Cincinnati College Preparatory Academy - West Handwashing Education

James Carlson, Lindsey Donges, and Brad Girten

Community Factors that Affect Population-Based Health• Transportation Availability• Busing system available for all students, or parents can choose to pick

their children up/drop them off. Additionally, some parents can walk their children to or from school depending on how far away they are. While busing system is convenient, being in close proximity with a variety of other ages of students can increase risk of acquiring communicable disease.

• Education• Level of education of students varies widely depending on grade

and how far they are into their curriculum. A large portion of the student population has not learned to read yet, thus reading materials would largely be ineffective unless someone read to them. Health education is not a major part of the curriculum, and regular education of health promotion strategies are sporadic. Some information is available in the nurse’s office

Demographics and Culture of Student Population• Over 85% of the student population is African American,

around 10% is Hispanic, and less than 5% is Caucasian or of Mixed descent.

• Strengths• Young population is resilient

with strong immune system. Recovers quickly from disease or injury.

• Energetic population can be directed to use that energy towards positive goals.

• Impressionable youth population can be educated and molded into a more ideal and healthy person.

• Challenges• Energetic population can

be difficult to work with. May be unable to focus or learn goals, frustrate instructors or healthcare providers.

• Impressionable youth population may learn contraindicated knowledge from outside sources such as media via television or internet.

Culture• Strong Media Influence:• Media via television or internet has strong influence over young,

impressionable population. May see role models engage in unhealthy behaviors and follow suit. Very important to counter potential ignorance in media with facts and evidence-based practice so that young population has source of reliable information.

• Peer Pressure:• Young population is particularly susceptible to influence from

their peers. Their friends can introduce them to unhealthy practices such as drugs, alcohol, cigarettes, etc. As with the media, it remains important for healthcare providers to provide counterbalance to this influence via facts and evidence-based practice.

Theoretical FrameworkHealth Promotion Model

Theoretical Framework cont.• Prior Related Behavior – Students may already have routine of not

washing hands before meals or after they’ve gone outside. Impressionability may help to break this routine, but will require giving them reasons they can understand to do so.

• Personal Factors:• Biological: Young population are exposed to a multitude of diseases via a

diverse population, thus must work even harder to prevent spread or development of disease in themselves.

• Psychological: Erikson’s Psychosocial Stage of Development is Industry vs. Inferiority, which is the gradual superseding of play by productive needs. This applies to handwashing as school-age children may be more likely as they age to understand the necessity of handwashing versus not performing a hygienic routine.

• Sociocultural: Parents busy with work may not have time to educate their children on the benefits of handwashing. Peers in same sociocultural group may not see benefits of handwashing, thus may not influence target population of positive handwashing routines.

Theoretical Framework cont.• Perceived Benefits of Action – Important to emphasize to young

population that proper handwashing technique will reduce how much they and their friends get sick.

• Perceived Barriers of Action – Young, immature population may not see effectiveness of handwashing as it is difficult to see a direct correlation between proper handwashing technique and getting sick less often.

• Perceived Self-Efficacy – Energetic, young population could see handwashing as easy, thus may take to it quickly at first.

• Activity-Related Affect – Energetic and young population once properly motivated may be enthusiastic about proper handwashing technique.

• Interpersonal Influences – Peers may not see importance of handwashing technique, and peer influence is highly influential of a young impressionable population. Internet and television influences may pose similar deterrents.

• Situational Influences – Time constraints in busy school schedule may reduce time available for washing hands before lunch or after recess.

Physical Environment, Transport, and Safety• Clinical Site is a large elementary school with Preschool and K-6th

grade.• Around two dozen classrooms over three floors, large cafeteria,

large auditorium for assemblies and plays, stairwells as well as elevators.

• YMCA and pool are attached. Nearby soccer field and basketball equipment.

• Transportation includes regular busing for students, as well as parents who pick their children up or walk them home.

• Safety: (In Cincinnati, OH)Serious crimes known to police (2000):

21,646

Property crimes known to police (2000):

18,975

Violent crimes known to police (2000):

2,671

Health and Social ServicesHealth Services: • Primary source of health services for target population is the school

nurse. • The school nurse provides primary care for their basic health needs

while in school, i.e. providing OTC medications with parent permission, examining basic injuries, and providing consultation for various health issues.

