World Water Day: Hand hygiene essential to containing spread of COVID-19

Today is World Water Day. It is set aside to celebrate water and raise awareness of the 2.2 billion people living without access to safe water.

It is about taking action to tackle the global water crisis. A core focus of World Water Day is to support the achievement of Sustainable Development Goal 6: water and sanitation for all by 2030.

According to the UN, “The theme for 2020 is “Water and Climate Change” and explores how the two issues are inextricably linked.

“In light of the growing COVID-19 pandemic, the 2020 campaign also promoted messages around handwashing and hygiene and gave guidance on staying safe while supporting the campaign.

“The campaign also shows how our use of water will help reduce floods, droughts, scarcity and pollution, and will help fight climate change itself.

“By adapting to the water effects of climate change, we will protect health and save lives. And, by using water more efficiently, we will reduce greenhouse gases.

“Our key messages for this day are clear:

We cannot afford to wait. Climate policy makers must put water at the heart of action plans.
Water can help fight climate change. There are sustainable, affordable and scalable water and sanitation solutions.

“Everyone has a role to play. In our daily lives, there are surprisingly easy steps we can all take to address climate change.

“Hand hygiene is essential to containing the spread of COVID-19, as well as other infectious diseases. Wash hands with soap and water

Published 24 March 2020: https://www.tvcnews.tv


As the coronavirus spreads, the need for public handwashing facilities becomes vital

In pre-coronavirus days, about a third of all public restroom users washed their hands. That wasn’t good enough then and it really isn’t good enough now. During this pandemic, we all need to be washing our hands, often!

The problem we have now is a lack of public facilities to wash them, even though workers at establishments deemed essential—like hospitals, grocery stores, food delivery places—still have to work. Not to mention people who are out, while still practicing social distancing practices.


Access to public restrooms has diminished

In December I wrote an article on about the need for more restrooms and more accessibility for the diverse people within the region. I never imagined how relevant this topic would become during this pandemic.

WMATA closed the facilities in many Metro stations years ago. Elsewhere, there is a constant lack of public restrooms. Many businesses, during normal times, shut their restrooms off to non-customers. The opportunities we do have are often poorly maintained, under-staffed, and under-cleaned bathrooms long ignored by public agencies. Even interested parties often struggle to gain budgetary and staffing allowances to maintain public restrooms. So our hands often go dangerously unwashed.

People experiencing homelessness, immunocompromised people, trans and non-binary folks, people with disabilities, and older adults are especially impacted. Bathrooms are often inaccessible physically or due to socially-instituted barriers.

Trans and non-binary people often cannot use gendered restrooms, or cannot use them safely. Public restrooms are often an infection risk for immunocompromised people, even during normal times. Most bathrooms are inaccessible for people with disabilities and many older adults.

Businesses and institutions often demand payment before restroom use as a mechanism to exclude people experiencing homelessness. Not only does this mean that many people lack adequate opportunities to use the toilet, which leads to health issues, but also that members of these communities have fewer opportunities for hand hygiene.

Furthermore, some of these communities may be at greater risk from the coronavirus, due to the virus’ biology, common comorbidities, and limitations in accessing healthcare.

We already know that the majority of deaths from the virus are among older people and immunosuppressed people. Barriers to accessing healthcare are especially large for people with disabilities, trans and non-binary people, and especially people who are homeless.

Members of the last group often suffer from other health conditions that are potentially deadly when combined with coronavirus. Besides, barriers to healthcare are likely to surface in barriers to testing, or the ability to get a test at all, much less treatment. If people in these groups are unable to wash their hands, they are at greater risk to contract a virus that poses more of a threat to their well-being than for other people. This situation could be different.


What other countries are doing

In other countries, transit stations and interchanges offer frequent opportunities for handwashing. In Seoul and Dubai, most transit stations have restrooms with stocked and supplied sinks—as does much of the system in Istanbul. Pretty much every transit interchange in Japan and Australia has restrooms of some sort—including large bus stations. Many places also encourage hand washing and sanitizing throughout one’s day.

