Hand Hygiene Knowledge, Attitudes, Practices, and Hand Dirtiness of Primary School Students Before and After a Behavioral Change Intervention During the COVID-19 Pandemic, Belize 2022–2023

Hand hygiene (HH) can prevent the spread of infectious diseases and school absenteeism. However, limited data exist on HH practices at schools. Our study assesses the impact of a pilot HH intervention in 12 schools in Belize during the coronavirus disease 2019 (COVID-19) pandemic. After a national assessment of existing water, sanitation, and hygiene resources (December 2021-January 2022), 12 pilot schools were selected to evaluate an HH intervention, which included environmental nudges and HH education. Baseline assessments occurred in March 2022, the HH intervention was implemented during October 2022-May 2023, and follow-up assessments were conducted in June 2023. Student knowledge, attitudes, practices (KAP), and hand dirtiness were assessed at baseline and follow-up. There were no changes in overall KAP median scores between the baseline and the follow-up surveys (knowledge: 3 of 4; attitudes: 11 of 12; practices: 8 of 8). There was an increase in the proportion of students who reported cleaning hands during critical moments, such as before eating and after using the restroom. Observations showed that 83% of students at baseline and 71% of students at follow-up washed their hands with soap after using the restroom. The median hand dirtiness score was seven at baseline and five at follow-up (lower score corresponds to dirtier hands). We did not observe improvements in HH after the intervention. It is possible that the decrease in perceived risk of infection as COVID-19 protocols from baseline to follow-up were reduced in schools contributed to the decrease in HH practices.