“Bye-Bye Germs”: Respiratory Tract Infection Prevention—An Education Intervention for Children

Abstract

Becoming one of the first studies in the field to do so, specially developed educational interventions (Germ’s Journey), designed to teach children about respiratory tract infection prevention, were delivered to 273 pupils aged five to six across five primary schools in the U.K. The intervention aimed to increase understanding of pathogens and respiratory tract illness, transmission and infection prevention, and preparedness for future pandemics due to a lack of such resources for young children at present. To assess the impact of the intervention, children were asked five questions related to knowledge of pathogens, transmission of infection, and infection prevention directly before and after activity-based workshops, as well as one month later. Responses were scored for pupils’ level of knowledge; differences in the frequency of responses between the time points were analysed using Pearson’s chi-squared test. Teachers also took part in semi-structured interviews to evaluate the workshop from the educators’ points of view. Children showed increased knowledge in all three areas immediately after the workshops. This improvement was retained to a lesser or equal extent one month following the learning intervention workshop. The consistent use of teaching resources and interventions such as Germ’s Journey should be implemented in the school curriculum in order to increase understanding and reduce the transmission of respiratory tract illness. Specially designed activity-based workshops using a range of learning skills can help young children to understand the link between pathogens, and infection transmission and control.

1. Introduction

Germ’s Journey is a project that co-creates (alongside end-users, international stakeholder partners and collaborators) interactive health-educational resources for children. Initially developed with a focus on children in the early years foundation stage (EYFS) in the UK, additional resources, based on bacterial illness, were subsequently developed for use in countries across Europe, Asia and Africa to educate pupils on how to prevent infection. One of the overall aims of the Germ’s Journey project is to provide freely available resources to low- and middle-income countries (LMICs), and address the UN Sustainable Development Goals for health and education (SDG 3 and 4) through knowledge exchange globally. While the aim of the project is to make the Germ’s Journey resources available to LMICs, we recognise that this study was conducted with UK children, so the results may not be generalizable to other countries.

In response to COVID-19, a need for new resources that focused on respiratory tract infection and were specifically aimed at young children was identified. The Germ’s Journey team became one of the first to create scientifically and educationally informed COVID-19 resources for young children. Infection control and education specialists created a book for use in the UK that was made freely available as an e-book during the first UK lockdown (March to June 2020), with hard copies of the book being donated to schools. Additional activity-based educational resources were developed to be used in school workshops as part of a post-pandemic “build back better” initiative [1]. These workshops were delivered to year 1 pupils in 2021. Though initially developed due to the COVID-19 pandemic, aiding children’s understanding of viral respiratory tract infection transmission, and infection prevention and control measures is fundamental not only for limiting the severity of COVID-19 cases moving forward but also for protecting pupils from, and preparing for, emerging respiratory infectious diseases and future pandemics.

Alongside infection prevention social distancing measures and correct coughing etiquette, children’s understanding of why they need to wash their hands is crucial for ensuring that the important measures taken to reduce the transmission of COVID-19 and other respiratory illnesses continue on a day-to-day basis. Behl et al. (2022), notes that the COVID-19 pandemic highlighted the “lack of sufficient knowledge in the understanding of the importance of biological threats and medical preparedness” [2]. To ensure that we are prepared for other viruses “considered as a potent biological threat” (due to being highly transmittable across the globe), such as “Acute Hemorrhagic Conjunctivitis (AHC), Rabies, Acquired Immune Deficiency Syndrome (AIDS), Cholera, Dengue, Influenza, Plague, Severe Acute Respiratory Syndrome (SARS)” [2], it is imperative that, from a young age, children are taught how and why to protect themselves and others from such infectious diseases.

Critical cases of COVID-19 in children are rare, and children “are more likely than adults to have asymptomatic or mild infections” [3]. Children are believed to have a quicker innate immune response to novel viruses than adults and may already have antibodies from prior exposure to coronaviruses that frequently circulate among young children [3,4]. However, as they are frequently asymptomatic despite carrying a high viral load, evidence suggests that children have played a considerable part in transmitting COVID-19 [5]. Furthermore, studies analysing faecal transmission found prolonged viral shedding in children who were asymptomatic [6].

Most children who have been hospitalised due to acute COVID-19 were not vaccinated, with many having co-morbidities such as type 2 diabetes [1]. UK studies show that children with neurodisabilities are particularly at-risk of hospital admission or death due to COVID-19 [7,8].