On Twitter, Michael Twitty recently observed a wide availability of hand sanitizer and opportunities to wash one’s hands in Senegal, with the encouragement and assistance of local leadership. In its most recent edition, The Economist noted that bus stops across the Indian state of Kerala were also providing hand washing basins.

In my own experiences in Jewish communities in the United States and Israel, the stand-alone sinks that are used for ritual hand washing are frequently used for hygienic hand washing too, even by people who are not observant of halakha.

 

What could we do here?

Reopening restrooms in Metro stations is a start. At the very least, these facilities—when maintained—offer a place for passengers to wash their hands, a habit that I hope continues after this pandemic. Also, making hand sanitizer regularly available throughout the WMATA system would be beneficial.

Adding restroom capacity at major interchanges would be helpful too. The restrooms installed in the 1970s probably do not meet the needs of a system that is currently far more heavily trafficked.

A program to install public restrooms and hand-washing stations across the region would be of great long-term benefit, especially for people who cannot afford to pay for services to which business restrooms are often tied.

 

Funding, staffing, and protocols would all need to be considered.

I am distinctly aware that installing these facilities costs a lot of money; the cost for adding a restroom facility is often about $250 to $300 per square foot. For a typical 56 square foot accessible bathroom, that comes out to between $14,000 and $16,800 – and that’s before labor costs, the cost of maintenance, and the cost of supplying toilet paper, water, and soap. The Portland Loo, a commonly-touted but ultimately problematic solution to restroom access, runs at about $90,000 per unit.

Installation costs are not the only expenditure: additional staff would be needed to make sure restrooms stay safe, in working order, and maintained. By and large, the reason public restrooms in many countries are usable is that resources are allocated to keep them that way. Workers would need to be properly paid, and provided the materials to keep bathrooms clean, and the time to do so regularly.

It is likely that additional protocols will need to come into place to keep restrooms clean and safe. One example might be automatic faucets or soap dispensers, which are already called for by the United States Access Board.

Yes, this will cost a lot of money and time, and maybe the political will won’t be there. But that is where our activism comes in. Funding choices are political and not choosing to allocate resources to essential things like hand hygiene is a conscious choice that can have drastic consequences. Besides, after the pandemic, we will all need to rejig our priorities to ensure health and safety in our public spaces.

As we move forward, let’s make sure that includes restrooms and the ability to wash our hands, as needed. Also, take other hand hygiene precautions: cough into your elbow, avoid shaking hands, and use your sleeves or elbow to touch surfaces when possible. After all, you don’t know when you’ll next be able to wash your hands.

Jonathan Paul Katz is a community planning student at the University of Maryland-College Park, and lives in Hyattsville. He is interested in the intersection of disability access and planning. In his spare time, he also writes a food blog, Flavors of Diaspora.

By Jonathan Paul Katz.
Published March 23, 2020
https://ggwash.org


The simple power of hand-washing

Myriam Sidibe is a warrior in the fight against childhood disease. Her weapon of choice? A bar of soap. For cost-effective prevention against sickness, it’s hard to beat soapy hand-washing, which cuts down risk of pneumonia, diarrhea, cholera and worse. Sidibe, a public-health expert, makes a smart case for public-private partnerships to promote clean hands — and local, sustainable entrepreneurship.

This talk was presented at a TED Institute event given in partnership with Unilever. TED editors featured it among our selections on the home page. Read more about the TED Institute.

READ MORE ABOUT MYRIOAM SIDIBE
Meet Myriam Sidibe, she has a PhD in hand-washing >>


World Water Day 2020 highlights the essential role of handwashing

Good hand hygiene protects you and those around you. One of the most important contributions we can make to slowing down transmission of COVID-19 and keeping ourselves and our communities safe is to wash our hands. This is the main message of World Water Day 2020 on 22 March, and everyone has a role to play.

