Hand Hygiene Roles, Challenges, and Intervention Feedback from School Staff: A Qualitative Analysis, Belize, 2022–2023
Abstract
1. Introduction
2. Methods
2.1. Study Design
2.2. Intervention
2.3. Interview Guide Development
2.4. Data Collection
2.5. Analysis
3. Results
3.1. Theme 1: Hand Hygiene Responsibilities of School Staff
“… when the memorandum was sent to all primary schools and high schools and sixth form, immediately we start elaborating a plan of action in my school… [so that] the day that we reopened school again, there would be a way of how students will be safe in the washing of hands.”(Baseline, School 2, Teaching Administrator)
“Well, ever since we came back to school, face to face, one of my responsibilities is to ensure that whenever children arrive at school, the first thing they do is wash their hands. So they can keep their hands clean before they enter the classroom.”(Baseline, School 4, Teacher)
3.2. Theme 2: Hand Hygiene Management Systems and Challenges
“…we get a few from the Ministry when it comes to liquid soap, Clorox, Flash. The parents are the ones [who] usually send donations or they send the child to school with alcohol, toilet paper, paper towels. We…send out letters to different organizations and they would supply us with some materials. Other than that, if we don’t have, then we have to use the fees collected by the school in order for us to purchase the supplies that we need.”(Baseline, School 10, Administrator)
“The only problem the school is having right now in providing anything for the staff is finance. Honestly, that’s it because it’s not the availability of the product. It’s available. But we don’t have the finance to purchase it.”(Baseline, School 5, Teacher)
“…we realized that…when…they [students] were not supervised they would waste…the liquid [soap]. And before the…week was over, we had to refill it…we met as a staff, and we agreed…that every teacher would… [have a] liquid container [in the classroom].”(Follow-up, School 2, Teaching Administrator)
3.3. Theme 3: Challenges with Ensuring Hand Hygiene Practice
“Because we teach them here and they go home and practice something completely different. And then because of this COVID for two years [they’ve] been doing something far different from what we’re training them to do here…”(Baseline, School 7, Teaching Administrator)
“…they’re [the students] aware of washing hands, and they know that they need to wash their hands… after they come from the bathroom… But sometimes I notice that… they actually… forget to wash their hands.”(Follow-up, School 4, Teaching Administrator)
3.4. Theme 4: Perceptions of Intervention: Environmental Nudges
“They [the students] see it. They know it’s there. And they use it. I know for the pavers, they…like it. ‘Oh, little stones to hop on’… So, it’s just a means to get to where they need …they enjoy hopping from…stone to stone. It’s fun for them.”(Follow-up, School 3, Administrator)
“… they [the students] have washed their hands, … some of them do take their time…there are a few that… I have to keep on reminding them … And some of them I noticed that [when] the soap is moved…I notice that they put it back where the arrow is.”(Follow-up, School 7, Teaching Administrator)
3.5. Theme 5: Perceptions of Intervention: Hand Hygiene Lessons
“…it was great to listen to the different ideas from other colleagues across…the country. And it was good because it was not northern teachers only, but it was countrywide.”(Follow-up, School 6, Teaching Administrator)
“So I came and I did it with the beat and the rhythm, and they love it, you know? ‘This is the way to wash your hands, wash your…’ and they started to sing all those things when they’re washing their hands. So I know…the message is there.”(Follow-up, School 8, Teaching Administrator)
3.6. Theme 6: Recommendations from School Staff
“And we want to focus more on the teaching in our lessons. Something that this year we were more concentrated on children practicing, but I believe that it has to be implemented… in every lesson, reminding children about [the] importance of having their hands clean.”(Follow-up, School 6, Teaching Administrator)
“To provide schools with more supplies and to give and to educate…or have more workshops so teachers can get involved, and they can see that whatever is learned in the workshop, they can bring it out to the students.”(Follow-up, School 4, Teaching Administrator)
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- Aiello, A.E.; Coulborn, R.M.; Perez, V.; Larson, E.L. Effect of Hand Hygiene on Infectious Disease Risk in the Community Setting: A Meta-Analysis. Am. J. Public Health 2008, 98, 1372–1381. [Google Scholar] [CrossRef] [PubMed]
- Wolf, J.; Johnston, R.B.; Ambelu, A.; Arnold, B.F.; Bain, R.; Brauer, M.; Brown, J.; Caruso, B.A.; Clasen, T.; Colford, J.M.; et al. Burden of Disease Attributable to Unsafe Drinking Water, Sanitation, and Hygiene in Domestic Settings: A Global Analysis for Selected Adverse Health Outcomes. Lancet 2023, 401, 2060–2071. [Google Scholar] [CrossRef] [PubMed]
- Willmott, M.; Nicholson, A.; Busse, H.; MacArthur, G.J.; Brookes, S.; Campbell, R. Effectiveness of Hand Hygiene Interventions in Reducing Illness Absence among Children in Educational Settings: A Systematic Review and Meta-Analysis. Arch. Dis. Child. 2016, 101, 42–50. [Google Scholar] [CrossRef]
- McGuinness, S.L.; Barker, S.F.; O’Toole, J.; Cheng, A.C.; Forbes, A.B.; Sinclair, M.; Leder, K. Effect of Hygiene Interventions on Acute Respiratory Infections in Childcare, School and Domestic Settings in Low- and Middle-Income Countries: A Systematic Review. Trop. Med. Int. Health 2018, 23, 816–833. [Google Scholar] [CrossRef]
- Mbakaya, B.C.; Lee, P.H.; Lee, R.L.T. Hand Hygiene Intervention Strategies to Reduce Diarrhoea and Respiratory Infections among Schoolchildren in Developing Countries: A Systematic Review. Int. J. Environ. Res. Public Health 2017, 14, 371. [Google Scholar] [CrossRef]
- World Health Organization. Advice for the Public: Coronavirus Disease (COVID-19). Available online: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public (accessed on 6 September 2023).
