Research in Developmental Disabilities 35 (2014) 3014–3025

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Research in Developmental Disabilities

To evaluate the effects of a simplified hand washing improvement program in schoolchildren with mild intellectual disability: A pilot study Regina L.T. Lee a,*, Paul H. Lee b a

World Health Organization for Collaborating Center, School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong School of Nursing, The Hong Kong Polytechnic Universtiy, Hung Hom, Kowloon, Hong Kong

b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 9 May 2014 Received in revised form 4 July 2014 Accepted 7 July 2014 Available online

A quasi-experimental study using a pretest–posttest design with a control group was used to evaluate the effects of a simplified 5-step multimedia visualization hand hygiene improvement program by schoolchildren with mild intellectual disability (MID). A total of twenty schoolchildren aged 6–12 years old with MID (12 males) were recruited and they were assigned into intervention (n = 10) and control (n = 10) groups. To evaluate the quality of their hand washing, Glow gel, which contains plastic simulated germs that are visible under an ultra-violet lamp, was applied to participants’ hands to assess the quality of hand washing by comparing the amount of visible Glow gel before and after hand washing using a 4-point scale. Four raters used this 4-point scale to assess the quality of hand washing through digital photo images of the participants’ hands. A total of eight digital photos per participant were taken. A fifteen-minute hand washing training session was conducted every school day for 4 weeks for the intervention group. Those in the control group received no training. A multimedia visual package on steps of hand washing was presented together with a reward system, whereby a number of stars were earned each week depending on the quality of hand washing. Results showed encouraging findings, as the schoolchildren in the intervention group showed significant improvement in hand washing (p < 0.001) and the improvement was stronger than that of the control group (p = 0.02). To conclude, a systematic instruction emphasizing multimedia visualization in a hand washing improvement program can be successfully implemented in a special school, and the effect of integrating multimedia visuals in the hand hygiene program could improve hand hygiene among schoolchildren with MID. ß 2014 Elsevier Ltd. All rights reserved.

Keywords: Schoolchildren with mild intellectual disability Simplified hand hygiene program Effectiveness Multisensory stimulation

1. Introduction Hand hygiene has been recognized as the most effective intervention to reduce the transmission of pathogens in the school community (Morton & Schultz, 2004; World Health Organization [WHO], 2009). However, poor hand hygiene compliance has been observed in young children; most children fail to perceive the importance of hand washing to their health and wellness (Lopez-Quintero, Freeman, & Neumark, 2009). Gastrointestinal and respiratory infections are the most

* Corresponding author. Tel.: +852 27666388; fax: +852 23341124. E-mail address: [email protected] (Regina L.T. Lee). http://dx.doi.org/10.1016/j.ridd.2014.07.016 0891-4222/ß 2014 Elsevier Ltd. All rights reserved.

