The Importance of Hand Washing A Health Campaign Dale...

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Running head: HAND WASHING CAMPAIGN

The Importance of Hand Washing

A Health Campaign

Dale Boedeker

Kathryn Debus

Caitlin Kos

Nichole Wood

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HAND WASHING CAMPAIGN

Washing hands is a very important step in preventative healthcare. The most common

infection source for the common cold is the constant touching of the face with infected hands.

Hand washing stations are found in every restroom, every kitchen, every clinic room and many

other locations. If there isn’t a sink there are likely disinfectant liquids and wipes. This Health

Campaign targets three and five year old kids. We conducted the campaign at a local daycare

facility on Grand Valley State University’s Allendale campus. This approach is different than

many other campaigns because we selected a daycare instead of a school or medical center. The

Campaign was divided into two groups: five year olds and four year olds. These two ages were

selected to start proper hand washing early in the participants’ lives. For our campaign we

utilized the Health Belief Model.

The Health Belief Model (HBM) is composed of three main components: background,

personal perceptions and action. Within each component, there are subcategories that make up

the backbone of the model. Background consists of sociodemographic factors such as age, sex,

ethnicity, personality and knowledge. Personal perceptions include two subcategories:

expectations and threats. The expectations are perceived benefits, perceived barriers and

perceived self-efficacy. Perceived benefits are the profits obtained by listening to the advice of

the health behavior change. Perceived barriers are potential obstacles that could deter someone

from doing the recommended change. Perceived self-efficacy is belief in oneself that the change

is possible and a positive one. Threats include perceived susceptibility and perceived severity.

Perceived susceptibility is the seriousness associated with the health behavior being currently

practiced as well as the proposed change. Perceived severity is how serious a person believes a

health behavior could be to them individually. Many times, people see a health behavior

affecting someone else rather than themselves. Finally, the action component is comprised of

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cues to action and behavior change. Cues to action are indicators that a person should want to

make the change. Behavior change is working through all of the steps of the model to come to a

conclusion whether or not to make the behavior change. Each component of the model helps to

determine if an individual will make a health behavior change presented to them.

HBM is one of the most referenced models in healthcare in relation to health campaigns.

An article entitled “Assessing Motivation for Physicians to Prevent Antimicrobial Resistance in

Hospitalized Children using the Health Belief Model as a Framework” is the basis for some

background research on this model and its effectiveness when determining if a health behavior

will be adopted. This research study was focused on antimicrobial resistance in children, and

how the physicians who treated these children felt about its importance. This article’s focus was

on the physicians treating the children with the antimicrobial resistance. When research was

conducted through focus groups, it was found that the physicians did not rate antimicrobial

resistance high on a list of major concerns in their field of work. Perceived susceptibility was

extremely low, as many physicians stated that antimicrobial resistance was not found to be of

high concern in their practice or hospital, but it was a higher concern nationally. This mentality

leads to physicians not adopting a healthcare practice as quickly or easily because it is not of

high concern to them. If perceived susceptibility is high, the physicians might make extra time

to learn more about antimicrobial resistance as well as how to better care for patients in this

situation. Perceived severity is the physician’s mentality that antimicrobial resistance is very

important and could be deadly if not taken care of properly. In this research study, severity was

high because all of the physicians felt that if a patient has this problem; it is of the upmost

importance to care for them properly and quickly. A perceived barrier determined by the focus

group was the type of way physicians were obtaining this information about antimicrobial

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resistance. Some sources are better than others, easier to use and understand, as everyone learns

differently. Not one source is going to work best to dissemination information. Utilizing the

health belief model, it can be seen that unless the perceived susceptibility changes, antimicrobial

resistance may not be a high priority among healthcare providers until it becomes more

prevalent, reducing the amount of time physicians will spend gaining excess knowledge on the

topic.

The article entitled “Hand Hygiene among Physicians, Performance, Belief and

Perceptions” focused on hand hygiene among physicians. The authors focused their research and

study on Geneva Hospitals in Switzerland. Pittett, Simon and other researchers used multiple

different theories and models to guide their research for hand hygiene. There were physicians

who were observed and some who did not know they were being observed; the ones being

observed were possibly influenced as well as their adherence to hand hygiene because they knew

they were being watched and speculated. Questionnaires were filled out after observation from

the physicians with different questions relating towards their thoughts about hand washing.

Health related models guided their questions. Some different questions that were asked were

relating to how their perception of difficulty to adhere, perception of risk to cross-transmission,

attitude toward hand hygiene, intention to adhere, and perceived subjective norm etc. Also,

some questions were targeted at different demographics, including what stage in their medical

process they were in (physician, medical student, fellow or resident). There were questions

asked about different availability of hand sanitizer or if sinks and soap were close by or had easy

access as well. At the end of the study, researchers found that adherence towards hand hygiene

was mainly due to the risk of cross-transmission, availability, environmental context, and social

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pressures. Only 44% of people who were involved in the study said they could be used as role

models for hand hygiene.

White, Kolbe, Carlson, and Lipson (2006) conducted an experimental-control design

study in four residence halls on a college campus. Cold and flu viruses are easily transmitted

throughout college campuses, so the authors designed a study to see if conducting a health

message campaign about hand hygiene and the availability of gel hand sanitizer would decrease

illness and absenteeism.