The provision of safe water, sanitation and adequate hygiene (WASH) is essential to protecting human health during all infectious disease outbreaks. Ensuring good and consistently applied WASH, environmental cleaning and waste management practices in communities, homes, schools, marketplaces and health-care facilities will further help to prevent human-to-human transmission of the COVID-19 virus. Strictly following good handwashing and personal hygiene practices is important for all, but especially in health-care settings, where it protects both patients and health-care workers.

Safe hygiene standards require a continuous and adequate supply of safe water, and sanitation systems that will continue to function even under stress or challenging conditions, such as under a changing climate. Within the WHO European Region, we have a strong multilateral mechanism: the Protocol on Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International Lakes. The Protocol’s primary objective is to promote the protection of human health and well-being within a framework of sustainable development, through improving water management, including the protection of water ecosystems, and through preventing, controlling and reducing water-related disease.

“Washing your hands is such a simple act, and yet such an essential step in halting infectious disease transmission and saving lives,” notes Oliver Schmoll, Programme Manager for Water and Climate at the WHO European Centre for Environment and Health in Bonn, Germany. “But in order to be able to maintain good hand hygiene, hospitals, schools and communities require a continuous supply of safe water and the availability of functional hand hygiene facilities and soap.”

To support water and sanitation practitioners and providers, as well as health-care professionals, WHO has recently published a technical brief, “Water, sanitation, hygiene and waste management for COVID-19”.

By WHO
Published March 20, 2020
http://www.euro.who.int/


Coronavirus: When hand hygiene practice in rural Chhattisgarh caught WHO attention

These Mitanins initially acquired the knowledge on six different stages of hand washing before they reached out to every tribal hamlet and rural habitation.

 

RAIPUR: Amid the coronavirus pandemic, a campaign by Mitanin (rural health workers) in the rural areas across Ambikapur district in north Chhattisgarh, where women were educated on washing hands has gained global praise.

The World Health Organisation (WHO) director-general Tedros Adhanom Ghebreyesus, much impressed with the steps taken on ‘SafeHands’ by the village community promoting hygiene practice in rural Ambikapur, had tweeted about it.

Groups of Mitanin interact with women from the morning where they narrating on how proper handwashing with soap followed by drying assume much significance to effectively counter the danger by eliminating all traces of coronavirus on hands. They explained to the masses about various “Dos and Don’ts” as protection from infection and prevent the spread of coronavirus.

“People in rural areas of Ambikapur are fast realising that proper handwashing is the most effective way the people can protect themselves not just against coronavirus but even other infectious diseases. Mitanin through health interventions are enlightening the masses on right ways of washing hands as basic hygiene practice”, said Ambikapur collector Dr Saransh Mittar, who himself is a medical doctor.

These Mitanins initially acquired the knowledge on six different stages of hand washing before they reached out to every tribal hamlet and rural habitation.

“In urban areas there are enough scope for knowing the ways on protection and prevention against coronavirus but not so in rural areas. We explained everything to Mitanin how they need to elucidate proper hand washing to masses. According to the WHO it is the most effective weapon against the spread of coronavirus infection”, said Dr PS Sisodia (CMHO) and Dr Amin Firdousi (urban health programme).

“We didn’t know how the right ways of handwashing with soap can be so effective and vital against coronavirus”, said Rajni Bai and others who were enlightened by Mitanin’s campaign at rural community level.


By Ejaz Kaiser

Express News Service
Published: 18th March 2020
https://www.newindianexpress.com/good-news


It’s still true: Good hand-washing is the best way to stay healthy

Everyone is concerned about staying healthy in the midst of the coronavirus pandemic.

But experts agree, one of the best things we all can do to prevent the transmission of any illness is to practice good hand hygiene.

“Wash your hands, with any soap, 20 seconds at least, or use an alcohol-based sanitizer — it will do the job,” said Dr. Frank Esper, of Cleveland Clinic Children’s.

Esper said germs can be transferred from person-to-person when we touch things like doorknobs, money or even other people.

“The grocery store, movie theater, for example, are all places where we all come together, and when you bring a bunch of people together, you’re bringing a bunch of germs together,” he said. “You can help prevent those infections by washing your hands.”