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commonly occurring illnesses among children due to improper hand washing procedure in the school setting, which is a worldwide concern in the public health agenda (Lopez-Quintero et al., 2009; WHO, 2009). According to the Centers for Disease Control and Prevention, the Center for Health and Health Care in Schools (2007), hand washing is the single most effective thing a person can do to reduce the spread of infectious diseases and it reports that failure to sufficiently wash hands contributes to nearly 50 percent of all food-borne illness outbreaks. A study led by Borchgrevink (2013) reported that only 5% of people washed their hands enough to kill infection and illness-causing germs after using the bathroom, as most people splash-and-go when it comes to hand washing. The same study also found that 33% of hand washers did not use soap and 10% skipped hand washing altogether. Several studies have found that a hand washing program is a community alleviation measure that can reduce influenza illness in the event of a severe pandemic (Godoy et al., 2012; Kampf & Kramer, 2004; Lee & Greig, 2010). Proper hand washing technique is effective in preventing the transmission of communicable diseases (Curtis & Cairncross, 2003; Rabie & Curtis, 2006). The development of a structural hand washing protocol as a key component of a hand hygiene program was associated with reduced school community outbreak rates (Center for Health Protection, 2007), including respiratory tract infections and pandemic influenza A/H1N1 virus in 2006, 2008, 2009; infectious agents contracted by schoolchildren reportedly led to infections in up to 50% of household members (Aiello, Larson, & Sedlak, 2008). A structural hand washing program is a community alleviation measure to reduce influenza illness in the event of a severe pandemic, as children in school settings are 18 times more likely to contract pathogens than those who stay at home (Bylinsky, 1994). There are limited research studies on the evaluation of a comprehensive hand hygiene program for children with intellectual disability to reduce their transmission of pathogens in a special care setting. The WHO’s (2009) standardized 7-step hand washing protocol was used to guide the teachers in training mild to moderate grade intellectually disabled students to practice everyday good washing by washing their hands properly, with song lyrics integrated into the standardized 7 steps for an approximate duration of 20 s. Studies have found that educational materials with songs and visual materials about washing hands seem to help children with special needs to recall the proper hand washing steps and increase the frequency of their hand washing, such as scrubbing for around 20 s with visual prompts and rhymes (Morton & Schultz, 2004; Pinto, 2011; Vessey, Sherwood, Warner, & Clark, 2007; Walmsley, Mahoney, Durgin, & Poling, 2013). The protocol of a simplified 5-step hand washing improvement program (see Appendix A) was modified from the 6-step of hand washing competence checklist of the South Staffordshire Primary Care Trust (2009) by breaking the 5 hand washing steps down into numbers, by integrating key words and phrases for specific items and specific tasks to be performed, especially for schoolchildren with mild grade intellectual disability. The simplified 5-step hand washing program (see Appendix C) was reviewed by an expert panel for feedback. Minor change had been made based on the experts’ comments such as the speed of the song, the breaking down of complex steps. The expert panel consisted of an infection control nurse, an educational psychologist, and school teachers. Prior to implementing the simplified hand washing program, training was provided to one schoolteacher and a school nurse from the identified special school in this pilot study. 1.1. Impacts of improper hand washing on the health and education of schoolchildren with MID A review of the literature concerning children with mild intellectual disability (MID) shows that they are vulnerable to infections due to their unhygienic lifestyles and poor self-care abilities, especially in the areas of nail biting, quality of hand washing, and perineal cleaning. Studies have shown that children with MID are more vulnerable to infectious diseases because their developmental disabilities render them unable to follow complicated steps for life skills such as proper hand washing (Cannella-Malone et al., 2011; Lohiya, Tan-Figueroa, Crinella, & Lohiya, 2000). Frequent hand-tomouth activities without proper hand washing place them at greater risk of acquiring infection (Lohiya et al., 2000). In addition, most children with MID face cognitive challenges in recognizing their own health problems, describing their symptoms and expressing their needs to healthcare professionals, leading to delayed treatment (Ward, Nichols, & Freedman, 2010). To address the improper hand washing problem efficiently, epidemic preparedness efforts are an important aspect of preventive measures against outbreaks of flu and other infectious diseases. Children’s hand washing practice should be trained and reinforced daily during childhood (Morton & Schultz, 2004). Studies have demonstrated the efficacy of a structured hand hygiene program with multimedia visualization for children with intellectual disability (Cannella-Malone et al., 2011; Rosenberg, Schwartz, & Davis, 2010), as well as the fact that early intervention was important in the prevention of infectious outbreaks (Bloomfield, Aiello, Cookson, O’Boyle, & Larson 2007). Few studies have used behavior-analytic approach such as verbal instruction, shaping and reinforcement of target skills, to foster health-related behaviors such as tooth brushing and hand washing, in people with disabilities (Poche, McCubbrey, & Munn, 1982; Swain, Allard, & Holborn, 1982; Walmsley et al., 2013). 1.2. Visual perception problems of schoolchildren with MID Children with special needs require extra guidance and more detailed instructions when learning basic life skills (Pinto, 2011). Generalization of skills across materials and settings has long been a concern for professionals responsible for developing and planning of instruction for schoolchildren with intellectual disabilities (Charlop-Christy & Daneshvar, 2003). Video-based modeling with instructions has been found to be an effective tool for teaching life skills of children with

