6. HYGIENE EDUCATION AND MOTIVATION

Hospitalized patients’ knowledge of influenza transmission and prevention.
Beneta T., Vaillanta L., Del Signore C., Crozet M.N., Nicolle M.C., Vanhemsa P. Journal of Hospital Infection 2007;57(3):293-5.
The objective of this study, carried out in the Edouard Herriot Hospital (Lyon, France) between 20 June and 24 July 2006.was to detail the awareness of influenza transmission and prevention among hospitalized individuals. The study indicates that continuous infection control efforts are needed to inform healthcare workers about hygiene procedures and influenza prevention need an additional component: effective patient education.

A survey of hand hygiene practices on a residential college campus.
Scott E., Vanick K. American Journal of Infection Control 2007; 35(10) 694-6.
Upper respiratory tract infections and gastrointestinal tract infections are the cause of a significant level of illness on college campuses. However, preventative measures such as handwashing and hand sanitation are often not well-supported, understood, or practiced on campus. A confidential, self-administered on-line survey was performed during April-May 2006. Nine hundred and ninety-four participants completed the survey. Of these, 49% were undergraduates, 30% were graduates, and 34% lived in residence halls on campus. The results show the need for hand hygiene education targeted at students. Finally, we strongly recommend that college authorities provide soap and a means of hand drying in all residential bathrooms.

Preventing food-borne illness in food service establishments: Broadening the framework for intervention and research on safe food handling behaviors.
Mitchell R.E., Fraser A.M., Bearon L.B. International Journal of Environmental Health Research 2007; 17(1):9-24.
Unsafe food handling practices in food establishments are a major contributor to transmission of food-borne illness. The paper evaluates predisposing influences (eg, knowledge, beliefs, perceived control, self-efficacy), enabling influences (eg, quality of training, work pressure and pace, safety protocols, appropriate equipment) and reinforcing influences (eg, management enforcement of policies, incentives, job stress and organizational justice) on worker behavior. Efforts to change food service workers’ behavior are more likely to be effective if they pay greater attention to the ecological context, address multiple influences on worker behavior, and view workers as partners in preventing food-borne illness.

Monitoring progress of the role of integration of environmental health education with water and sanitation services in changing community behaviours.
Metwally A.M., Saad A., Ibrahim N.A., Emam H.M., El-Etreby L.A. International Journal of Environmental Health Research 2007;17(1);61-74.
The study was carried out in four districts in Upper Egypt. Interventions included hardware interventions which comprised provision of safe drinking water through small-scale water supply systems and double-pit pour flush latrines (PFL) as a low-cost approach to disposal of human waster. Software interventions comprised integrating hygiene promotion and environmental awareness-related intervention for demand generation and desired behavioural change, national advocacy, information and capacity building. The study showed that integrated water, sanitation and hygiene health education can produce significant and sustainable improvements in household behaviours.

REVIEW: Behavioural considerations for hand hygiene practices: the basic building blocks.
Whitby M., Pessoa-Silva C.L., McLaws M.-L., Allegranzi B., Sax H., Larson E., Seto W.H., Donaldson L., Pittet D. Journal of Hospital Infection 2007;65:1-8.
In October 2005, the WHO World Alliance for Patient Safety launched the first Global Patient Safety Challenge “Clean Care is Safer Care”, to tackle healthcare-associated infection on a large scale. Within the Challenge framework, international infection control experts and consultative taskforces met to develop new WHO Guidelines on Hand Hygiene in Healthcare. This paper explores aspects underlying hand hygiene behaviour that may influence its promotion among healthcare workers.

Warned, but not well armed: preventing viral upper respiratory infections in households.
Larson E.L. Public Health Nursing 2007;24:48-59.
Public health nurses can use several strategies for prevention of upper respiratory infections (URIs): (a) provide more tailored educational messages on preventive strategies (vaccination, hand hygiene, spatial separation of infected household members, avoidance of antibiotics to treat viral URI, and environmental cleaning), which are delivered personally rather than passively; (b) use patient encounters to encourage vaccination for risk groups; (c) encourage use of alcohol hand sanitizers by householders during the cold and flu season; and (d) provide opportunities for skill development (e.g., cover your cough).

Effect of intensive handwashing in the prevention of diarrhoeal illness among patients with AIDS: a randomized controlled study.
Huang D.B., Zhou J. Journal of Medical Microbiology 2007; 56: 659-63.
Seventy-five patients were randomly assigned to an intensive handwashing intervention (after defecation, after cleaning infants who had defecated, before preparing food, before eating, and before and after sex) and 73 patients were assigned to the control group. Patients assigned to the intensive handwashing intervention group washed their hands more frequently compared with the control group (7 vs. >4 times a day, respectively; P<0.05) and developed fewer episodes of diarrhoeal illness (1.24+/-0.9 vs. 2.92+/-0.6 new episodes of diarrhoea, respectively; P<0.001) during the 1-year observation.