The good news, according to Esper, is we don’t need anything fancy to keep hands clean.

“A regular, good, generic soap will do just as fine as the expensive ones with labels that say ‘antibacterial’ and things like that,” he said.

Esper said parents can teach their kids good hand hygiene practices at any age — but usually once kids are of school age, they can get a better handle on how to wash up properly.

And for small children, hand sanitizer is a good choice.

“The youngest children — the 1- and 2-year-olds — are not very good hand-washers,” Esper said. “They generally have a hard time working with soap and water and doing the whole sequence. That’s where alcohol-based sanitizers help — you can just squirt it into their hands and rub, rub, rub — and it works so much better for the smaller children.”

 

By Elizabeth Misson, Cleveland Clinic News Service
Published March 6, 2020
Copyright 2020 by Cleveland Clinic News Service.
https://www.news4jax.com


Clean hands save lives, so wash up, Berkeley expert says

Why aren’t we in the habit of washing our hands? Germs are invisible, and each of us has a hard time thinking of ourselves as a person with contaminated hands, says Berkeley Haas professor David Levine, an expert on overcoming barriers to improving health.

You don’t have to remind David Levine, UC Berkeley professor of business administration, to carry hand sanitizer and wash his hands thoroughly with soap.

But why do many of us — from children to adults — lack these habits, even in a pandemic? Much of Levine’s research focuses on ways to overcome barriers to improving health, especially in underprivileged nations. And as head of Hygiene Heroes, a program he’s led with UC Berkeley students on four continents since 2014, schoolchildren learn through the team’s special curriculum — it includes interactive stories, games and songs, and characters like Gerry the Germ — how to change health-related behaviors.

Berkeley News recently talked with Levine, a Berkeley alumnus who’s been on the faculty since 1987, about the importance of hand-washing, why people don’t always do it and what it will take for people and organizations to adopt healthier habits.


How did hand-washing become a focus in your work?

When I got tenure at Berkeley, I decided I should work on the most important problem I could help with. So, I chose the health of poor children in poor nations. Doctors taught me that hand-washing is the most important single behavior in preventing childhood illness, but the challenge of behavior change remained. And behavior change is something I study.

I’m currently working mostly in India. I have other behavior change projects on dental hygiene, safe water, safe cooking (to avoid smoky stoves that kill millions each year) and sexual and reproductive health. Any school can access my curriculum on hand hygiene and preventing respiratory infections; I’m glad to help run pilots or experiments.

Coronavirus has brought about death and also is a risk to businesses. I may start a small research project focused on when consumers prefer businesses with mandatory hand-washing and other signals of good hygiene. We will run some online surveys exploring what indicators of good hygiene are worth the hassle of longer lines or having to wash hands oneself. If good hygiene is profitable, it should spread more quickly.

What are the data on how hand-washing can prevent disease, and which diseases does it stop?
Hand-washing with soap prevents perhaps roughly a third of diarrheal diseases and a similar share of respiratory infections, such as colds and the flu. The proportion may be a bit lower for COVID-19, but we are not sure.

Both soap and hand sanitizer are highly effective. They key, in both cases, is to rub awhile. The standard advice is to rub for 20 seconds — about as long as it takes to hum “Happy Birthday” twice.

Elders often remind youngsters to wash their hands. Why doesn’t the habit stick? Is it a matter of not learning the right way, or not realizing why it’s important?

Leading doctors figured out it was important to wash hands with soap in the middle of the 1800s. But at the start of this century, most doctors did not wash their hands between patients. The result was that hospital-caused infections killed more people than auto accidents. Doctors’ hygiene has improved recently, but for 150 years, progress was quite slow. Germs are invisible, and each of us has a hard time thinking of ourselves as a person with contaminated hands spreading disgusting poop or snot around.

Has anything worked, to get people to change behavior and wash their hands — whether they’re surgeons or fast food workers or schoolkids in the bathroom? You’ve talked about the need to “harness shame.”