- McMichael, C. Water, Sanitation and Hygiene (WASH) in Schools in Low-Income Countries: A Review of Evidence of Impact. Int. J. Environ. Res. Public Health 2019, 16, 359. [Google Scholar] [CrossRef] [PubMed]
- Ly, A.N.; Craig, C.; McDavid, K.; Maheia, D.; Gongora, Y.; Morey, F.; Manzanero, R.; Medley, A.; Stewart, A.; Lino, A.; et al. Hand Hygiene Knowledge, Attitudes, Practices, and Hand Dirtiness of Primary School Students before and after a Behavioral Change Intervention during the COVID-19 Pandemic, Belize 2022–2023. Am. J. Trop. Med. Hyg. Accepted.
- Dreibelbis, R.; Kroeger, A.; Hossain, K.; Venkatesh, M.; Ram, P.K. Behavior Change without Behavior Change Communication: Nudging Handwashing among Primary School Students in Bangladesh. Int. J. Environ. Res. Public Health 2016, 13, 129. [Google Scholar] [CrossRef]
- Huang, H.C.; Le, N.; Battle, M.; Villasenor, J.M.; Maule, L. Nudging Handwashing among Primary School Students in the Philippines: Evidence from a Cluster Randomized Trial. Am. J. Trop. Med. Hyg. 2021, 105, 1806–1815. [Google Scholar] [CrossRef]
- Grover, E.; Hossain, M.K.; Uddin, S.; Venkatesh, M.; Ram, P.K.; Dreibelbis, R. Comparing the Behavioural Impact of a Nudge-Based Handwashing Intervention to High-Intensity Hygiene Education: A Cluster-Randomised Trial in Rural Bangladesh. Trop. Med. Int. Health 2017, 23, 10–25. [Google Scholar] [CrossRef]
- Delva, S.; Marseille, B.; Foronda, C.L.; Solomon, A.Y.; Pfaff, T.; Baptiste, D.-L. Hand Hygiene Practices in Caribbean and Latin American Countries: An Integrative Review. J. Clin. Nurs. 2023, 32, 2140–2154. [Google Scholar] [CrossRef] [PubMed]
- Ezezika, O.; Heng, J.; Fatima, K.; Mohamed, A.; Barrett, K. What Are the Barriers and Facilitators to Community Handwashing with Water and Soap? A Systematic Review. PLoS Glob. Public Health 2023, 3, e0001720. [Google Scholar] [CrossRef] [PubMed]
- Ly, A.N.; McDavid, K.; Craig, C.; Maheia, D.; Gongora, Y.; Medley, A.; Morey, F.; Manzanero, R.; Morazan, G.; Lino, A.; et al. Water, Sanitation, and Hygiene Infrastructure and Resources in Schools in Belize during the COVID-19 Pandemic, 2021–2023. Int. J. Environ. Res. Public Health 2024, 21, 470. [Google Scholar] [CrossRef] [PubMed]
- MAXQDA. VERBI Software MAXQDA, Version 2020; Computer Software; MAXQDA: Berlin, Germany, 2020. [Google Scholar]
- Bingham, A.J. From Data Management to Actionable Findings: A Five-Phase Process of Qualitative Data Analysis. Int. J. Qual. Methods 2023, 22, 16094069231183620. [Google Scholar] [CrossRef]
- Alexander, K.T.; Dreibelbis, R.; Freeman, M.C.; Ojeny, B.; Rheingans, R. Improving Service Delivery of Water, Sanitation, and Hygiene in Primary Schools: A Cluster-Randomized Trial in Western Kenya. J. Water Health 2013, 11, 507–519. [Google Scholar] [CrossRef]
- Curtis, V.; Schmidt, W.; Luby, S.; Florez, R.; Touré, O.; Biran, A. Hygiene: New Hopes, New Horizons. Lancet Infect. Dis. 2011, 11, 312. [Google Scholar] [CrossRef]
- Schell, S.F.; Luke, D.A.; Schooley, M.W.; Elliott, M.B.; Herbers, S.H.; Mueller, N.B.; Bunger, A.C. Public Health Program Capacity for Sustainability: A New Framework. Implement. Sci. 2013, 8, 15. [Google Scholar] [CrossRef]
- Chatterley, C. National Assessment of WASH in Schools-Belize. Available online: https://issuu.com/unicefbelize/docs/final_wash_assessment (accessed on 6 September 2023).
