Diarrheal and respiratory diseases cause 3.5 million deaths annually among children in the developing world.1 Reduced rates of these diseases have been measured during intensive, home-based handwashing interventions.2 Effecting behavior change is often

1
Effect of a Hand Washing Promotion Program in
Chinese Primary Schools
A. Bowen MD MPH1,2 H. Ma BS3 J. Ou MD4 W.
Billhimer MS5 T. Long PhD5 M. Zeng MS6 E. Wang
MS7 J. Painter DVM MS1 E. Mintz MD MPH1 R.M.
Hoekstra PhD1 S. Luby MD1,8 1National Center for
Infectious Diseases, Centers for Disease Control
Prevention, Atlanta, GA 2 Office of Workforce
Career Development, Centers for Disease Control
Prevention, Atlanta, GA 3 China Centers for
Disease Control Prevention, Beijing, China 4
Fujian Provincial Center for Disease Control
Prevention, Fuzhou, China 5 Procter Gamble
Company, Cincinnati, OH 6 Procter Gamble
Company, Guangzhou, China 7 Procter Gamble
Company, Beijing, China 8 ICDDRBCenter for
Health Population Research, Dhaka, Bangladesh
INTRODUCTION
OBJECTIVE
RESULTS
Diarrheal and respiratory diseases cause 3.5
million deaths annually among children in the
developing world.1 Reduced rates of these
diseases have been measured during intensive,
home-based handwashing interventions.2 Effecting
behavior change is often expensive,
time-consuming, and may be only temporary or not
retained. We evaluated a school-based
handwashing program for elementary students to
determine whether a more scalable intervention
could reduce illness rates and absenteeism. The
program has been in use since 1995 and has
reached more than 80 million Chinese first-grade
students.
This study evaluated the impact of a
school-based hand washing intervention program on
the knowledge and attitudes of first-grade
students toward hand washing. The impact of soap
and this program on the reduction of acute
respiratory illness and diarrheal disease
symptoms as well as infectious disease-related
school absence among these children and their
teachers was also assessed along with changes in
hand washing frequency.
Participation There were 52,369 student-weeks of
observation. Results Wilcoxon ranked sums
tests were performed on school-based means. Both
interventions reduced illness rates compared to
the control group (Fig. 1). Fig. 1 Illness rates
observed. Both interventions reduced
the incidence of absence from school relative to
the control group (Fig. 2).

Fig. 2 Incidence of absence from
school The duration of absence due
to illness was reduced by both interventions
(Fig. 3). Fig. 3 School absence prevalence
rates Only the Expanded Intervention
yielded significant benefit relative to the
control group in all parameters measured.
Fujian Province
CONCLUSIONS

• Provision of a hand washing promotion program and
  soap significantly reduces the rates of illness
  and absence, as well as duration of absence among
  1st grade students. While the program alone
  without additional soap did yield less illness
  and school absence, the benefit was not
  statistically significant. These benefits
  continued in both intervention groups for 4
  months after introducing the simple hand washing
  program.
• If soap is concomitantly available, a simple,
  scalable school-based hand washing program could
  improve the health and lives of children
  worldwide.
• References
• World Health Organization. World Health Report
  2005 make every mother and child count. Geneva
  World Health Organization, 2005190-91.
• Luby SP, Agboatwalla M, Freikin DR, Painter J,
  Billhimer W, Altaf A, Hoekstra RM. Effect of
  handwashing on child health a randomised
  controlled trial. Lancet 2005 366225-233.

METHODS
Setting 30 schools from each of 3 counties in
Fujian Province, China. This largely rural
region consists of nearly 35 million people and
is approximately 64 agrarian and light
industry. Groups The schools were randomly
assigned to the following groups Control group
No hygiene intervention beyond normal routine
hygiene training, Standard intervention a
corporate sponsored hygiene promotion
program, Expanded intervention a corporate
sponsored hygiene promotion program
antibacterial soap for school sinks a peer
hygiene monitor for each class.
Intervention The corporate sponsored hygiene
promotion program consists of 1 hour of
instruction conducted by hygiene trained teachers
during the first month of the 1st grade and 1
antibacterial soap take-home kit per pupil. It
combines classroom education, posters, games and
take-home activities directed to proper
handwashing with soap, tooth-brushing, and
cleaning the childrens workspace and
home. Measurements Teachers collected illness
symptom information from students weekly and
recorded student absences daily between January
and April, 2005. Mean illness and absence rates
were calculated for each school.
This work was funded by PG Beauty