Interestingly, doctors did usually wash their hands — if they knew somebody was watching. We see the same pattern in public restrooms. Most people do not wash their hands with soap. But they do if they know someone is watching.

It’s important to establish a norm that it is disgusting not to wash hands with soap after leaving the toilet or before eating — and, more recently, not to wash hands with soap after a sneeze. (For guidance specifically on preventing the spread of COVID-19, see the CDC webpage)

To harness shame, managers must go beyond repeating messages to their employees about hand-washing to changing social norms. If they can convey the right messages, employees will feel disgust when they sneeze into the air or fail to wash hands with soap before eating. Effective change must build on messages about pathogens to include messages about poop and snot.

Washing your hands protects you — and the community. That is why social norms are important; we need society to use social pressure to protect itself.

What has your work promoting healthy routines in other countries shown?

Like many others, I find that providing easy access to soap or hand sanitizer is crucial. Also, like many others, I find that health messages — plus the availability of soap — is usually not enough.

Fortunately, even in resource-poor areas such as India, my team has found that adopting routines for hand-washing with soap work. When the lunch bell rings, students line up at the classroom door, and a lead student squirts a little soapy water on each student’s hands. The students scrub as they walk to sinks, rinse and then eat. Parents in our country may recognize this routine from their own children’s preschool days. Every school in America should establish similar routines.

What needs to happen to change health hygiene in the United States?

Managers in the United States must build new organizational routines related to hygiene. These will vary by the risks each business faces and must outlast the acute phase of this pandemic.

For example, hygiene is the most important near people who are sick. So, every doctor’s office should require people to wash their hands with soap or hand sanitizer as they enter.

It is important to establish routines for hygiene wherever people spend a lot of time together. So, every senior living facility should ask you to clean your hands as you enter. And places where people live together, like dorms and prisons, should establish appropriate routines for hand-washing before meals. For example, as you enter a dining area, someone can remind you to use hand sanitizer.

Good management has always involved a cycle of identifying problems and creating procedures to address them. Fighting COVID-19 requires using familiar management tools to address this novel threat.

First, businesses have to analyze where they can spread germs: an ATM keypad, a grocery cart, etc. Then, they have to create and implement procedures to keep workers and customers safe. Those new procedures require training, monitoring, incentives and often supplies. As a familiar example, the check sheets in some restaurants — “This bathroom was last cleaned by _________ at ___________ o’clock” — are part of an effective routine. Workplaces must extend that level of attention to hygiene to many other surfaces.

What opportunities does the current coronavirus pandemic present, to get people to adopt healthy or healthier hygiene habits? Are you optimistic about the chance for change?

Millions of people are paying more attention to hygiene today than they were a month ago. Some of the safer habits, like hand-washing a bit more often, will stick, but many people will become less careful when the pandemic dies down. I hope that organizations, from doctors’ offices to dormitories, can retain routines that keep people healthier.

Gretchen Kell
Published March 16, 2020
https://news.berkeley.edu


Why COVID-19 can’t beat a good hand-washing

And pretty much any other contagious disease.

Researchers are still working to understand how deadly COVID-19 is and how it spreads. But they know one thing for sure: Washing your hands is the key to minimizing the novel coronavirus’ powers of destruction.

Hand washing really, really works—and not just during outbreaks of new respiratory viruses. It also helps prevent the spread of a wide variety of disease-causing microbes, known as pathogens, from food-borne diseases like E.coli to flesh-eating bugs. And it works to contain the spread of illness whether you’re the one who is sick or you’re trying to avoid catching something in the first place. (It even works better than hand sanitizer, so lay off the Purell unless you’re on the go).

“Hand washing with soap for 20 seconds is one of the single most important practices to protect yourself, your family, and your community,” says Matthew Freeman, a professor of epidemiology and global health at Emory University.

On a purely physical level, hand washing works by actually removing the microbes from your hand thanks to some basic chemistry. Soap is what’s known as a surfactant, which means it breaks down the oils and dirt on your skin; water rinses the broken-down oils and dirt away, carrying microbes along for the ride. “By rubbing your hands together you create the friction to get the oils off,” Freeman says.

