Infection prevention and control is a key strategy for tackling antimicrobial resistance in the UK’s five-year action plan [1
] and twenty-year vision [2
]. Washing hands is thought to be the most effective action a person can take to reduce risk of infection-related illness [3
]. It is estimated though that in the UK only 52% of people (19% in the world) wash their hands with soap after using toilet facilities [4
]. It is, therefore, vital that the importance of hand hygiene is effectively communicated and that this communication results in long lasting change [4
Children are a key target of hand hygiene promotions. They are particularly prone to infections because their immune systems are still developing. Sickness in children raises the risk of infection within households. It also increases absenteeism. This adds pressure to school systems and impacts children’s learning. Additionally, parents need to take leave to care for sick children, and there is an increase in general practitioner visits [5
]. Another reason for promoting hand hygiene to children is that habits formed in childhood tend to be retained for life [6
]. Moreover, once children are educated in handwashing, they in turn promote hand hygiene to the wider community [1
In this study, the effectiveness and efficiency of persuasive space graphics (PSG) in motivating handwashing in English primary school toilets are evaluated. PSG are graphics integrated within an architectural environment to encourage specific actions. The PSG in this study are based around the concept of “use 123 to get germ free”, where 1 is the soap, 2 is water and 3 is the drying device. Hand hygiene messages and graphics are integrated within the soap dispenser, taps and hand dryer (see Figure 1
). Graphics are also placed in cubicle areas and surrounding wall space. A co-design methodology was used to develop the PSG; the theoretical basis for this will be reported in future work. The designs will become available for schools to download and print from [7
Globally many interventions have been targeted at children; those most notable in the UK include Hands up for Max!, e-Bug, and on a smaller scale, Glo-yo. Hands up for Max! was developed by the former Health Protection Agency (now Public Health England) and provides educational resources (lesson plans, a six-minute animation, posters on how to wash hands and stickers) to primary schools. In a cluster randomised controlled trial (178 schools) using school supplied absence data, Hands up for Max! was primarily evaluated for whether it reduced absences. In addition, employing children focus groups, teacher interviews and observations, eight of these schools were also selected to participate in a sub-study of hand hygiene knowledge, attitude and behaviours, and an assessment of how the schools implemented the intervention. It was found that Hands Up for Max! increased knowledge and awareness, but this did not lead to a reduction in absences [8
]. The study’s authors also found that educating children on hand hygiene, while necessary, is not in itself sufficient. Structural factors such as the time available to wash hands and the cleanliness of facilities are also key [8
]. A related evaluation found low take up of the intervention beyond the trial; for successful implementation, educational resources need to be embedded into the curriculum [9
], a European project led by Public Health England with a consortium of 28 partner countries, aims to educate children about hand and respiratory hygiene, as well as the prudent use of antibiotics to combat antibiotic resistance [11
]. e-Bug provides primary and secondary school teachers and students with educational packages that include lesson plans and activities. Resource packs were posted to every primary (n
= 19,142) and secondary (n
= 5637) school in England in 2010 and again in 2015. Sent out with the 2015 packs was an invitation for educators to take part in an online survey evaluating the resources. Of the 695 respondents (2.8% response rate), 94% rated the resource as either good or excellent [12
]. However, given the low response rate these results need to be interpreted with some caution. In an earlier evaluation (conducted in England, France and Czech Republic) the effectiveness of the packs was measured by assessing children’s (aged 9–11 and 12–15) knowledge gain when using e-Bug. There was little difference in knowledge gain between e-Bug schools and those following the usual curriculum [13
Glo-yo is a small yo-yo like device that incorporates an educational video and dispenses iridescent soap that can indicate how well hands have been washed under UV light (also incorporated into the device). It was developed at the University of Nottingham, with children (aged 5–8) from two primary schools coming up with the initial designs. It was evaluated at the same two schools using children’s self-reports of handwashing, microbial sampling of their hands, and reports from parents and teachers. Although no significant difference was found in microbial load on children’s hands, a 34% increase in handwashing was reported. In follow-up interviews a year later, teachers and children also reported a sustained improvement in handwashing [14
Both Hands up for Max! and e-Bug are classroom-based interventions that need to be delivered by teachers. This puts a demand on teacher time and the interventions are asynchronous and geographically separate from the action of handwashing. Point-of-decision signs have been effective in changing behaviour in many studies [15
]. In our study, like Glo-yo [14
], children helped to co-design communication to be placed at the point-of-decision (i.e., in toilet facilities). Unlike Glo-yo where a new product is introduced into the toilet facilities, the PSG are incorporated into existing facilities (see Figure 1
To develop hand hygiene promotions that are both economical and impactful, it is necessary to understand the effectiveness and efficiency of interventions. Effectiveness is the degree to which an intervention achieves a desired outcome (in this case an increase in hand hygiene), whereas efficiency is how successful an intervention is compared to other interventions [16
]. Efficiency goes beyond comparing the effectiveness of interventions (as this is usually measured under ideal conditions) to how well an intervention can be adopted and implemented in real-life settings [16
]. The research questions for this evaluation are
Before conducting a major roll-out of any intervention it is prudent to do a smaller-scale test [17
]. In this study, the PSG are evaluated in four settings. Three of the settings are the UK primary schools (children aged 4 to 11) where the designs for the PSG were created and the fourth setting is a UK national children’s museum, which is a project partner.