Correct hand-hygiene practices have been recognised as a key measure for limiting the transmission of respiratory illnesses [9,10,11,12]. Aiello et al. found a 21% reduction in respiratory illnesses as a result of hand-hygiene interventions [13], whilst Warren-Gash et al. highlighted a considerable reduction in respiratory illness in childcare settings in low-income countries due to hand-hygiene practices [14]. Studies in India [15] and Pakistan [16] also reported decreases in respiratory illnesses following hand-hygiene interventions.

Evidence suggests that educational interventions, particularly within schools, have the potential to increase understanding of germs, encourage and improve hand-hygiene behaviour in children and reduce infection transmission [17,18,19]. Moreover, research regarding habit formation indicates that “for many behaviors … achieving meaningful health outcomes depends on repeated performance” [20]. Fináncz et al. (2023) notes that “adult health behavior is established and formed in childhood”, with formal education such as schooling playing a key role [21]. Research [22,23,24] has shown that educating children from an early age has a more significant effect on their health habits than doing so during the later years of their school lives. By encouraging children to practice good hand-hygiene habits from an early age, these habitual behaviours are argued to be self-sustaining, meaning that these habits will continue long term [20]. In a school intervention aiming to increase children’s oral hygiene habits, research found that children who took part in a habit-based intervention had better oral health (i.e., less plaque) and better toothbrushing habits than those in the control group [25], highlighting the potential for increased understanding and behavioural change due to school-based interventions regarding health and hygiene education. Although there have been many school-based educational interventions regarding health for young children, these primarily focused on nutrition, oral health and exercise [26,27,28,29,30,31,32,33,34,35,36], with little research considering the effects of infection prevention educational interventions. Nevertheless, published studies demonstrate that school-based interventions are effective and play an important role in improving health education understanding and inducing positive behavioural change.

Previous work by the Germ’s Journey research group was effective at engaging children in hand-hygiene practices related to bacterial infections [37,38,39,40]. After conducting previous studies to evaluate whether the Germ’s Journey resources engaged children, increased understanding, and improved handwashing practice and behaviour with regard to bacterial infection [37,38,39,40], the next step of the project was to develop and evaluate a set of resources that taught children about respiratory tract infections, with the aim of initially teaching infection prevention against SARS-CoV-2, as well as to contribute to our preparedness for future health risks, emerging infectious diseases and pandemics.

This study aimed to evaluate the Germ’s Journey educational workshop and resources and their impact on children’s understanding of (A) pathogens and respiratory tract illness, (B) pathogen transmission and (C) Infection prevention methods. The Germ’s Journey project’s overall focus is on teaching children about hand-hygiene practices, with this particular study focusing on respiratory infection prevention within UK primary schools, including handwashing and correct coughing and sneezing etiquette.

Research Questions:

• Does the Germ’s Journey educational workshop increase children’s understanding of pathogens and respiratory tract illness?
• Does the Germ’s Journey educational workshop give children a greater understanding of pathogen transmission?
• Does the Germ’s Journey educational workshop improve children’s understanding of infection prevention methods?

2. Materials and Methods

2.1. Participants

A multi-site case study approach was used to strengthen the generalizability of the findings [41] and enable broader applicability [42]. This study’s sample consisted of 273 year 1 pupils aged five to six years old across five inner-city and rural schools in Leicestershire (

Table 1. School case studies’ demographic information.

	Church of England Academy Trust	Community School	Community School	Community School	Roman Catholic Academy Trust	England National Average
School Number	1	2	3	4	5
Ages	4–11	3–11	3–11	3–11	3–11
No. of pupils	207	462	707	487	249
No. of groups in Year 1	1	3	3	2	1
Class size	28	3 × 30	3 × 30	2 × 30	25
SEN support	5.6%	6.7%	8.3%	13.4%	30.9%	14.6%
Free School Meals	7.9%	3.7%	15.3%	44.1%	43.4%	23.5
Not English first language	9.3%	3.2%	97.2%	30%	36.9%	20.9%
OFSTED	2016: Good	2018: Good	2017: Good	2014: Outstanding	2018: requires improvement
** Index of multiple deprivation Score (2019)	29,438 D9	32,607 D10	9221 D3	5039 D2	5112 D2

** The IMD scores are grouped so that all fall into 10 groups, where 10 is the least deprived and 1 is the most deprived.

).