Washing your hands with just water can help a bit if the alternative is not washing your hands at all, but it’s way less effective than scrubbing with suds.

But why does this simple practice work so well to prevent the spread of contagious disease? After all, washing your hands regularly (and properly—see here for instructions) might seem like it’s just a first step. Everything around your hands is still covered in potentially pathogenic microbes.

Again, the answer is pretty basic: your hands touch the world, and they also touch you (and your face. Stop touching your face.) If you are sick, washing your hands regularly makes it less likely that you’ll spread pathogens from your hands to the things you touch, where they can be picked up by others. If you’re not sick, you can pick up microbes on your digits and carry them to your mucus membranes, like your eyes, nose, and mouth. (Stop. Touching. Your. Face.)

People have known about the effectiveness of hand washing for hundreds of years, says Freeman—even if they didn’t know why it worked. For instance, many of the world’s religions promote hand washing as a ritual practice. In the 19th century, as Western physicians stumbled toward an understanding of the germ theory of disease, hand washing slowly became an important thing to do in medical settings (though it was initially shockingly controversial). But it took much longer to get hand washing to the general public, says Freeman. It’s only in the last 40 years or so that public health authorities have started working hard to convince people to wash their hands after leaving the house, before eating, and even—eek—after using the bathroom.

Wash your hands, with soap, for about 20 seconds: it’s a simple recipe for good health.

But “possibly because it’s something that people know they should do, it’s very hard to get a sense of how many people actually do it,” he says. Research has shown that, globally, only around 19 percent of people wash their hands after using the bathroom. But there’s not a lot of data out there about how often people wash their hands at other times, and some studies indicate that even supposed-hand-washers don’t regularly subject themselves to the proper 20 to 30 seconds of sudsing.

Right now, you’re probably seeing a lot more hand washing (and a lot more thorough hand washing) than you’re used to. That’s because all of the messaging in the news and elsewhere about COVID-19 reminds people to wash their hands. But you should really be doing it all the time.

“Changing practices and habits are really hard,” Freeman says. Consider creating what Freeman calls a “cue to action” that encourages hand washing at key times, such as when you enter your house from the outside world. It could be as simple as placing a note where you hang up your keys. Freeman and his wife (who also studied hand washing practices) placed a sticker on the back of their first child’s highchair to remind them to wash her hands before they all sat down to dinner.

This outbreak is likely to change your hygiene habits for the better, and there’s no reason not to change them permanently. “Wash your hands like you’ve been chopping jalapeños and you need to change your contacts,” one Canadian health official said recently. Wash early, wash often, and wash well. And don’t touch your face. Seriously.

By Kat Eschner
March 9, 2020

https://www.popsci.com/


“The very sight of her hands did almost turn my stomach”: a brief history of hand-washing

As the disease known as coronavirus spreads around the world, the public has received one key piece of advice: hand-washing is our best defence. But what would our ancestors have made of this tactic? Katherine Harvey explores for HistoryExtra…

Contrary to the popular belief that people in the Middle Ages were disgustingly smelly and dirty, medieval people frequently washed their hands, usually on rising and before and after meals. This was not just a case of good manners; they were well aware of the link between dirt and illness. Consequently, the 14th-century surgeon John of Arderne required prospective apprentices to have “clene handes and wele shapen nailes…clensed fro all blaknes and filthe”. Hand-washing mattered because it was seen to remove both external dirt and harmful bodily excretions.

This dual concern with dirt and bodily excrement continued into the Renaissance. Italian physician Tommaso Rangone (1493–1577) advised that hands must regularly “be cleaned of superfluities, sweat and grime that nature often deposits in those places”. Other medical writers also recognised that hands could transmit disease, although their concerns focused on skin diseases such as scabies, rather than the more well-known plague. Therefore, hand-washing was thought to be necessary for good health.

