eWalker, C. L. F., Rudan, I., Liu, L., Nair, H., Theodoratou, E., Bhutta, Z. A., O\u0026rsquo;Brien, K. L., Campbell, H., \u0026amp; Black, R. E. (2013). Global burden of childhood pneumonia and diarrhoea. \u003cem\u003eThe Lancet, 381\u003c/em\u003e, 1405\u0026ndash;1416. https://doi.org/10.1016/S0140-6736(13)60222-6 \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWang, C., Pan, J., Yaya, S., Yadav, R. B., \u0026amp; Yao, D. (2019). Geographic Inequalities in Accessing Improved Water and Sanitation Facilities in Nepal. \u003cem\u003eInternational Journal of Environmental Research and Public Health\u003c/em\u003e, \u003cem\u003e16,\u003c/em\u003e 1269. https://doi.org/10.3390/ijerph16071269 \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eZomer, T. P., Erasmus, V., Vlaar, N., van Beeck, E. F., Tjon-A-Tsien, A., Richardus, J. \u003cstrong\u003e\u003c/strong\u003eH., \u0026amp; Voeten, H. A. (2013). A hand hygiene intervention to decrease infections among children attending day care centers: design of a cluster randomized controlled trial. \u003cem\u003eBMC Infectious Diseases\u003c/em\u003e, 13(1). https://doi.org/10.1186/1471-2334-13-259 \u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hand Hygiene, School Children, Knowledge, Attitude, Practice, Bangladesh","lastPublishedDoi":"10.21203/rs.3.rs-7358688/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7358688/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e School children are silent carrier and higher risk to acquire infectious diseases. Good hand hygiene can be an effective preventive measure to protect transmissions of infections. This study was aim to examine the effect of hand hygiene program among school aged children at city corporation Adarsha high school in Dhaka, Bangladesh.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign and Methods:\u003c/strong\u003e A quasi experimental one group pre-test post-test study was conducted among 40 students conveniently. Hand hygiene education intervention was given for two weeks. This study was guided by the KAP survey model which is influence behavior change begins with knowledge, shapes attitude and results in improved practice. Data were collected by using structured self-administered questionnaires including (1) Demographic Questionnaire, (2) Hand Hygiene Knowledge Questionnaire, (3) Hand Hygiene Attitude Questionnaire, and (4) Hand Hygiene Practice Questionnaire. Data were analyzed using both descriptive statistics and inferential statistics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The results of the present study showed that the average age of school students was 11.62±1.44 years. There was a statistically significant mean difference between pre- and post-test scores of knowledges (t=-5.605, p\u0026lt;.001), attitude (t=-3.839, p=\u0026lt;.001) and practice (t=-8.273, p=\u0026lt;.001) of hand hygiene among school children’s.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The findings of this study provide baseline information to the policymaker to implement hand hygiene program using KAP model effective for school students. Further intervention study is needed on diverse setting and population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for Practice: \u003c/strong\u003eIn order to improve hand hygiene knowledge, attitude and practice among school children can be integrating in school curriculum play an effective role in preventing the spread of infectious disease. Nurse and Health educators can get the guideline for developing school-based hygiene promotion intervention particularly in Low middle income countries.\u003c/p\u003e","manuscriptTitle":"Effect of Hand Hygiene Program Among School Children in Bangladesh","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-14 10:11:17","doi":"10.21203/rs.3.rs-7358688/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-18T13:01:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-15T02:54:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-15T02:53:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-08-12T19:02:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"52d15a19-600f-49cd-8ca0-3d288d9d7876","owner":[],"postedDate":"August 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T16:14:54+00:00","versionOfRecord":{"articleIdentity":"rs-7358688","link":"https://doi.org/10.1186/s12889-025-25592-x","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-12-12 15:59:41","publishedOnDateReadable":"December 12th, 2025"},"versionCreatedAt":"2025-08-14 10:11:17","video":"","vorDoi":"10.1186/s12889-025-25592-x","vorDoiUrl":"https://doi.org/10.1186/s12889-025-25592-x","workflowStages":[]},"version":"v1","identity":"rs-7358688","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7358688","identity":"rs-7358688","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}