2.2. Instrumentation

2.2.1. Pre- and Post-Questions to Assess Children’s Learning

To assess the impact of the workshop on the children’s understanding of respiratory tract pathogens, transmission and infection control, children were individually asked a series of identical questions both directly before and after the workshop, and then again a month later. The children were asked “How do germs make us poorly?”, “Where do germs live?” (knowledge of pathogens), “Can we get germs from coughs and sneezes?” (transmission), and “How do we get rid of germs” and “Why must we always catch our coughs and sneezes in a tissue or in our elbow?” (infection control).

Due to the young ages of the children (5 to 6 years old) and their limited reading ability, the researchers decided to ask the children the questions orally and record their responses, rather than require the children to read and respond to a worksheet. Whilst this enabled the children to talk freely to the researcher and explain their understanding without the limitations of having to read and articulate their answers in written form (something that could be quite challenging for young children), it is important to note that some children were shy around the researchers, possibly limiting the answers in some cases. Children from School 2 were asked similar questions a year after the Germ’s Journey workshop to assess the retention of knowledge over a longer period.

2.2.2. Semi-Structured Interviews with Teachers

One month after the workshops, interviews were conducted with the teachers of the classes to help us to evaluate the impact on the children’s learning from the educator’s perspective. Teachers took part in semi-structured interviews, adding another layer of evaluation to the findings. Questions were asked in order to evaluate the workshop from the teachers’ point of view. It is important to be aware of the limitations of this method, including the potential for teachers to feel an obligation to answer positively about the workshop. However, the researchers negated against this by reinforcing to the teachers the importance of their honest responses in evaluating the workshop. Teachers were asked questions as prompts to initiate discussion regarding how children engaged with the workshop, the methods/resources used within the workshop, their observations of children’s understanding and behaviour with regard to infection prevention and hand-hygiene practices since the workshop and any areas of improvement for, or possible challenges in, conducting the workshop again.

2.3. Procedure—Pedagogic Learning Design

2.3.1. Intervention Workshop Activities

The workshop consisted of seven learning activities; three were delivered to the whole class, followed by four separate activities that ran simultaneously in a carousel style on different tables around the classroom, which rotated different groups of children in a timed manner. The workshop followed the UK Department for Education’s (DfE) National Curriculum, with activities including Science, English (reading and comprehension and writing), PHSE: Health education, and Art and Design [43], as well as following the DfE Statutory Guidance for Physical Health and Mental Wellbeing in Primary School, which states that pupils should learn about personal hygiene and germs and the importance of handwashing [44]. All activities are available on the Germ’s Journey website. The workshops and resources were underpinned by widely recognised theories of learning, including Scaffolding [45], Zone of Proximal Development (ZPD) [46] and Experiential Learning [47]. Scaffolding is the notion that when provided with support, children are able to learn new concepts more effectively, enabling them to carry out learning tasks around these concepts independently. Similarly, ZPD highlights that when given guidance in new topics, children are able to achieve more than they would have been able to achieve alone. Experiential leaning advocates for hands-on learning experiences for children, particularly when learning about abstract concepts such as invisible microbes.

2.3.2. Whole-Class Activities

The workshop started with a video reading of “Bye-Bye Germs: Be a Handwashing Superhero!” by the book’s artistic illustrator, which included questions and spaces for the children to respond. The video included a British Sign Language (BSL) interpreter and subtitles to improve accessibility and increase inclusion for children with special educational needs (SEN). The second activity introduced the concept of “good” and “bad” germs, using illustrations of microbes with emotive faces (matching their classification of being “good” or “bad”) and facts that had been hidden around the classroom for the children to find (Figure 1). Finally, the researcher, using microbe toys, explained how invisible pathogens can be transmitted, showing the variations in pathogens (SARS-CoV-1 and 2, Pseudomonas, Staphylococcus aureus, and MRSA). This activity discussed the differences between bacteria and viruses. The whole-class activities introduced the topic to the children, encouraging discussion and questions, thus enabling the children to be supported, which was in line with the underpinning theories of Scaffolding and ZPD.

