Introduction
Good hand hygiene (HH) is widely acknowledged as an important non-pharmaceutical method for reducing the transmission of infectious diseases. Children are at particularly high risk of infection due to their immature immune systems. Healthcare-associated infections (HAIs) are also a major cause for concern worldwide, with poor HH suggested to be responsible for up to 20% of cases. Patients, especially paediatric patients, are often overlooked when it comes to the promotion of hand hygiene compliance (HHC) in hospitals.
This report describes the clinical evaluation of the ‘Soaper Stars’; a collection of child-friendly HH products with linked educational resources, developed using the COM-B approach to behaviour change. The Soaper Star products and educational materials were designed to encourage correct HH practices in paediatric patients and in schools.
Objectives
The study aimed to evaluate the Soaper Star HH boxes and educational workshops through the following objectives:
I. Do the Soaper Star HH Boxes increase the frequency of paediatric patients’ hand-hygiene practice within hospitals?
II. Do the Soaper Star HH Boxes give paediatric patients a greater awareness of hand-hygiene and infection prevention (IP)?
III. Do the Soaper Stars school workshops improve pupils’ understanding of hand-hygiene and IP?
Methodology
The project took a mixed methods approach, gathering quantitative and qualitative data through observations of paediatric patients, questionnaires and interviews with healthcare workers (HCWs) across five hospital sites, as well as pre- and post-intervention worksheets, observations and knowledge checks with children in four schools.
Soaper Star Design and Development
The Soaper Stars characters and products were co-created by the Germ’s Journey team and PAL International, a hygiene and infection control manufacturer. Further refinements were made with input from a focus group of postgraduate education students. The Soaper Star boxes contain child-friendly HH products (liquid soap, hand sanitiser and wipes) along with educational resources (activity sheets, handwashing posters, stickers and colouring pencils).
Hospital Trials
The hospital trials took place in four NHS hospitals and one private Nuffield hospital. Ward managers recruited suitable paediatric patients based on inclusion and exclusion criteria, gaining consent from parents/carers and, where possible, the patients themselves.
Over three days, researchers observed the hand hygiene practices of the paediatric patients during their mealtimes. On the first day, standard hospital practice was observed, with patients receiving hospital-issued hand wipes on their meal trays.
On the second day, the Soaper Star HH products were provided to the patients, but no education or discussion about hand hygiene took place.
On the third day, the patients received the full Soaper Star boxes, including the educational resources. Feedback was gathered from patients’ families and HCWs about the Soaper Star boxes.
School Workshops
Schools were recruited from the East Midlands region, including some that had previously hosted Germ’s Journey workshops. The Nuffield group also approached primary schools they had existing links with.
The Soaper Stars educational workshops, underpinned by pedagogic theories of learning, were delivered to whole classes of year 3 (aged 7-8) and year 4 (aged 8-9) pupils. The workshops introduced the Soaper Star characters, discussed the importance of handwashing, when to wash hands, and the correct handwashing technique.
Pupils completed pre- and post-intervention worksheets to assess their understanding of the ‘why, when and how’ of hand hygiene. A follow-up worksheet was completed four weeks later to measure knowledge retention.
Results
Hospital Trials
Observations of hand hygiene practices around mealtimes showed a significant (p ≤ 0.05) increase in the use of the Soaper Star products compared to the hospital-issued wipes. When just the Soaper Star products were provided, 63% of participants used them, compared to only 25% using the hospital wipes. With the full Soaper Star boxes, 50% of participants used the contents.
Parents and carers provided positive feedback on the Soaper Star boxes, commenting that they were “child-friendly” and useful for both patients and visitors. Healthcare staff also responded positively, with 44% stating they felt the Soaper Star boxes had increased the frequency of handwashing.
The Leeds Nuffield hospital, which conducted its own trial, found that 76% of participants showed interest in the Soaper Star boxes, with 69% using the products. Nurses observed that children tended to use the soap and sanitiser more than the wipes, and that some were following the handwashing steps depicted on the poster.
School Workshops
Prior to the workshops, year 3 pupils had a good baseline understanding that handwashing is important to stop the spread of germs, but gaps in their knowledge about when and how to wash hands.
Immediately after the workshops, there was a 15-22% increase in pupils’ knowledge about when to wash hands, and a 19-29% increase in their understanding of proper handwashing technique. This improved knowledge was maintained at the 4-week follow-up.
The nurses leading the workshops at the Leeds Nuffield school reported that the pupils were excited to open the Soaper Star boxes and investigate the contents. The handwashing poster was particularly helpful in teaching the step-by-step technique.
Discussion
The results of this study demonstrate that providing children with age-appropriate knowledge about the importance of hand hygiene, along with child-friendly means to maintain their handwashing, can lead to greater compliance, not just by the children themselves, but also by their families.
The Soaper Star boxes, containing HH products and educational resources, were well-received by both paediatric patients and school pupils. Across the hospital trials, the Soaper Star products were used more frequently than the standard hospital-issued wipes. In the school workshops, the educational materials helped to fill gaps in pupils’ knowledge and increase their understanding of when and how to wash their hands.
These findings reinforce the importance of taking a holistic approach to hand hygiene promotion, addressing both the ‘why’ and the ‘how’ of handwashing. The COM-B model, which underpinned the Soaper Star development, emphasizes that behaviour change requires capability, opportunity and motivation. By providing the knowledge, tools and positive reinforcement, the Soaper Star intervention supported children in developing and maintaining good hand hygiene habits.
While the hospital trials showed promising results, the study design did have some limitations. Recruiting suitable paediatric patients was challenging, and the observations could have been subject to the Hawthorne effect, with participants potentially altering their behaviour due to the presence of researchers. Additionally, the use of proxy measures like product consumption, rather than direct observation of handwashing, may not provide a complete picture of compliance.
The school workshops, on the other hand, benefited from a more controlled setting and the ability to assess changes in pupils’ knowledge through pre- and post-intervention assessments. The consistency in improved understanding, which was retained over time, indicates the effectiveness of the educational approach.
Overall, the Soaper Star intervention demonstrates the value of tailoring hand hygiene promotion to the needs and capabilities of children. By making the process engaging, informative and accessible, this approach has the potential to instill lifelong hand hygiene habits, ultimately contributing to improved infection prevention both within healthcare settings and the wider community.
Conclusion
The results of this clinical trial and educational evaluation highlight the importance of providing children with the knowledge, tools and motivation to maintain good hand hygiene. The Soaper Star HH boxes and school workshops led to increased compliance and improved understanding among both paediatric patients and primary school pupils.
These findings emphasize the need for a holistic, child-centric approach to hand hygiene promotion. By addressing the ‘why, when and how’ of handwashing, and making the process fun and engaging, the Soaper Star intervention was able to encourage better hand hygiene practices not only in the children themselves, but also among their families and caregivers.
As healthcare-associated infections continue to pose a significant threat, especially for vulnerable populations like children, interventions like the Soaper Stars can play a crucial role in breaking the chain of transmission and promoting a culture of infection prevention. Further research exploring the long-term impacts and cost-effectiveness of such approaches would be valuable in guiding future hand hygiene initiatives.