Food hygiene knowledge and self-reported behaviours of UK school children (4-14 years).
Eves A., Bielby G., Egan B., Lumbers M., Raats M., Adams M. British Food Journal 2006 ; 108 706 - 720 .
The food hygiene knowledge and self-reported behaviours of pupils (4 and 14 years; Key Stages 1- 3 in the English system – or Scottish equivalent) were determined using age-appropriate knowledge quizzes completed by 2,259 pupils across England, Scotland, Northern Ireland and Wales. Attitudes towards food hygiene and barriers to performing desirable hygiene-related behaviours were established through semi-structured interviews with 82 pupils who completed knowledge tasks in South East England.

Food hygiene education in UK primary schools: a nation-wide survey of teachers' views.
Bielby G., Egan B., Eves A., Lumbers M., Raats M., Adams M. British Food Journal 2006 ; 108 721 – 731 .
Postal questionnaires were distributed to 3,806 primary schools throughout the UK (response rate 23 per cent). The questionnaire was developed based on the results of in-depth interviews with school teachers and included topics such as where teachers gained up-to-date food hygiene messages, methods used to teach food hygiene, and how key food hygiene messages are reinforced. Teachers cited most preferred resources for teaching food hygiene, influences on the choice of these resources, and limitations on use.

Assessment of consumer food safety education provided by local authorities in the UK .
Redmond E.C., Griffith C.J. British Food Journal 2006 ; 108 732 – 752 .
A considerable quantity of food safety advice is provided to UK consumers. The materials etc are unique and diverse, and suggests a need for sharing of materials and areas of innovation between local authorities. Provision of generic, managed and co-ordinated food safety education resources in the UK may not only decrease time and financial costs, but also increase consumer confidence in the accuracy of information provided and alleviate potential confusion of information from differing sources.

A pilot study to evaluate the effectiveness of a social marketing-based consumer food safety initiative using observation.
Redmond E.C., Griffith C.J. British Food Journal 2006; 108 : 753 – 770.
A pilot study in South Wales suggested that “one-off” food safety interventions using a social marketing approach may result in short-term improvement of consumer food safety behaviours. Interventions targeting specific food safety behaviours may produce a “halo effect” upon other food safety behaviours that are known, yet not consistently implemented during domestic food preparation. Intervention effect was greater immediately after implementation of the strategy than 4-6 weeks later. Use of the risk-based scoring system and observation techniques were effective for assessing food hygiene behaviours and evaluating effectiveness of interventions.

The extension programme and food safety education in the USA .
Singleton J., Hillers V. British Food Journal 2006; 108: 771 – 774 .
The purpose of this paper is to explain the work and importance of the “extension” programme in the USA . “Extension” works in six major areas, including family, consumer science and agriculture. Extension grants that address food safety are issued via the National Integrated Food Safety Initiative (NIFSI). Target audiences for the programmes include various groups of consumers (pregnant/nursing mothers, infants, teens, etc.), as well as multipliers or gatekeepers who disseminate knowledge to groups of consumers.

Sustained high levels of stored drinking water treatment and retention of hand-washing knowledge in rural Kenyan households following a clinic-based intervention.
Parker A.A., Stephenson R., Riley P.L., Ombeki S., Komolleh C., Sibley L., Quick R. Epidemiology and Infection 2006;
A new study by Parker et al., demonstrates high hand washing knowledge retention rates among clients, who received hand washing education during their visits to a Maternal and Child Health clinic in Nyanza Province, Kenya. Two weeks after the health clinic visit, 41% of clients were able to perform all hand washing steps correctly. After one year, 34% of clients were able to demonstrate all six hand washing steps correctly.

Confidence in controlling a SARS outbreak: experiences of public health nurses in managing home quarantine measures in Taiwan.
Hsu C.C., Chen T., Chang M., Chang Y.K. American Journal of Infection Control 2006;34:176-81.
Public health nurses in Taiwan faced unprecedented challenges in implementing policy to prevent disease spread during the 2003 SARS epidemic. This paper assesses factors related to nurses’ confidence in managing community SARS control programmes. Nurses’ individual risk perception and the prompt update of epidemic information significantly affected levels of professional confidence, a key factor influencing quarantine implementation success. Strategies to promote collaboration and advocate participatory policy making involving health workers at all levels are needed to control effectively infectious disease outbreaks.