2.3.3. Carousel Activities

Four activities were run simultaneously, with the small groups of children moving around until all groups had completed all activities. In one activity, the children could draw a germ with the support of a video tutorial by the book’s illustrator, engaging with the physical structure of a virus whilst developing drawing skills. A second activity demonstrated the importance of using soap, which used the pepper-in-water experiment, where soap on their hands dispersed pepper on the surface of the water. This was supported by a video demonstration of correct handwashing, using paint (representing soap) on rubber gloves, to show the correct hand actions needed when handwashing to cover all parts of the hands. Children also took part in a third activity, which was a glow-in-the-dark hand gel exercise, demonstrating the concept of invisible germs and how areas can be missed when handwashing. Lastly, children were given a worksheet with an illustration of a classroom scene, where they circled the places where contamination is typically most common. All activities were supported by Germ’s Journey researchers, who engaged the children in discussion about the purpose of all the activities, again highlighting the employment of Scaffolding and ZPD. By developing an interactive pedagogic approach to the learning intervention workshop design, the researchers drew on dialogic learning techniques to ensure that children had an opportunity to articulate their understanding after each learning activity. This helped to embed the learning from firsthand experiential learning by interacting with the resources directly (soap and pepper, glow-in-the dark gel, drawing the structure of a virus) for cognitive appreciation of the “why”. These activities were designed to be hands-on experiences for the children, in accordance with the theory of Experiential Learning.

A workshop Brief/lesson plan for the session can be found in Appendix A and on the Germ’s Journey website (www.germsjourney.com (accessed on 1 March 2024)).

2.4. Analysis

The answers given by the children were recorded, and each question had an individual set of criteria and “score” for the answers (

Table 2. Scoring criteria for children’s pre- and post-questions.

Question:	Individual Score Criteria
	0	1	2	3
1: “How do germs make us poorly?”	Child said, “I don’t know,” did not give an answer or gave an answer that did not involve germs or handwashing	Answers had a connection to germs or hand washing	Answer involved germs or not washing hands, but did not state “inside body”	Answers that included “inside body”, “in mouth”, and/or “eating with dirty hands”
2: “Where do germs live?”	Child said “I don’t know” or gave no answer	Child suggested an area that could be contaminated	N/A	N/A
3: “Can we get germs from coughs and sneezes?”	Child answered “no”	Child answered “yes”	N/A	N/A
4: “How do we get rid of germs?”	Child said “I don’t know” or gave no answer	Child gave an answer other than “washing hands”	Answer included washing hands	Answer included “washing hands with soap”
5: “Why must we always catch our coughs and sneezes in a tissue or in our elbow?”	Child said “I don’t know” or gave no answer	Answer mentions germs but does not mention the spread/transmission of germs or other people	Answer included the spread of germs to other people	N/A

). These scores were calculated to give a percentage of children who scored 0, 1, 2 or 3 directly before, directly after and then a month after the workshop. Scores were also calculated to give the percentage change in the answers given directly before and after and the percentage change directly before and a month following the workshop. This enabled the researchers to decipher the direct impact that the workshops had on the children’s understanding of pathogen transmission and hand-hygiene practices in comparison to their baseline measures. Statistical analysis (Pearson’s chi-squared test) was conducted using IBM SPSS (version 28). Significance was set at p ≤ 0.05.

The teachers’ semi-structured interviews were analysed using thematic analysis, in which responses were categorised into individual themes that arose.

To ensure the validity and reliability of the study, a mixed-methods design was employed, using quantitative (children’s questions) and qualitative (teacher’s semi-structured interviews) data collection tools.

3. Results

Five schools covering a range of social–economic areas participated in the workshops, with 273 children aged between 5 and 6 years old participating.

3.1. Children’s Understanding of Pathogens and Transmission

To assess the children’s understanding of pathogens, they were asked “how do germs make us poorly?”. The responses were grouped and scored according to the level of knowledge the answer demonstrated. If the child said, “I don’t know”, did not give an answer or gave an answer that did not involve germs or handwashing, it was scored as 0. Answers that had a connection to germs or hand washing were scored as 1; if the answer involved germs or not washing hands, but did not state “inside body”, it was scored as 2; and answers that included “inside body”, “in mouth”, and/or “eating with dirty hands” were scored as 3. The results are presented in Figure 2.

Before the workshop, 45.56% of the children gave an answer scoring 0, which dropped to 23.79% following the workshop, a decrease of 21%. For answers scoring 1, the percentages went from 26.3% before the workshop to 23% after the workshop. Positive answers (those scoring 2 or 3) increased following the workshop, rising from 16.3% to 24.54% and 11.85% to 28.62%, respectively.

At the one-month follow-up, answers scoring 0 remained low at 21.62%, but answers scoring 1 had increased to 38%. The percentage of pupils giving positive answers, scoring 2 or 3, had dropped from the post-workshop levels but were higher than the pre-workshop levels at 15.83% and 23.94%, respectively.

Overall, there was a 12.09% increase in answers scoring 3 between the baseline knowledge and one month after the workshop, as well as a 23.93% drop in answers scoring 0, demonstrating the retention of knowledge one month on from the workshop.