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disabilities (Charlop-Christy, Loc, & Freeman, 2000; Delano, 2007; LeBlanc et al., 2003). Thus, it is very important to develop a structural hand washing checklist with breaking down of complex hand washing techniques through video modeling and poster instructions for teaching the life skills of schoolchildren with intellectual disability in order to reduce the transmission of pathogens for respiratory and gastrointestinal infection in the school community. There is no specific strategy to promote hand washing protocol using multimedia visualization among schoolchildren with intellectual disability in special schools in Hong Kong, although they are the most vulnerable group to be infected with influenza illness. A concern about using a nonstandardized 7- or 9- or 11-step hand washing procedure developed for the general population on schoolchildren with intellectual disability is that it may not be appropriate. Mildly intellectually disabled students often require extra time and demonstration in order to be successful in articulating certain psychomotor skills. They may have difficulty understanding language and exhibit hyperactive and impulsive behaviors. All of these symptoms can make it difficult to learn the standardized hand washing lessons. In this study, a simplified 5-step hand washing program for mild grade intellectually disabled schoolchildren had been modified from the World Health Organization’s (2009) 7-step hand washing technique and South Staffordshire Primary Care Trust’s (2009) 6-step hand washing procedure. The piloted 5-step hand washing intervention is simplified for training students with mild grade intellectual disability, as they have shown difficulty articulating the hand washing procedure. Thus, a simplified and structural hand washing program with multimedia perceptual instructions can assist school nurses, schoolteachers and parents in intervening earlier to prevent the spread of germs, especially in special schools (see Appendix C). The purpose of this study is to fill this gap by piloting a simplified 5-step hand washing improvement program and evaluating its effectiveness on the quality of hand washing among schoolchildren with MID in the intervention group of this study (see Appendix A). 1.3. Present study In this study, the multimedia viualization simplified 5-step hand washing improvement program (see Appendix C) was piloted in a special school with MID schoolchildren. The effectiveness of the program was evaluated within and between groups with pre- and post-tests on the quality of hand washing. The purpose of this study was to evaluate the effectiveness of a multimedial visualization simplifed 5-step hand washing improvement program by comparing the quality of hand washing (fluorescent stain) on both hands of each student as the outcome measure for the pre- and post-tests in both intervention and control groups. The study was an evidence-based intervention strategy on the effect of a hand washing intervention implementing a simplifed 5-step hand washing program with custom-made video models for mild grade intellectually disabled students in a special care school. The intention was to develop and evaluate a simplified 5-step hand washing intervention program faciliated by video models with song for schoolchildren with MID in order to promote the proper hand washing procedure in special care schools. The intervention consisted of a four-week hand washing improvement program applying multimedial perceptual instruction and visualization, and emphasizing fun and multimedia visualization learning strategies (see Appendix A). The instruction was conducted over a period of four weeks. It was expected that the quality of hand washing would improve signifcantly in the intervention group, but not in the control group. It was hypothesized that no significant differences would be found in the control. The purpose of this 4-week study was to evaluate an evidence-based intervention strategy on the effect of a hand washing intervention, adopting a simplified 5-step hand washing improvement program with song lyrics and rhymes to train students with MID to visualize, comprehend and memory the 5-step of hand washing in the intervention group as a pilot study. To facilitate the learning of hand washing skills for students with MID, a simplified 5-step hand washing intervention program for students with MID was developed and evaluated. The followings elements were included in the simplified 5step hand washing intervention program: (1) simplified 5-step hand washing technique, including demonstration and return demonstration; (2) a song and a video; (3) posters; (4) a rewards system; and (5) checklists. The whole program lasted for four weeks and was conducted in May and June of 2013. Details of the protocol of the simplified 5-step program can be found in Appendix A. 2. Methods 2.1. Participants This study was conducted in a special care school community with a 300-student capacity for students aged 6–18 years old with intellectual disability, located in Yau Tsui Mong District, Hong Kong. Services provided include special care for children with mild and moderate intellectual disability. The school has 60 employees and 20 classrooms. The schoolteacher to intellectually disabled student ratio is 1:7. Skilled health services include the management of epilepsy, dental care, nursing care, occupational therapy, speech therapy and social welfare. Written consent had been obtained from the parents of the piloted special school via the school communication system prior to conducting the study. In this pilot study, the selected special school that had agreed to be both the intervention and control groups had 20 mildly intellectually disabled students from P.1 to F.2 students in 2013. The selected school assigned