- Chard, A.N.; Freeman, M.C. Design, Intervention Fidelity, and Behavioral Outcomes of a School-Based Water, Sanitation, and Hygiene Cluster-Randomized Trial in Laos. Int. J. Environ. Res. Public Health 2018, 15, 570. [Google Scholar] [CrossRef]
- O’Reilly, C.E.; Freeman, M.C.; Ravani, M.; Migele, J.; Mwaki, A.; Ayalo, M.; Ombeki, S.; Hoekstra, R.M.; Quick, R. The Impact of a School-Based Safe Water and Hygiene Programme on Knowledge and Practices of Students and Their Parents: Nyanza Province, Western Kenya, 2006. Epidemiol. Infect. 2008, 136, 80–91. [Google Scholar] [CrossRef]
- Bieri, F.A.; Gray, D.J.; Williams, G.M.; Raso, G.; Li, Y.-S.; Yuan, L.; He, Y.; Li, R.S.; Guo, F.-Y.; Li, S.-M.; et al. Health-Education Package to Prevent Worm Infections in Chinese Schoolchildren. N. Engl. J. Med. 2013, 368, 1603–1612. [Google Scholar] [CrossRef]
- Winter, J.C.; Darmstadt, G.L.; Lee, S.J.; Davis, J. The Potential of School-Based WASH Programming to Support Children as Agents of Change in Rural Zambian Households. BMC Public Health 2021, 21, 1812. [Google Scholar] [CrossRef] [PubMed]
- Chittleborough, C.R.; Nicholson, A.L.; Basker, E.; Bell, S.; Campbell, R. Factors Influencing Hand Washing Behaviour in Primary Schools: Process Evaluation within a Randomized Controlled Trial. Health Educ. Res. 2012, 27, 1055–1068. [Google Scholar] [CrossRef] [PubMed]
- Appiah-Brempong, E.; Harris, M.J.; Newton, S.; Gulis, G. A Framework for Designing Hand Hygiene Educational Interventions in Schools. Int. J. Public Health 2018, 63, 251–259. [Google Scholar] [CrossRef] [PubMed]
School Number | Rural/Urban | Baseline | Follow-Up |
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School 1 | Urban | Teaching administrator | Administrator * |
Teacher | |||
School 2 | Urban | Teaching administrator | Teaching administrator |
School 3 | Rural | Administrator | Administrator * |
Teacher | |||
School 4 | Rural | Teaching administrator | Teaching administrator |
Teacher | |||
School 5 | Rural | Teacher | Administrator |
School 6 | Rural | Teaching administrator | Teaching administrator * |
Teaching administrator | |||
School 7 | Rural | Teaching administrator | Teaching administrator * |
Teacher | |||
School 8 | Rural | Teaching administrator | Teaching administrator |
School 9 | Rural | Administrator | Teaching administrator |
Teacher | |||
School 10 | Rural | Administrator | No interview |
Teacher | |||
School 11 | Rural | Teaching administrator | Teaching administrator * |
Teacher | |||
School 12 | Rural | Administrator | Teacher |
Teacher |
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Ly, A.N.; Craig, C.; Maheia, D.; Gongora, Y.; Romero, V.; Blanco, R.; Lino, A.; McDavid, K.; Stewart, A.; Trinies, V.; et al. Hand Hygiene Roles, Challenges, and Intervention Feedback from School Staff: A Qualitative Analysis, Belize, 2022–2023. Int. J. Environ. Res. Public Health 2025, 22, 835. https://doi.org/10.3390/ijerph22060835
Ly AN, Craig C, Maheia D, Gongora Y, Romero V, Blanco R, Lino A, McDavid K, Stewart A, Trinies V, et al. Hand Hygiene Roles, Challenges, and Intervention Feedback from School Staff: A Qualitative Analysis, Belize, 2022–2023. International Journal of Environmental Research and Public Health. 2025; 22(6):835. https://doi.org/10.3390/ijerph22060835
Chicago/Turabian StyleLy, Anh N., Christina Craig, Dian Maheia, Yolanda Gongora, Vickie Romero, Rosalva Blanco, Allison Lino, Kelsey McDavid, Allison Stewart, Victoria Trinies, and et al. 2025. "Hand Hygiene Roles, Challenges, and Intervention Feedback from School Staff: A Qualitative Analysis, Belize, 2022–2023" International Journal of Environmental Research and Public Health 22, no. 6: 835. https://doi.org/10.3390/ijerph22060835
APA StyleLy, A. N., Craig, C., Maheia, D., Gongora, Y., Romero, V., Blanco, R., Lino, A., McDavid, K., Stewart, A., Trinies, V., Medley, A., Morey, F., Manzanero, R., Lozier, M., & Murray, K. O. (2025). Hand Hygiene Roles, Challenges, and Intervention Feedback from School Staff: A Qualitative Analysis, Belize, 2022–2023. International Journal of Environmental Research and Public Health, 22(6), 835. https://doi.org/10.3390/ijerph22060835