• Additionally, there are various materials on several health issues available in the nurse’s office, such as pamphlets and posters.

Social Services:• Most children at CCPA-West are from lower/working class families, with

some from the middle class• The area where the school is located has a lot of families using

government assistance• For example Medicaid or CHIP

• In the area there are various social service places like food pantry's and free health clinics• These children and their families can go here and get assistance

free of charge if uninsured or get food if they have low incomes.

Political Factors and Policies• Affordable Care Act• This policy was passed in 2012• Known as Obamacare, will help millions of people uninsured

become insured • Helps middle class families who are covered by private insurance,

Medicaid, or Medicare to have more affordable and secure care• Nearly 86 million Americans have gained from coverage of

preventive care free of charge• Millions of children were effected by this healthcare act because

this act covers children with pre-existing medical conditions, and they were not covered before

• Cincinnati Public Schools levy was passed/renewed on November 6th 2012, generating $51.6 million dollars a year, passing at 66%.

Educational Level• Educational level of students: Preschool, K-6th grade• Of Population:• High school graduates above age 25: 159,012 (2000)• Bachelor’s degree or higher, percent of persons above age 25: 26.6% (2000)

Social Economics

Average Income

Average Housing• Household Size: 2.10 (Census, 2000)

• Median Household Income: $29,493 (1999)

• Percent of persons below poverty line: 21.9% (1999)• Persons per square mile: 4,248.9 (2000)

Population Pyramid

5

6

7

8

9

10

11

12

13

-15 -10 -5 0 5 10 15

Population Pyramid: CCPA-West Elementary

Male

FemalePercent of Population

Age

Analysis of Population Pyramid• Inferences based on Age Analysis:• Significantly more girls than boys in total population• Largest group is nine-year old girls

• Kindergarten age group (ages five and six) is significantly large (greater than a quarter of the population).• This group is unlikely to have developed appropriate

reading skills; interventions must be tailored to their needs

• Posters and other educational materials should largely consist of pictures rather than words and written information

Problem List• Poor Hygiene• Students may not think about their personal hygiene, spend as

much time as needed washing before meals, after going to the bathroom, etc.

• Lack of knowledge about spread of disease• Students may not know or have not been taught of how germs

are spread through contact from people or objects• Lack of understanding of consequences of not washing hands• Students may not think about why they should wash hands, may

not see correlation between not washing hands and getting sick or spreading sickness

Short Term Goals• Students will wash hands during bathroom breaks as well as prior to

eating lunch.• Students will each receive handouts about proper handwashing.• Flyers will be posted in the restrooms and nurses office about the steps

of handwashing.• Students will be able to demonstrate proper handwashing technique.

Long Term Goals• Higher handwashing rates in students will reduce rates of influenza and

other communicable diseases.• New/incoming students will be taught by teachers or incoming senior

students how to properly wash hands before lunch and after recess at the beginning of the year and in the middle of the school year as well.

• Students will continue to be able to demonstrate proper handwashing technique at least six months after initial intervention.

Shocking Fact• According to the World Health Organization each year about

3.5 million children die before their fifth birthday due to preventable diseases, mainly diarrhea and acute respiratory diseases. The adoption of the habit of washing hands with soap and water before eating and after defecating, can prevent nearly half the number of deaths from diarrhea, and almost on-fourth of deaths from acute respiratory diseases.

• So it is vital for us as nurses to promote handwashing!• Especially in schools and that is what one of your main goals

was for this community clinical

Measurable Objectives• Teachers will observe students perform handwashing during bathroom

breaks• Teachers will observe students perform handwashing prior to eating lunch• Students will be able to perform proper handwashing technique.

Intervention Activities Level of Intervention: Primary (prevention)• Educational posters hung up in all bathrooms that students

and staff have access to. Posters will be tailored largely to children who can’t read, i.e. mostly visual.

• Educational materials distributed to teachers.• Additional materials made available in the Nurse’s Office.