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two groups as intervention and control groups by the school nurse. None of the participants had previously participated in any simplified 5-step hand washing program. The school authority agreed to participate and was willing to adhere to the research protocol. The trainers for the 5-step hand washing intervention included one school nurse who had been practicing for 3 years in school nursing, and one schoolteacher who had been teaching for over 10 years in the selected school. This school comprises five floors, and we conducted this study on only one floor. All rooms on the selected floor have a handwashing famility. The inclusion criteria for the recruitment of schoolchildren with intellectual disability for this study were: schoolchildren aged 6–13 with mild grade intellectual disability based on a standardized intelligence test (IQ score of 50–69) who are studying from grade 1 to grade 8 in special schools in Hong Kong (Education Bureau, 2001); and being free from physical impairment. The exclusion criteria were: schoolchildren with moderate and severe intellectual disability based on a standardized intelligence test (IQ score of IQ  49); and schoolchildren with extreme difficulty comprehending, memorizing, and visualizing. 2.2. Intervention and control groups The same participating special school recruited ten students to the intervention group and ten other students to the control group. None of the schoolchildren from these two different groups sat in the same classroom to prevent contamination between the intervention and control groups. No hand washing program in the control group in the same special school selected to participate in this pilot study. 2.2.1. Instruction for the intervention group with MID for a simplified 5-step hand washing improvement program When schoolchildren with special needs enter school programs, they usually lack the life skills and knowledge necessary to carry out daily tasks such as washing their hands and face, brushing their hair and teeth, and wiping their noses (Mechling & Collins 2012). When these are reinforced on a daily basis, it is hoped that their level of functioning will go from very passive to slowly participating in them. It has been shown that there is no specific strategy to promote hand washing among schoolchildren with MID in special schools (United Nation, 2012). The research protocol was sent to the two trainers of the participating special school: one school nurse and one school teacher. Many of the strategies used to teach the low-functioning autistic child self-help skills are similar to occupational therapy techniques used to teach mentally retarded children (MacDuff, Krantz, & McClannahan, 2001; Mechling, 2005). Before teaching a particular skill, it was particularly helpful to do a task analysis by writing down the numbers of all the steps involved from the onset to completion of a given task. The trainers should endeavor to use key words and phrases while children use specific items or perform a task. Schoolchildren who have developmental disabilities may not be able to follow complicated steps for life skills such as hand washing. Therefore, a simplified 5-step hand washing technique was developed with song lyrics and pictoral steps (Duffy & Fuller, 2000; MacDonald, O’Donnell, & Davies, 1999). The simpified 5-step hand washing improvement program for schoolchildren with MID in special schools is as follows: step (1) between fingers, step (2) back of hands, step (3) back of fingers, step (4) fingers tips, and step (5) thumbs (see Appendix C). Wrist-rubbing is omitted as it may adversely increase the transmission of microbes. The palm-to-palm and palm-to-palm with fingers interlaced steps are also merged to simplify the hand washing technique that has been validated by a panel of three experts, including an infection control pediatrician, an infection control senior nurse and an educational psychologist. The simplified 5-step hand washing program protocol for schoolchildren with mild grade intellectual disability was modified based on feedback from the experts (see Appendix A). The content validity index was 1. The simplified 5-step hand washing protocol was revised based on the experts’ feedback after feasibility testing. Each hand washing training session lasted for 15 min and was conducted every school day for 4 weeks. 2.2.2. No intervention in the control group with MID Another school teacher from the same school was then assigned to monitor the other 10 recruited schoolchildren in the control group. The teacher was responsible for teaching the 7-step hand washing technique recommended by the Center for Health Protection of Hong Kong (2005) as their routine schedule. Posters of the standardized 7-step hand washing technique (see Appendix D) were also posted over the washbasins in the classrooms where the control group was located. 2.3. Measures The palm and dorsum of both hands of the participants had been photographed using digital camera images under standardized photographing environment using ultraviolet light as the pre-test, as shown in Fig. 1. Participants were asked to wash their hands with soap and photos were taken again afterwards as the post-test. The intervention outcome measure was quantified in terms of the percentage of fluorescent stain on each hand, graded photos using a 4-point scale (0, 1, 2, 3) showing the amount of fluorescent stain on each hand adopted from previous study by Walmsley et al. (2013). In Fig. 1, a rating of 0 requires most of the hands (e.g. large amount of glowing on the palms, dorsum and fingers) to be covered with fluorescent stain (Glow gel); a rating of 1 requires a reduction in the amount of fluorescent stain evident and for the substance to be absent from some sections of the hands; a rating of 2 requires a substantial reduction in the amount of fluorescent stain evident (e.g. only some glowing on the palms, dorsum and fingers), and a rating of 3 requires nearly all the

[(Fig._1)TD$IG]

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Fig. 1. 4-Point scale to rate the palm and dorsum of right and left hands which were photographed environment using ultraviolet light for the glowing of the fluorescent stain.

fluorescent stain to be removed from the hands (e.g. no glowing on the palms, dorsum and fingers). A higher rating means a cleaner hand. Both hands, with fluorescent stain captured by digital camera images labeled with a code number for each participant and placed ‘‘R’’ to indicate the right hand and placed ‘‘L’’ for the left were collected 8 times for each child within four weeks as the pre- and post-tests. A total of four raters used this 4-point scale to assess the quality of hand washing through digital photo images of the participants’ hands. 2.3.1. Validity and inter-rater reliability The inter-rater reliability of the four raters for left and right hand, measured using intraclass correlation coefficient (ICC), were 0.89 and 0.93 respectively, showing good agreement between the raters (Burns & Grove, 2011). 2.4. Procedure 2.4.1. Data collection Written consent had been obtained from the parents of the piloted special school via the school communication system prior to conducting the study. In this pilot study, the selected special school that had agreed to be both the intervention and control groups had 20 mildly intellectually disabled students from grade 1 to grade 8 students in 2013. The selected school assigned two groups as intervention and control groups by the school Digital photos for the palm and dorsum of both hands