Creating demand for sanitation and hygiene through Community Health Clubs: a cost-effective intervention in two districts in Zimbabwe.
Waterkeyn J., Cairncross S. Social Science and Medicine 2005;61:1958-70.
This study describes the development of Community Health Clubs which significantly changed hygiene behaviour and built rural demand for sanitation. In one year in the Makoni District, 1,244 health promotion sessions were held by 14 trainers involving 11,450 club members (68,700 beneficiaries). In the Tsholotsho District, 2105 members participated in 182 sessions held by three trainers involving 12,630 beneficiaries. Within 2 years, 2,400 latrines had been built in Makoni, and in Tsholotsho latrine coverage rose to 43% contrasted to 2% in the control area, with 1,200 latrines built in 18 months. The remaining 57% of club members without latrines in Tsholotsho all practised faecal burial, a method previously unknown to them. Club members’ hygiene was significantly different (p=0.0001) from a control group across 17 key hygiene practices including hand washing, showing that if a strong community structure is developed and the norms of a community altered, sanitation and hygiene behaviour are likely to improve. This methodology could be scaled up to contribute to ambitious global targets.

Household-based ceramic water filters for the prevention of diarrhoea: a randomized, controlled trial of a pilot programme in Colombia.
Clasen T., Garcia Parra G., Boisson S., Collin S. American Journal of Tropical Medicine and Hygiene 2005;73:790-5.
Oxfam GB undertook a pilot project to explore the use of household-based ceramic water filters in three remote communities in Colombia. In a randomised, controlled trial over a period of 6 months, the filters were associated with a 75.3% reduction in arithmetic mean thermotolerant coliforms (TTCs). A total of 47.7% and 24.2% of the samples from the intervention group had no detectible TTCs/100 mL or conformed to WHO limits for low risk (1-10 TTCs/100 mL), respectively, compared with 0.9% and 7.3% for control group samples. Overall, the prevalence of diarrhoea was 60% less among households using filters than among control households. However, the microbiologic performance and protective effect of the filters was not uniform throughout the study communities, suggesting the need to consider the circumstances of the particular setting before implementing this intervention.

A model of hygiene practices and consumption patterns in the consumer phase. Christensen B.B., Rosenquist H., Sommer H.M., Nielsen N.L., Fagt S., Andersen N.L. and Nørrung B. Risk analysis 2005; 25: 49-60.
A mathematical model is presented, which addresses individual hygiene practices during food preparation and consumption patterns in private homes. The simulated results show that the probability of ingesting a chicken risk meal at home does not only depend on the hygiene practices of the persons preparing the food, but also on the consumption patterns of consumers, and the relationship between people preparing and ingesting food. This finding supports the need of including information on consumer behaviour and preparation hygiene in the consumer phase of exposure assessments.

Observation of food safety practices using notational analysis.
Clayton D ., Griffith C.J. British Food Journal (2004), 106(3 ): 211-227.
A total of 115 food handlers from 29 catering businesses were observed carrying out 31,050 food preparation and hygiene actions in their workplace. Notational analysis was found to offer little advantage, compared to traditional observation methods. However, this technique was successful in identifying and recording a greater number of cross-contamination events than would have been highlighted using traditional approaches. The results demonstrated that, based on hygiene guidelines, food handlers were required to implement de-contamination actions on a large number of occasions. These de-contamination actions were frequently inadequately conducted.

It does last! Some findings from a multi-country study of hygiene sustainability.
Cairncross S., Shordt K. Waterlines 2004;22:4-7.
This paper report a study of hygiene behaviour after a time elapse of one or more years following a hygiene promotion programme in Ghana, India, Uganda, Nepal Kenya and Sri Lanka. Hygiene aspects studied were handwashing (when and how), latrine use and maintenance and household hygiene (water storage, environmental cleanliness and covering food). Hygiene behaviour was sustained, but the extent to which this occurred depended on a number of variables such as the intensity of the programme, whether it was a one-to-one intervention etc. The authors concluded that continued access to services (water and sanitation) is not enough to sustain hygiene behaviour; it is the “software” aspects which are more important. Hygiene promotion should not be a low-visibility add-on. Sustained behaviour only results from giving high priority and adequate resources to hygiene promotion.

Microbiological and observational analysis of cross contamination risks during domestic food preparation.
Redmond E.G., Griffith C. J., Slader J. and Humphrey T. (2004). British Food Journal. 106: 581-597.
An observational approach in conjunction with isolation techniques for campylobacter and salmonella facilitated evaluation of the risk of cross contamination during food preparation. Identification of suspected exposure routes linked naturally contaminated raw foods with important food-handling malpractices, contaminated contact surfaces and ready-to-eat foods. In a model domestic kitchen, 29% of food preparation sessions resulted in positive campylobacter isolations from prepared salads, cleaning materials and food-contact surfaces. Typing showed that campylobacter strains isolated from prepared chicken salads were the same as strains isolated from the raw chicken pieces, indicating transfer during food preparation.

Observation of food safety practices using notational analysis.
Clayton D., Griffith C.J. British Food Journal 2004;106:211-27.

Microbiological and observational analysis of cross contamination risks during domestic food preparation.