The changes in the frequencies of all the responses were found to be statistically significant (p ≤ 0.05)

In response to the question “where do germs live?”, answers were scored as 0 if the child said “I don’t know” or gave no answer and 1 if the child suggested an area that could be contaminated. The results are shown in

Table 3. Where do germs live?

Pupils’ Answers	Score	Pre	Post	Follow-Up	% Change between Pre- and Post-Workshop	% Change Between Pre-Workshop and Follow-Up
No answer/did not know	0	43.59% (119)	10.82% (29)	12.31% (32)	32.77% decrease	31.28% decrease
Answer includes contaminated areas	1	56.41% (154)	89.18% (239)	87.69% (228)	32.77% increase	31.28% increase

. Prior to the workshop, 43.59% of the children were not able to suggest areas where germs may be found; this decreased to 10.82% immediately following the workshop and remained low at 12.31% at the one month follow-up. The changes were found to have statistical significance (p ≤ 0.05).

Approximately one year after the workshop, children from School 2 were asked “where can you find germs?”, with 82.92% (68) identifying areas potentially contaminated with pathogens. These children were also asked if all germs were bad, with 78.04% (64) knowing that this was not the case, demonstrating good knowledge retention.

To examine the children’s understanding of germ transmission, they were asked “Can we get germs from coughs and sneezes?”; 81.21% of the children were able to answer “yes” before the workshop, which increased to 89.03% immediately after the workshop and maintained a small increase at 86.58% at the one-month follow-up. Corresponding decreases were seen for the number of children who said “no” (

Table 4. “Can we get germs from coughs and sneezes?”.

Pupils’ Answers	Score	Pre-Workshop	Post-Workshop	Follow-Up	% Change between Pre- and Post-Workshop	% Change between Pre-Wokshop and Follow-Up
No	0	18.79% (28)	10.97% (17)	13.42% (20)	7.82% decrease	5.37% decrease
Yes	1	81.21% (121)	89.03% (155)	86.58% (129)	7.82% increase	5.37% increase

).

Approximately one year after the workshop, Children from School 2 were asked “how are germs spread?”, and 65.85% (54) could identify how pathogens were transmitted, showing good retention of knowledge one year after the original workshop.

3.2. Children’s Understanding of Respiratory Tract Illness and Infection Prevention Methods

To assess the children’s knowledge of infection prevention, they were asked “how do we get rid of germs?” Negative answers (“I don’t know”, no answer) were scored as 0, answers that did not mention “washing hands” were scored as 1, answers saying “washing hands” but not mentioning soap scored 2, and answers that stated “washing hands” with soap scoring 3.

When asking pupils “how do we get rid of germs?”, results show a 15.03% decrease in children scoring 0 (not knowing/giving an answer) directly after the workshop compared to their baseline knowledge before the workshop. Likewise, the results show a 9.77% decrease in children giving an answer scoring 1 (an answer other than “washing hands”) directly after the workshop compared to directly before it. There were 10.46% and 12.82% increases in children giving answers scoring 2 (answer includes “washing hands”) and 3 (answer includes “washing hands with soap”) directly after the workshops compared to directly before the workshop. When asking pupils the same question one month after the workshop, the results show a 13.45% decrease in children scoring 0, with their answer compared to those noted directly before the workshop. Interestingly, although the majority of children (55.88% (152)) knew that “washing hands” removes germs, which given the handwashing guidance surrounding COVID-19 is not surprising, only 13.24% (36) of children specified “washing hands with soap” before the workshop. This then increased by 15.98% directly after the workshop, with 42 more children displaying knowledge of correct hand-hygiene practices, using soap to remove germs. Analysis of the changes in responses indicated that all changes had statistical significance (Figure 3).

Finally, the children were asked “why must we always catch coughs and sneezes in a tissue or in our elbow?” The results of this question show a 23.34% decrease in children providing an answer scoring 0 (not giving an answer/not knowing) directly after the workshop compared to their baseline knowledge directly before the workshop. There was a minor increase (2.63%) in children giving an answer scoring 1 (answer mentions germs but does not mention the spread/transmission of germs or other people) directly after the workshop compared to directly before and a 20.71% increase in children giving an answer scoring 2 (answer includes the spread of germs to other people) directly after the workshop. Furthermore, the results show a 22.87% decrease in children scoring 0, with a 22.21% increase in children’s answers including spread and/or other people (scoring 2) a month following the workshop, demonstrating that this new knowledge had been retained (Figure 4).