Examples of Posters

When to wash your hands• Always wash your hands before: • Preparing food or eating • Treating wounds, giving medicine, or caring for a sick or injured

person • Inserting or removing contact lenses• Always wash your hands after: • Preparing food, especially raw meat or poultry • Using the toilet or changing a diaper• Touching an animal or animal toys, leashes, or waste • Blowing your nose, coughing or sneezing into your hands • Treating wounds or caring for a sick or injured person • Handling garbage, household or garden chemicals, or anything that

could be contaminated — such as a cleaning cloth or soiled shoes • In addition, wash your hands whenever they look dirty.

How to wash hands correctly• It's generally best to wash your hands with soap and water.

Follow these simple steps: • Wet your hands with running water.• Apply liquid, bar or powder soap.• Lather well.• Rub your hands vigorously for at least 20 seconds. Remember

to scrub all surfaces, including the backs of your hands, wrists, between your fingers and under your fingernails.

• Rinse well.• Dry your hands with a clean or disposable towel or air dryer.• If possible, use your towel to turn off the faucet.

Evaluation of Measurable Objectives

• Our group will not be at the elementary school during the coming winter months when the interventions will be implemented and the flu season will be at its peak.

• Peak Flu Season Months= December through March• The next student group assigned to CCPA-West will have to assess

population to see if interventions were successful in teaching proper handwashing technique.• Suggested method of assessment is to distribute questionnaires

to teachers to ask them about their observations of students’ handwashing habits/technique

• Additionally, the next group will need to compare number of days of absence in students and compare to previous years in order to extrapolate whether or not sickness rates may have been reduced in population.• Days of absence can be gathered from front office or nurse’s

office.

Peer Reviewed Research Articles• According to a study by Schmidt and colleagues the teaching of hand

hygiene and the follow up check of compliance with hand hygiene techniques is fairly simple and cheap . In the study there was a strong correlation in the decrease in contamination and of those who were washing there hands accordingly when tested again at a follow up time after the initial teaching was taught.

• Further more a high tech, expensive lab is not needed to conduct similar studies to measure amount microbes on hands after initial teachings you can buy a microbiology test kit for $3.80 to perform this study. It is suggested that this testing method is suitable for evaluating the effectiveness for hand washing campaigns in low income areas.

• Effective handwashing can decrease many related costs and missed days of work from both children and those who they come in contact with.

Peer reviewed Research Articles• According to a study done by Neuzil KM, Hohlbein C, Zhu Y (2002)

symptomatic influenza illness is frequent among school-aged children.• This prospective, population-based study quantifies a major effect of

Influenza virus on multiple and diverse outcomes in schoolchildren and their families, including significant increases in school absenteeism, analgesic use, parental industrial absenteeism, and secondary illness among family members.

• Such information is important for both individual and public policy decisions regarding the use of influenza vaccine in school-aged children.

Reference List• Amos, D. S., & Brown, J. (2012, November 07). Recounts possible in school-levy tally.

Cincinnati.com. Retrieved from http://news.cincinnati.com/article/20121107/NEWS0106/311070032/Recounts-possible-school-levy-tally

• Center for disease control and prevention. (2012, May 11). Retrieved from http://www.cdc.gov/handwashing/

• Neuzil KM, Hohlbein C, Zhu Y. Illness among schoolchildren during influenza season: effect on school absenteeism, parental absenteeism from work, and secondary illness in families. Arch Pediatr Adolesc Med. 2002;156:986–991. [PubMed]

• Nordhaus-Bike AM. In box. Community health: clean hands rule. Hosp Health Netw. 2000;74:14. [PubMed]

• U.S. Department of Education, National Center for Education Statistics. (2012). School district demographics system. Retrieved from website: http://nces.ed.gov/surveys/sdds/ed/index.asp

• U.S. Department of Labor, Fedstats. (2009). Cincinnati mapstats. Retrieved from website: http://www.fedstats.gov/qf/states/39/3915000.html

• White CG, Shinder FS, Shinder AL, Dyer DL. Reduction of illness absenteeism in elementary schools using an alcohol-free instant hand sanitizer. J Sch Nurs. 2001;17:258–265. [PubMed]

Thank you Nurse Bea!• We just wanted to say a special thanks to Nurse Bea for

allowing us to work with her all semester.• We really enjoyed our time at CCPA and learning about

what a school nurse does on a daily basis.