Volume 76, Issue 6
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645


Intensive handwashing promotion can reduce diarrheal and respiratory disease incidence. To determine whether less intensive, more scalable interventions can improve health, we evaluated a school-based handwashing program. We randomized 87 Chinese schools to usual practices: standard intervention (handwashing program) or expanded intervention (handwashing program, soap for school sinks, and peer hygiene monitors). We compared student absence rates, adjusting for cluster design. In control schools, children experienced a median 2.0 episodes (median 2.6 days) of absence per 100 student-weeks. In standard intervention schools, there were a median 1.2 episodes ( = 0.08) and 1.9 days ( = 0.14) of absence per 100 student-weeks. Children in expanded intervention schools experienced a median 1.2 episodes ( = 0.03) and 1.2 days ( = 0.03) of absence per 100 student-weeks. Provision of a large-scale handwashing promotion program and soap was associated with significantly reduced absenteeism. Similar programs could improve the health of children worldwide.


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  1. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ, 2006. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 367 : 1747–1757. [Google Scholar]
  2. Black RE, Morris SS, Bryce J, 2003. Where and why are 10 million children dying every year? Lancet 361 : 2226–2234. [Google Scholar]
  3. Akyol A, Ulusoy H, Ozen I, 2006. Handwashing: a simple, economical and effective method for preventing nosocomial infections in intensive care units. J Hosp Infect 62 : 395–405. [Google Scholar]
  4. Luby SP, Agboatwalla M, Feikin DR, Painter J, Billhimer W, Altaf A, Hoekstra RM, 2005. Effect of handwashing on child health: a randomised controlled trial. Lancet 366 : 225–233. [Google Scholar]
  5. Curtis V, Cairncross S, 2003. Effect of washing hands with soap on diarrhoea risk in the community: a systematic review. Lancet Infect Dis 3 : 275–281. [Google Scholar]
  6. Rabie T, Curtis V, 2006. Handwashing and risk of respiratory infections: a quantitative systematic review. Trop Med Int Health 11 : 258–267. [Google Scholar]
  7. Haggerty PA, Muladi K, Kirkwood BR, Ashworth A, Manunebo M, 1994. Community-based hygiene education to reduce diarrhoeal disease in rural Zaire: impact of the intervention on diarrhoeal morbidity. Int J Epidemiol 23 : 1050–1059. [Google Scholar]
  8. Luby S, Agboatwalla M, Painter J, Altaf A, Billhimer W, Hoekstra R, 2004. Effect of intensive handwashing promotion on childhood diarrhea in high-risk communities in Pakistan: a randomized controlled trial. JAMA 291 : 2547–2554. [Google Scholar]
  9. Mobley CE, Evashevski J, 2000. Evaluating health and safety knowledge of preschoolers: assessing their early start to being health smart. J Pediatr Health Care 14 : 160–165. [Google Scholar]
  10. Master D, Longe S, Dickson H, 1997. Scheduled hand washing in an elementary school population. Fam Med 29 : 336–339. [Google Scholar]
  11. White CG, Shinder FS, Shinder AL, Dyer DL, 2001. Reduction of illness absenteeism in elementary schools using an alcohol-free instant hand sanitizer. J Sch Nurs 17 : 258–265. [Google Scholar]
  12. Uhari M, Mottonen M, 1999. An open randomized controlled trial of infection prevention in child day-care centers. Pediatr Infect Dis J 18 : 672–677. [Google Scholar]
  13. Bell DM, 2006. Non-pharmaceutical interventions for pandemic influenza, national and community measures. Emerg Infect Dis 12 : 88–94. [Google Scholar]
  14. Gotz H, Ekdahl K, Lindback J, de Jong B, Hedlund KO, Giesecke J, 2001. Clinical spectrum and transmission characteristics of infection with Norwalk-like virus: findings from a large community outbreak in Sweden. Clin Infect Dis 33 : 622–628. [Google Scholar]
  15. Weycker D, Edelsberg J, Halloran ME, Longini IM Jr, Nizam A, Ciuryla V, Oster G, 2005. Population-wide benefits of routine vaccination of children against influenza. Vaccine 23 : 1284–1293. [Google Scholar]