2. Evaluation Frameworks
Frameworks offer a systematic way to analyse interventions and help to incorporate all the aspects that evaluations should address. They can also help ensure that key implementation strategies are incorporated into future dissemination plans [18
]. There are a variety of frameworks and tools that can be used, such as RE-AIM (reach, effectiveness, adoption, implementation and maintenance) [19
], PRECIS-2 (PRagmatic Explanatory Continuum Indicator Summary) [20
], PRISM (Performance of Routine Information System ManagementO [21
], CFIR (Consolidated Framework for Implementation Research) [22
], TREND (Transparent Reporting of Evaluations with Non-randomized Designs) [23
], and MRC (Medical Research Council) evaluation framework [24
]. All these frameworks are functional, comprehensive and could be used to evaluate this study. RE-AIM was selected as the primary framework because it could be easily applied to the school setting. Moreover, it could be used to evaluate this small-scale intervention, while at the same time informing further development of the intervention for future dissemination to more settings.
RE-AIM offers a comprehensive evaluation framework that can be used to evaluate and design public health interventions across five dimensions (reach, effectiveness, adoption, implementation and maintenance). The dimensions operate at setting level (adoption, implementation and maintenance) and/or participant level (reach, effectiveness and maintenance).
“Reach” is a measure of the representativeness of individuals who have agreed to participate in an intervention.
“Effectiveness” (referred to as “Efficiency” in some versions of the framework) is a measure of targeted outcomes including quality of life, economic costs and unintended negative consequences.
“Adoption” is a measure of the proportion and representativeness of settings that agree to the intervention.
“Implementation” is a measure of the degree to which settings deliver interventions as intended.
“Maintenance” is a measure of whether individuals sustain behaviour change and whether organisations continue to deliver the intervention [25
Taken together, the five dimensions offer a holistic evaluation of the impact of an intervention [25
]. RE-AIM is usually used to evaluate interventions that have taken place, but it can also be used to aid the development and design of interventions [26
]. As this stage in this study, the evaluation is an initial test of the designs in the three co-design schools and partner museum. The framework is firstly used to evaluate the intervention as it is, primarily its effectiveness (RQ1). Then efficiency is examined by considering the potential for wider reach, adoption and implementation (RQ2) in a larger roll-out to more schools and more settings. Maintenance and the potential for long-term impact are also considered (RQ1 and RQ2).
The limitations of each of the five evaluations are described separately under each evaluation. As the results of each evaluation broadly correspond with the results of the others, it is possible to draw conclusions, albeit tentatively. Some limitations remain and are discussed next.
The idiosyncrasies of the different settings meant that different data collection methods had to be employed for evaluations 2 and 3, making comparisons of settings problematic.
The PSG were only tested in settings involved in the co-design stage of the study. Though the child participants were sampled across each school and most had not participated in the co-design phase, they still could have felt an affiliation with the PSG that would not be felt in other settings. None of the children from the partner museum participated in the design of “123”. Furthermore, only four settings participated and so it is not clear how generalisable the results are. It is, however, prudent to pre-test interventions before rolling out major campaigns [17
]. The evaluation results are sufficiently positive to warrant further evaluations in a large roll-out.
The evaluations were conducted over a short time period (three months pre and post-installation). From this assessment the immediate impact of the PSG can be identified. Whether hand hygiene is maintained and whether settings continue to implement the designs should ideally be tested two years post-intervention [25
Some flexibility in research design may be necessary when conducting research in schools [26
]. Ideally, all children in each of the settings would have participated in every evaluation. However, this would have been disruptive to the school day and the children’s learning. The number of participants sampled for each evaluation was balanced against the potential for disruption. Moreover, two schools did not participate in two of the evaluations.
Five evaluations (participant demographic, handwashing frequency, handwashing quality, design persuasiveness and stakeholder views) were conducted to examine the effectiveness and efficiency of the “123” PSG in three UK schools and one museum setting. The results are promising, suggesting that the “123” PSG were substantively effective in increasing hand hygiene in the school settings in which they were designed. This should be validated with further evaluations in more school settings. In the museum setting, the “123” PSG likely increased hand hygiene but the messages need to be simplified for this setting where participants likely only see the designs once. It can also be concluded that PSG are an efficient way of communicating hand hygiene as they require little teacher time to implement and are low cost to produce. PSG can be used either independently of, or in conjunction with, other class-based hand hygiene programs.
This study is important because the toilet space has been largely neglected in prior hand hygiene interventions. This is short-sighted because hand hygiene needs to be communicated at the point-of-decision and not just taught in lessons remote from the activity of handwashing. The findings of this study can be used by researchers and developers of hand hygiene interventions. They could also be used more generally by those developing health-related interventions where messages can be helpfully incorporated into the environment (e.g., doctors’ surgeries and hospitals).