3.3. Teachers’ Semi-Structured Interview Findings

After the workshop, teachers were asked to give their opinions about the session. Findings included themes regarding the challenge of teaching abstract concepts such as invisible pathogens and how the Germ’s Journey workshop had helped with this, the importance of ensuring that methods of infection prevention are taught from an early age and the previous challenges associated with teaching this important topic day-to-day in the classroom before the Germ’s Journey intervention. The findings were positive, with teachers mentioning no challenges involved in implementing the intervention within their own classrooms.

3.3.1. Abstract Concepts—Invisible Pathogens

One teacher, following the workshop, spoke of the difficulty for children to understand the concept of invisible pathogens; however, the workshop activities made this easier to understand, with the teacher commenting that “before the session, the children had a bit of an idea of germs, but they didn’t actually understand as they can’t see them. The workshops were really practical and they could actually see the difference that handwashing was making … I think because the workshops were practical, and that they could see the ‘germs’ with the glo-gel activity, it makes it more real for them and they really enjoyed that”. Similarly, another teacher highlighted the practical and interactive aspects of the workshop supporting the concept of invisible pathogens, commenting that they “could tell [the children] loved seeing the glo-gel activity as it gave them a proper understanding of germs even though they are invisible”. It was also highlighted by another teacher that the workshop mitigated the challenges of teaching abstract concepts to young children as, when speaking about the glow gel activity and the microbe toy activity, the teacher explained that the children “loved that and lots of them spoke about it on the way home, because [for children] to visualize [invisible microbes] is quite hard”.

As part of the workshop, the children were taught about different types of germs and whether they were “good” or “bad”. One teacher highlighted that one of the things they felt the workshops had introduced to the children was “more about what germs are”, particularly following the COVID-19 pandemic, “because they know that germs are this thing, they’re not a good thing”, but that the workshop had also explained the concept of “good germs and bad germs. Which I think they benefitted [from]”.

3.3.2. Embedding the Topic of Infection Prevention from an Early Age

It was noted by a teacher that “The workshops are really important, especially at the moment if someone is off school and the children do catch germs, they need to be aware. So, I think this is something we need to do, right at the beginning, to get it into the children’s routines so that they are prepared.” Although it is important to teach the topic to children at a young age, with this finding, it is vital that the way in which the topic is taught is suitable for the target age group. It was highlighted that the combination of physical activities and discussion-based activities “worked best with their attention span”, with another commenting “that it worked really well”. Another teacher noted that “it was engaging for the children… because there was a mixture of both, they didn’t [lose their attention], they kept their concentration for such a young age”. When speaking about the glow gel activity in particular, one teacher noted that “that one has definitely embedded with them, and I think they enjoyed that the most as well”, with another teacher explaining that the children particularly liked “the experiments, when they were physically doing things. But I do think they enjoyed it all in general because it was so at their level, and they understood it, and you could see that”.

3.3.3. Behavioural Change

The teachers noted that the increase in understanding after the workshop had also impacted the children’s hand-hygiene behaviour and sneezing and coughing etiquette. One teacher noted that, due to the COVID-19 pandemic, “we’re pretty good at doing the handwashing”, but that “once the workshop was finished, they took a lot from it about why they were washing their hands and the importance of washing them properly”, with another teacher noting that the workshops had increased their understanding of “the amount of time that [the children] actually have to wash their hands for”, further noting that the children “tell each other, and point it out to each other, e.g., if someone sneezes, they’re aware that they need to go and wash their hands”. Another teacher noted that the children “were used to handwashing with the routines [(e.g., before and after playtime/lunch time)]” but “have realised that you need to wash hands more often, E.g. if you sneeze or cough”, with another teacher noting that the change in handwashing behaviour is because “they’ll be wanting to do it more, because they realise the impact that it has”. One teacher noted that when the children were “in line [to wash their hands], they were telling eachother, that you have to ‘do this’, and you have to ‘wash here’ and ‘don’t forget the backs of your hands’”.

The tensions between the importance of the topic and the challenges of embedding it day-to-day were as follows:

It was highlighted that before the COVID-19 pandemic, teaching the importance of infection prevention was not a priority compared to all the other topics that teachers need to teach. However, this workshop and its resources have helped with overcoming this challenge, with one teacher stating that “[the children] now want to wash their hands before lunch or break as they realise the impact handwashing has, and seeing what happens if you don’t. I think that this is sometimes missed when we’re teaching and trying to get everything done so that we can get through the day’s lessons. [The children] need to remember these things to help keep us all safe in the classroom”.