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were taken before the 5-step handwashing program was implemented and after four weeks when the program had been completed. 2.4.2. Design and data analysis This was a quasi-experimental study with a control group, including a pre-test and an immediate post-test (Burns & Grove, 2011). Because the sample size was small, non-parametric tests were used to analyze the data. The quality of hand washing of both the palm and dorsum of both hands was compared within and between groups, with pre- and post-tests as the outcome measures. At the between-group level, improvements of the intervention and control groups were compared since the pre-test scores might differ significantly between the groups. Improvement were calculated by subtracting the pretest scores from the post-test scores using the 4-point scale stated previously. The quantitative data was analyzed using the Statistical Package for Social Science (SPSS 20.0) for Windows. The between-group and within-group differences of the total quality score (ranging from 0 to 12 for left and right hands, and from 0 to 24 for combining both hands) were examined using the Mann–Whitney U test and the Wilcoxon signed-ranks test respectively. It was expected that there would be an increase in fluorescent stain rating (after completion of hand washing improvement) in the intervention group compared with the control group. The quantitative data were analyzed using the Statistical Package for Social Science (SPSS 19.0) for Windows. 2.5. The teacher’s and school nurse’s feedback concerning training instruction and program feasibility To ensure the feasibility of this pilot study, the 5-step simplifed hand washing improvement program were carried out by one school teacher and a school nurse with the research team members. The feedback was very encouraging and positive. School nurse and teacher agreed that the simplified 5-step hand washing technique was acceptable and reasonable to this target group in terms of the rhymes of the song and the wordings for each hand washing step on the poster. They also suggested preparing a small pocket leaflet with the taught simpified 5-step hand washing technique for students with MID to take home. Minor change was made to the program protocol based on school nurse’s concern on the arrangement of the hand washing before meal time. 3. Results 3.1. Characteristic of the study sample Twenty schoolchildren with MID aged 6–12 were recruited from the one special school as intervention and control groups. The mean age of the piloted study sample was 9.4. There were 12 males and 8 females assigned into the intervention (n = 10) and control (n = 10) groups (Table 1). This school comprises five floors, and we conducted this study on only one floor. All rooms on the selected floor have a handwashing famility. The inclusion criteria for the recruitment of schoolchildren with intellectual disability for this study were: schoolchildren aged 6–13 with mild grade intellectual disability based on a standardized intelligence test (IQ score of 50–69) who are studying from grade 1 to grade 8 in a special school in Hong Kong (Education Bureau 2001); and being free from physical impairment. The exclusion criteria were: schoolchildren with moderate and severe intellectual disability based on a standardized intelligence test (IQ score of IQ  49); and schoolchildren with extreme difficulty comprehending, memorizing, and visualizing. 3.2. Performance differences in quality of hand washing in the beginning 3.2.1. Between-group comparison during pre and post-tests At pre-test as shown in Table 2, the difference of hand washing quality between the two groups were insignificant (p = 0.28) for left hand (see Fig. 2) but that on right hand (see Fig. 3) was significant (p = 0.04) in which the control group had better quality (7.10 vs. 5.25). Combining both hands, the difference between the two groups was insignificant (p = 0.07) (see Table 2 and Fig. 4). At post-test as shown in Table 2, the hand washing quality of the control group was significantly better

Table 1 Characteristic of study sample (N = 20). Demographics

Mean (SD)

Age Age range

9.35 (11.21) 6–13

Control

Intervention

Gender

n (%)

n (%)

n (%)

Male Female

12 (60) 8 (40)

6 (60) 4 (40)

6 (60) 4 (40)

Nationality

n (%)

n (%)

n (%)

Chinese

20 (100)

10 (100)

10 (100)

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Table 2 Comparison of the total score of four raters (0–12) of hand wash quality evaluation. Pre

Post

Difference

pa

Left hand Control Intervention pb

0.50 (1.30) 0.50 (1.01) 0.28

1.53 (1.95) 0.70 (1.36) 0.02

+1.16 (2.14) +0.20 (1.74) 0.02

0.003 0.004

Right hand Control Intervention pb

7.10 (2.99) 5.25 (4.08) 0.04

9.13 (2.39) 10.73 (1.58) 0.002

+1.63 (3.09) +5.48 (4.04)

To evaluate the effects of a simplified hand washing improvement program in schoolchildren with mild intellectual disability: a pilot study.

A quasi-experimental study using a pretest-posttest design with a control group was used to evaluate the effects of a simplified 5-step multimedia vis...
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