Hands must regularly ‘be cleaned of superfluities, sweat and grime that nature often deposits in those places’

Early modern concerns about hand hygiene often focused on meals, so most people washed before and after eating. Some advice books insisted that even clean hands must be rewashed at the table, using a basin and ewer, so that everyone else would feel reassured about sharing food. As such, poor hygiene could provoke real repugnance: after dining with his Uncle Wight in 1663, Samuel Pepys recorded that “the very sight of my aunt’s hands…did almost turn my stomach”.

17th-century diarist Samuel Pepys.

 

Georgian polite society fretted a great deal about servants’ hands, particularly in relation to food preparation and table service. The 18th-century author Eliza Haywood required her maids to wash their hands regularly, and other employers made serving staff keep their hands “in open view, neat and clean”, according to a conduct book of the day. Jonathan Swift’s Directions to Servants (1745) specifically criticised domestic helpers who prepared salads with unwashed hands after handling meat or visiting the lavatory.

In the 19th century, scientists such as Louis Pasteur and Joseph Lister made significant advances in germ theory and its practical applications, which explained why hand-washing works in curbing the spread of disease. Though perhaps lesser known, another important pioneer was the Vienna-based Hungarian obstetrician Ignaz Semmelweis (1818–65), who realised that labouring women caught puerperal fever from doctors who went straight from the morgue to the delivery room. He proved that maternal mortality could be drastically cut by routine hand-washing with a chlorine solution.

This revolutionary new knowledge had surprisingly little immediate impact, partly due to resistance from physicians who resented being blamed for their patients’ deaths. Nevertheless, the following decades saw frequent attempts to persuade the wider public of the value of hand hygiene, the motivations for which were sometimes concerned as much with reaping profits as promoting public health. In the 1920s, the soap manufacturing company Lever Brothers ran a Clean Hands Campaign that urged children to wash their hands “before breakfast, before dinner and after school”. Their Lifebuoy soap was marketed as the best way to tackle germs, as in a 1927 advert in which a father advises his son that “Dirty hands are dangerous”. This wise parent practises what he preaches, using the product several times each day.

Adverts such as this had considerable impact, but their message still bears repeating. Despite centuries of advice, many of us are no better than the “plaine people in the countrie” who riled the Tudor physician William Bullein – because they would not clean their filthy hands.

Katherine Harvey is a historian of medieval Europe based at Birkbeck, University of London.

By Katherine Harvey

Published at HistoryExtra; The official website for BBC History Magazine, BBC History Revealed and BBC World Histories Magazine
March 5, 2020 at 1:08 pm

https://www.historyextra.com


Wash your hands, Brother John!

Use of a six step hand hygiene technique as recommended by the World Health Organization is important to ensure thorough cleansing of hands, but learning and memorising the steps is a major barrier to its adoption. We hereby describe a musical mnemonic based on the popular nursery rhyme “Brother John” (also known as “Frère Jacques”) that can help learning and remembering of the proper technique.

Regular hand hygiene education at day care and school is recommended as an effective method to prevent gastrointestinal and respiratory infections, which are common in children.1 Hand cleansing may seem a relatively simple task, and the correct technique can improve the effectiveness of hand hygiene at eliminating microorganisms.2 Numerous studies have investigated the specific effect of school based hand hygiene interventions on infections and school absenteeism; however, few interventions have focused on how hand hygiene technique is taught to children.3

Using songs, in particular musical mnemonics based on popular nursery rhymes, may help children learn the process of hand hygiene techniques by making it more fun, thereby increasing attention and the development of memory and motor coordination.45 Learning through song lyrics, where the instructions are stated before completion of each step, has been shown to produce quicker acquisition of novel skills compared with prose self instruction.6

Children are exposed from an early age to musical mnemonics or cues that assist with learning (the ABC song for the alphabet, and the Head, Shoulders, Knees, and Toes song to identify body parts). However, few musical mnemonics exist to help teach hand hygiene to children. We reviewed a convenience sample of 15 videos online that targeted children to determine the following: presence of a musical mnemonic (with lyrics complementing each step of handwashing); song duration; and demonstration of decreased microbial burden as immediate visual feedback. We found no videos that showed the six step technique using a song mnemonic; the few that showed certain steps had songs that were longer than the recommended duration of handwashing (20-30 seconds) and were not easily reproducible by our school aged co-author.7