Areas of improvement and possible challenges when recreating the workshops were as follows:

When asked if there was anything that could be improved with the workshops, one teacher noted that for some of their pupils, the classroom worksheet activity (where children were asked to circle the places where contamination is most common) was more challenging, with those children needing more movement-based activities. However, the other teachers noted that they would not change anything, commenting “no, I liked it, it all flowed really well” and “no it was brilliant”.

In terms of any potential challenges involved in recreating the workshops at school, none of the teachers saw any issues. However, if the activities were to be recreated at home, the teachers noted challenges related to technology access, stating that “with home, not everyone can access the internet, however we can print the resources off for children to use at home” and “I think it would definitely be access to technology at home would be the biggest barrier”.

4. Discussion

4.1. Children’s Understanding of Pathogens and Transmission

Despite not always presenting symptoms, evidence shows that children are still able to transmit COVID-19 due to carrying a high viral load, even when not unwell themselves [5,6]. The concept of children being able to transmit pathogens to others, though not feeling unwell themselves, is difficult for young children to grasp.

With many young children not attending schools and not being able to socialize with their peers for months at a time during the lockdown period [48], the incidents and chance of transmitting pathogens to one another was significantly reduced. Therefore, when schools re-opened, the issue of transmitting contagious illnesses to one another became pertinent. An important factor in reducing the transmission of illnesses among children is increasing children’s awareness and understanding that respiratory tract illnesses can be spread to one another through droplets when they cough and sneeze.

The increase in the proportion of correct answers with regard to how pathogens cause illness demonstrates an increase in knowledge as a direct result of the learning intervention workshop. With many children (71.85% (194)), before the workshop intervention, either scoring 0 (presenting no knowledge of how germs make us poorly) and 1 (presenting little knowledge of how germs make us poorly), this suggests that although children are aware of COVID-19, having lived through the pandemic, this sample of children were mostly unaware of how pathogens can actually cause illness. This demonstrates a need for better and more consistent education around the topic in order to limit transmission of contagious illnesses and increase preparedness for future pandemics, reinforcing the importance of promoting habit-forming health educational interventions from an early age that carry on in later life [21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36].

One month following the workshop, one teacher noted the significance of ensuring that children are taught about pathogen transmission from an early age “to get it into the children’s routines so that they are prepared.” Another teacher highlighted the importance of having learning activities that are suitable for the target age of the children, with a combination of activities “[working] best with their attention span”.

It was important to highlight in the workshops that some germs can cause illnesses, but they are also important to keep our bodies healthy. This is particularly important as it ensures that children are not scared of pathogens, particularly at a time of uncertainty and given their awareness of the anxieties of those around them regarding the COVID-19 pandemic; instead, it is important that children are aware of the actions needed to reduce the risk of illness. One teacher highlighted that following the workshops, children had been discussing “good and bad germs”, further noting that they “think they [(the children)] benefitted [from]” participating in the project.

By increasing children’s awareness that illnesses can be passed on to one another through coughs and sneezes, this, in turn, creates the foundation for why it is important to engage in infection prevention methods, and how they can actively do this. Findings from the semi-structured interviews with teachers supported this, with one teacher explaining that children understood more “why they were washing their hands and the importance of washing them properly”. With two other teachers noting that the workshops had increased the children’s understanding of how illness is transmitted through coughs and sneezes, and the infection prevention methods to prevent transmission: “they have realised that you need to wash hands more often, e.g. if you sneeze or cough”, “[the children] point it out to each other, e.g., if someone sneezes, they’re aware that they need to go and wash their hands”. This also gives agency to the children, to feel that they can help themselves to limit infection by catching their germs, this is referred to as the ‘locus of control’ and can help reduce anxiety [49,50].

4.2. Children’s Understanding of Respiratory Tract Illness and Infection Prevention Methods

Having a good understanding of how to prevent the transmission of respiratory tract illness is crucial in the fight against COVID-19, among other respiratory infections, and helps to prepare this generation of children for future pandemics. The results of this study show that following the intervention, children had an increased understanding of microorganism transmission via coughs and sneezes (Table 4), with children also showing a greater understanding of why it is important to use a tissue or inner elbow to prevent the transmission of infectious disease when coughing and sneezing (Figure 4)

With young children being susceptible to contagious illnesses and particularly contagious carriers of COVID-19, it is crucial that they know how they can protect themselves and others in order to limit the spread of illnesses. Studies have shown the importance of correct hand-hygiene practices as a key infection prevention measure for respiratory tract illnesses, including SARS-CoV-2 [9,10,11,12], with studies finding substantial reductions in respiratory tract illnesses in children due to correct hand-hygiene practices [14,15,16].

