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.

References
1

1. Jefferson T,
2. Del Mar C,
3. Dooley L,
4. et al.
Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review.BMJ2009;339:b3675. PubMed doi:10.1136/bmj.b3675

2
1. Reilly JS,
2. Price L,
3. Lang S,
4. et al.
A pragmatic randomized controlled trial of 6-Step vs 3-step hand hygiene technique in acute hospital care in the United Kingdom. Infect Control Hosp Epidemiol2016;37:661-6. PubMed doi:10.1017/ice.2016.51

3
1. Willmott M,
2. Nicholson A,
3. Busse H,
4. MacArthur GJ,
5. Brookes S,
6. Campbell R
Effectiveness of hand hygiene interventions in reducing illness absence among children in educational settings: a systematic review and meta-analysis. Arch Dis Child2016;101:42-50. PubMed doi:10.1136/archdischild-2015-308875

4
1. Thaut MH,
2. Peterson DA,
3. McIntosh GC,
4. Hoemberg V
Music mnemonics aid verbal memory and induce learning—related brain plasticity in multiple sclerosis. Front Hum Neurosci2014;8:395. PubMed doi:10.3389/fnhum.2014.00395

5
1. Lee RL,
2. Leung C,
3. Tong WK,
4. Chen H,
5. Lee PH
Comparative efficacy of a simplified handwashing program for improvement in hand hygiene and reduction of school absenteeism among children with intellectual disability. Am J Infect Control2015;43:907-12. PubMed doi:10.1016/j.ajic.2015.03.023

6
1. Bloom LB,
2. Kettering TL,
3. Walker D
A comparison of song-lyric and prose self-instruction procedures for increasing novel skills in children. J Appl Behav Anal2019. PubMed doi:10.1002/jaba.548

7
World Health Organization. Hand hygiene: why, how & when? 2009. https://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf

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