An Investigation of the Factors Underlying Consumers' Implementation of Specific Food Safety Practices.
Clayton D ., Griffith C.J. and Price P. British Food Journal. 2003; 105 : 434-453.
Social cognition models were used to determine consumers attitudes, beliefs and knowledge of food safety. Results suggest measures of perceived behavioural control, perceived barriers and perceived risk may provide developers of food safety intervention materials and more useful information compared with measures of knowledge or intention.

Childhood diarrhoea and observed hygiene behaviour in Salvador, Brazil.
Strina, A., Cairncross, S., Barreto, M.L., Larrea, C. and Prado, M.S. Am J Epidemiol 2003;157:1032-1038.
Using structured observation, researchers scored behaviour as either hygienic or unhygienic. Among children with mainly positive hygiene behaviour, the prevalence of diarrhoea was 6.4days/child year, compared with 14.2days/child year for children with mainly unhygienic behaviour (highly significant difference). There was a significant association between a positive hygiene score and the presence of adequate excreta disposal facilitates in the home. The authors concluded that families predisposed to acquire adequate sanitation in their homes have a measurably better awareness of hygiene, which is expressed in their behaviour. The study data is indicative of the important role of hygiene behaviour, as well as water supply and sanitation facilities.

Consumer food handling in the home: a review of food safety studies.
Redmond, E.C. and Griffith, C. Journal of Food Protection 2003;66:130-161.
Following an extensive search, unpublished and published literature found on consumer food safety studies was examined according to social cognitive components, observed behaviour and food safety findings. Only studies that assessed individual consumers and targeted consumer groups were included in the review. This reports the findings from a review of 88 consumer food safety studies carried out in the last 25 years. The studies used a variety of survey techniques such as questionnaires, interviews, direct observation, and focus groups. The use of the various methods has resulted in differences in the findings on food safety behaviour of consumers. It is suggested that observational data provides the most reliable information on how consumers actually behave.

Diarrhoea and effects of different water sources, sanitation and hygiene behaviour in East Africa. Tumwine, J.K., Thompson, J., Katua-Katua, M., Mujwajuzi, M., Johnstone, N., Wood, E. and Porras, I. Tropical Medicine and International Health 2002;7:750-756.
This work analysed domestic water use and environmental health in East Africa and charted any major changes or trends since the last study in 1972. They also investigated the links between the prevalence of diarrhoea and the nature of water supplies, sanitation facilities and hygiene behaviour. They surveyed over 1000 households in 33 sites in Uganda, Tanzania and Kenya in 1997. The type of water source, the amount of water used for cleaning and bathing, ownership of a latrine or other sanitation facility and hygiene practices are important determinants of the incidence of diarrhoea.

The effect of a comprehensive handwashing program on absenteeism in elementary schools. Guinan, M et al. American Journal of Infection Control 2002;30:217-20.
The study looked at the effectiveness of a comprehensive handwashing programme on absenteeism, with 290 students from 5 schools taking part. Each test classroom had an alcohol-based hand gel and received an educational programme (talk on the importance of handwashing and a video on micro-organisms and disease transmission). Data on absenteeisms was collected for 3 months, and the number of absenteeisms was 50% lower in the test group than the control group. This study highlights the importance of hand hygiene in the school setting, but children may also take their learnings back into the family home too.

Food safety education: what should we be teaching consumers? Medeiros, L.C., Hillers, V.N., Kendall, P.A. and Mason, A. Journal of Nutrition Education 2001;33:108-113.
This paper highlights that food safety education needs to target changing those behaviours most likely to result in illness. To be more effective the messages should be directed towards specific audiences. Consumers’ failure to link food-handling practices in the home with foodborne illness is a hindrance in convincing them to change their behaviour. The authors recommend that consumer food safety education should primarily focus on hand washing, adequate cooking and avoiding cross-contamination.

Practices and perceptions of food safety among seniors who prepare meals at home. Gettings, M.A. and Kiernan, N.E. Journal of Nutrition Education 2001;33:148-154.
This study was to determine whether a need exists for education for those over 60 years old, and what the content should be and how the effect should be designed. Focus groups were conducted and the participants then prepared meals. The groups said they will always use appropriate practices if told that inappropriate practices are linked to a real threat to their health from illness and/or death. They want information from educators and other credible sources.

Improving food hygiene standards – a customer focussed approach. Leach, J., Mercer, H., Stew, G. and Denyer, S. British Food Journal 2001;103:238-252.
This highlights that educational programs, particularly focused to less educated subjects, are greatly needed. A questionnaire completed by mothers revealed that 36% knew all 6 foodborne pathogens investigated but only 11% correctly indicated food that transmit them. Only 54% reported washing hands before and after touching raw or unwrapped food and 50% reported using soap to wash hands. The respondents learned about foodborne disease from the mass media (56%) and GP’s (10%), but 82% still wanted to learn more.