Following the workshop, one teacher highlighted the importance of teaching children the correct infection prevention methods, such as handwashing, but the challenge of embedding these practices day-to-day in the classroom remained, though they explained how the workshop had helped with this issue. Previous research has shown that teachers play a crucial role in embedding habit-forming health behaviours in young children, with school-based interventions being key to this endeavour [21,22,23,24]. The results of this study show that this type of intervention not only increases children’s understanding but is also helpful in ensuring that this vital knowledge is taught to children.

With children being key transmitters of viruses and respiratory tract infections, such as SARS-CoV-2, and attending school following the closures, it is crucial that they are aware of how they can limit the spread of contagious illnesses and why this is so important. In order to successfully increase children’s understanding and awareness of respiratory tract illness and infection prevention methods, and subsequently reduce the transmission of such illnesses and future pandemics, preventing hospitalisations and death, consistent teaching and educational interventions such as Germ’s Journey should be included into the school curriculum to equip young children with the knowledge they need to sustain healthy hand-hygiene practices for the rest of their lives.

With research showing that health education and habit-forming interventions improve children’s understanding and behaviour, alongside the employment of theories of learning underpinning the Germ’s Journey workshop, the positive results in this study are in line with the researchers’ expectations. Given that the workshop and resources were carefully developed to be scientifically sound, interactive and motivational for children, this study’s aim to support children’s understanding was met, ultimately leading to better hand-hygiene practice and infection prevention behaviours.

4.3. Limitations

The limitations of this study include the regional reach of the schools, as we undertook this study in one county due to time implications and the need to access schools immediately following the pandemic, with many schools not allowing visitors to limit infections [50]. Furthermore, as noted in the methodology, although beneficial in most cases, when asking the children the pre-workshop, post-workshop and one-month later follow-up questions, some children were shy around the researchers, which may have affected or hindered their responses.

5. Conclusions

The COVID-19 pandemic highlighted the importance of infection prevention practices such as handwashing and correct coughing and sneezing etiquette to protect against respiratory tract illnesses and prepare for future pandemics. Yet, the Germ’s Journey team noted a lack of resources during the outbreak specifically aimed at young children. Therefore, as a direct and immediate response to this issue, the Germ’s Journey team became one of the first to develop and evaluate co-created educational resources for young children to explain how and why to protect themselves and others from respiratory tract infections.

Educating children about the importance of infection prevention methods in order to keep themselves and others healthy is crucial. By ensuring that children understand not only that they need to practice infection prevention methods but also why this is so important, education enables them and future generations to protect themselves and those around them against contagious illnesses, something that is critical in the fight against COVID-19 and future pandemics.

Importantly, this study found that despite many children knowing before the workshop that handwashing removes pathogens (which is expected given the information given about limiting the transmission of COVID-19), only a small number of children specified handwashing using soap. This increased after the Germ’s Journey workshop intervention. Additionally, 45.55% (123) of children also did not know how pathogens cause illness before the workshop, demonstrating a surprising gap in knowledge despite living through the COVID-19 pandemic.

In addition to this, most children (81.21%) knew that pathogens can be transmitted through coughs and sneezes before the workshop; however, only 37.87% of children showed awareness of how this relates to the transmission of pathogens to other people by coughing and sneezing when asked “why must we always catch our coughs and sneezes in a tissue or in our elbow?” before the workshop. There was an increase in children’s understanding of this both directly and a month after the workshop.

Previous research [19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40] shows that educational interventions are a key method for improving children’s handwashing understanding and behaviour,. Previous Germ’s Journey studies have shown that the workshops increase children’s engagement in and understanding of the topic of infection prevention and hand-hygiene practices [38,39], with findings also showing the benefit of a multi-component, resource-based workshop for improving children’s hand-hygiene practices [41]. The results of this study reinforce this further, showing the increase in children’s understanding of pathogens and respiratory tract illness, pathogen transmission and infection prevention methods as a direct result of the Germ’s Journey educational intervention and, importantly, the sustained nature of this greater understanding a month later and a year later in one school.

With regard to expanding this study, further research could explore how to co-develop (alongside end-users) and undertake a culturally relevant version of the workshop and resources internationally within schools, community centres and health clinics, particularly in more remote and hard-to-reach areas, in which hand-hygiene and infection prevention education is potentially life-saving.