Fuelled by these findings, we decided to develop a musical mnemonic that targeted school aged children. We used the melody of a well known children’s song, Brother John (Frère Jacques), and incorporated the six recommended steps for hand hygiene. The lyrics were developed in collaboration with children of preschool and primary school age, ensuring that our intended audience could easily understand them, and leveraged the rhythmic and rhyme patterns of a popular song to improve memory retention.

The six steps to achieve effective hand hygiene, sung to the tune of Brother John (also known as Frère Jacques)
(fig 1, video on bmj.com): CLICK HERE TO SEE VIDEO

1. Are you sleeping // Scrub your palms
2. Are you sleeping // Between the fingers
3. Brother John, Brother John // Wash the back (one hand), wash the back (other hand)
4. Morning bells are ringing // Twirl the tips (one hand) around (other hand)
5. Morning bells are ringing // Scrub them upside down
6. Ding, ding, dong; ding, ding, dong // Thumb attack (one thumb)!Thumb attack (other thumb)! (sung with gusto)

Each line is repeated as is necessary to complete each step.

Fig 1

The six step technique for hand hygiene, as recommended by the World Health Organization, sung to the tune of Brother John (Frère Jacques) for song lyric self instruction in hand washing. Some steps involve doing one hand at a time. R=right L=left (image by N Thampi)

To investigate whether this song lyric self instruction method could be effective in reducing microbial burden, fluorescent marking was applied at the outset and hands were examined after washing with soap and water for residual fluorescence. Figure 2 shows reduction in the presence of fluorescent marking on the hands following handwashing while singing the musical mnemonic, indicative of potential effectiveness at decreasing microbial flora.

 

Fig 2

Fluorescent marking on hands, before and after handwashing using the song lyric self instruction. Fluorescent marks indicate presence of microbial flora. (A) Before handwashing, fluorescent marking under the black light is white and scattered throughout the palmar and dorsal aspects of both hands. (B) After handwashing there is a notable absence of fluorescent marking on palms, back of hands, and fingertips, with traces in the nail bed (image by N Thampi)

This song lyric self instruction has broad implications for school based public health campaigns. We showed that a musical mnemonic developed for preschool and school aged children can teach the World Health Organization hand hygiene technique effectively, potentially reducing infection transmission, with a duration of approximately 20 seconds. Given the longstanding clinical challenges of compliance with the six step technique, there is also potential for this musical mnemonic to be adopted in the healthcare setting; further testing would be required before definitive comparisons can be drawn. We plan to test the song in the classroom setting to determine its social acceptability, and its potential for peer-to-peer learning and long term memory retention. With its catchy tune and clear, lyrical instructions, our technique offers the opportunity to develop hand hygiene muscle memory, self-correction, and public health gains among children.

Footnotes
Acknowledgments The authors wish to acknowledge the children who provided early feedback on the musical mnemonic, particularly Ajay Villeneuve for demonstrating its ease of acquisition, use, and social acceptance among the preschool age group. We would like to thank Paddy Moore, Rhonda McIntosh, and Andre Coutu from CHEO Communications for producing and developing the video content, and the children who shared our enthusiasm for handwashing in song. A video demonstrating the six step technique using the musical mnemonic can be found at bmj.com.

Contributions NT and LNV conceived the musical mnemonic, YL contributed to the video, LNV performed the demonstration, NT and YL drafted and revised the manuscript. NT is guarantor.

Funding None received

Competing interest statement All authors have completed the Unified Competing Interest form (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

Guarantor N Thampi

Patient and public involvement The musical mnemonic was field tested among the co-author’s classmates and paediatric family members. All volunteered freely to participate.

Provenance and peer review: not commissioned; not externally peer reviewed.

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Published by: British Medical Journal – https://www.bmj.com/content/367/bmj.l6050