  16. Rohde JE, Sadjimin T, 1980. Elementary-school pupils as health educators: role of school health programmes in primary health-care. Lancet 1 : 1350–1352. [Google Scholar]
  17. Steere AC, Mallison GF, 1975. Handwashing practices for the prevention of nosocomial infections. Ann Intern Med 83 : 683–690. [Google Scholar]
  18. Greenberg MT, Weissberg RP, O’Brien MU, Zins JE, Fredericks L, Resnik H, Elias MJ, 2003. Enhancing school-based prevention and youth development through coordinated social, emotional, and academic learning. Am Psychol 58 : 466–474. [Google Scholar]
  19. Rosen L, Manor O, Engelhard D, Brody D, Rosen B, Peleg H, Meir M, Zucker D, 2006. Can a handwashing intervention make a difference? Results from a randomized controlled trial in Jerusalem preschools. Prev Med 42 : 27–32. [Google Scholar]
  20. Onyango-Ouma W, Aagaard-Hansen J, Jensen BB, 2005. The potential of schoolchildren as health change agents in rural western Kenya. Soc Sci Med 61 : 1711–1722. [Google Scholar]
  21. Swai M, 1987. Early learning about ORT; children can be teachers. Dialogue Diarrhoea 29 : 7. [Google Scholar]
  22. Brewis A, Gartin M, 2006. Biocultural construction of obesogenic ecologies: parent-feeding versus child-eating strategies. Am J Hum Biol 18 : 203–213. [Google Scholar]
  23. Koopman LP, Smit HA, Heijnen ML, Wijga A, van Strien RT, Kerkhof M, Gerritsen J, Brunekreef B, de Jongste JC, Neijens HJ, 2001. Respiratory infections in infants: interaction of parental allergy, child care, and siblings—The PIAMA Study. Pediatrics 108 : 943–948. [Google Scholar]
  24. Breuner CC, Smith MS, Womack WM, 2004. Factors related to school absenteeism in adolescents with recurrent headache. Headache 44 : 217–222. [Google Scholar]
  25. Wang LY, Zhong Y, Wheeler L, 2005. Direct and indirect costs of asthma in school-age children. Prev Chronic Dis 2 : A11. [Google Scholar]
  26. Bartlett AV, Moore M, Gary GW, Starko KM, Erben JJ, Meredith BA, 1985. Diarrheal illness among infants and toddlers in day care centers. II. Comparison with day care homes and households. J Pediatr 107 : 503–509. [Google Scholar]
  27. Cairncross S, Shordt K, Zacharia S, Govindan BK, 2005. What causes sustainable changes in hygiene behaviour? A cross-sectional study from Kerala, India. Soc Sci Med 61 : 2212–2220. [Google Scholar]
  28. Stanton BF, Clemens JD, Khair T, Khatun K, Jahan DA, 1987. An educational intervention for altering water-sanitation behaviours to reduce childhood diarrhoea in urban Bangladesh: formulation, preparation and delivery of educational intervention. Soc Sci Med 24 : 275–283. [Google Scholar]
  29. Tibballs J, 1996. Teaching hospital medical staff to handwash. Med J Aust 164 : 395–398. [Google Scholar]
  30. Early E, Battle K, Cantwell E, English J, Lavin JE, Larson E, 1998. Effect of several interventions on the frequency of hand-washing among elementary public school children. Am J Infect Control 26 : 263–269. [Google Scholar]
  31. CDC, Tippy taps: a design for simple, economical, and effective handwashing stations. Available at: http://www.cdc.gov/safewater/publications_pages/tippy-tap.pdf. Accessed July 19, 2006.
  32. Laskar MS, Mahbub MH, Harada N, 2005. Effect of handwashing on child health. Lancet 366 : 893. [Google Scholar]
  33. Yalcin SS, Yalcin S, Altin S, 2004. Hand washing and adolescents. A study from seven schools in Konya, Turkey. Int J Adolesc Med Health 16 : 371–376. [Google Scholar]
  34. Curtis V, 2003. Talking dirty: how to save a million lives. Int J Environ Health Res 13 (Suppl 1) : S73–S79. [Google Scholar]
  35. Kaltenthaler E, Waterman R, Cross P, 1991. Faecal indicator bacteria on the hands and the effectiveness of hand-washing in Zimbabwe. J Trop Med Hyg 94 : 358–363. [Google Scholar]
  36. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, 2003. How many child deaths can we prevent this year? Lancet 362 : 65–71. [Google Scholar]

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  • Received : 19 Dec 2006
  • Accepted : 27 Feb 2007

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