The students in the experimental group were exposed to the message campaign and

provided with gel hand sanitizer. These students not only increased their knowledge about the

health benefits of hand washing, but they also reported higher rates of hand washing and using

gel hand sanitizer than the control group. Throughout the study, the students in the experimental

group also experienced fewer cold and flu illnesses, therefore missing fewer class or work

engagements than the control group.

The goal of this study was to see if creating a health campaign would help prevent

illnesses and decrease absenteeism among college student, which it did.

The article entitle “Compliance with Hand Washing” is discussing a situation that

Shriners Burn Hospital in Cincinnati, Ohio went through in regards to proper hand washing. A

group of healthcare providers in the hospital began substituting hand washing with glove

wearing, instead of doing both. Mathew Maley, an employee at the hospital began to do some

research. “Our facility treats pediatric burns exclusively, and over the past 2 years we had

observed a gradual rise in the nosocomial infection rate” (Maley, 2000). Through their

investigation they discovered that employees weren’t washing their hands, and in doing so

infected the gloves with pathogens. “Coagulase-negative Staphylococcus (CNS) was observed

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on all of the 40 glove boxes used in the study” (Maley 2000). The researchers also found MSSA,

MRSA, streptococcus, fungus, micrococcus species, bacillus species, and acinerobacter bacteria.

Careless employees were infected the sterile gloves that the careful employees also used.

According to Maley (2000), a quick fix was “the tops of all glove boxes used in all 14

acute-patient rooms were removed. This allowed staff to grab sterile gloves by the cuffs and not

the fingers, limiting the contamination.” The company switched gloves to a brand that had a flip

top allowing for the gloves to be re-sealed. The switch dropped their infection rates back to zero.

The hospital began to revamp its training programs to better illustrate the importance of hand

washing, just as we did with the preschoolers.

The explicit purpose of this campaign is to explore the perceived threat and susceptibility

from pathogens amongst the preschool population at the Grand Valley State University

Children’s Enrichment Center using hands on demonstrations, learning, and storytelling. Our

team was made up of four individuals studying Health Communications. Our program used a

black light, a small exercise ball, step-by-step posters, Glitterbug powder, and a children’s book

on hand washing.

Method

Participants

Our campaign was targeted at children ages three to five years old. We presented our

campaign to 18 children total, both male and female, but in two separate groups. The first group

had 10 children, ages four to five years old. The second group had eight children, ages three to

four years old. We chose to target children in this age group because it’s essential to learn the

importance of hand washing at a young age. At this age, we felt the children would be receptive

to activities, hands on learning, and visuals.

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The campaign was done at GVSU’s Children Enrichment Center. They provide care for

GVSU students, faculty, staff and community as a whole. The participants were eager to

participate, so there was no need for an incentive. We wrapped up the end of our campaign with

a book, which required the children to be quiet and listen. If the children were cooperative

during story time, we provided them with stickers as an incentive. The students were quiet and

attentive during the story and enjoyed receiving stickers at the end.

Apparatus

The materials that we used throughout our campaign included; hand washing kit,

storybook about hand washing, posters with simple steps and information on them, a ball and

stickers. Each of these materials played a vital role within our campaign to make it effective for

the children. The hand washing kit was a fun way to show how germs can spread and how well

they can stick to people and to different items. It is a kit that contains “GlitterBug powder,”

which is powder that can be detected under a black light (See Appendix A). When it is used, it is

a representation of actual germs and how they can spread and how they are hard to see but only

with microscopic tools or in this case the black light. The storybook was called Scrubba Dub,

Carlos and it was about a boy who did not like to wash his hands and he was always dirty

because he loved to play outside. It then goes through the process of how he learns to wash his

hands. The posters were used to show steps of how to wash your hands and when to wash your

hands (See Appendix B and C). We also used a ball to help show the children how germs are

spread from objects that we touch, and that objects can contain germs. Lastly, we used stickers

as a reinforcement to listen to story time and we wanted a small prize for the children for being

such great listeners during our presentation.

Procedure

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To execute the health campaign, we first got in contact with Sharalle Arnold, the director

of the Child Enrichment Center (CHC) on the campus of Grand Valley State University. This is

a daycare center for children from three to five years of age. We asked Sharalle if it would be

possible to conduct our health campaign with the children at the CHC. They were more than

happy to help, and we kept in contact. Two group members visited the CHC a week prior to the

campaign to meet with Sharalle and Jennifer, a teacher at the CHC, to discuss the entire

campaign.

Posters were made as visual aids to help the children understand two main portions of the

campaign. One of the posters had the five steps for effective hand washing (See Appendix B). It

also included a picture of the most commonly missed spots on the hands (See Appendix D). The

second poster had the times children should wash their hands. This poster included a picture of a

cartoon germ as well as the logo of the Glitter Bug powder that will be used in the campaign

(See Appendix C).

A hand washing kit made by GlitterBug was borrowed from a professor at Grand Valley

State University. It included GlitterBug powder and lotion as well as a UV light which allowed

the powder to be visible. We tested the kit out to see which GlitterBug product worked best to

show the transfer of germs as well as the easiest form to wash off. It was determined that the

GlitterBug powder was most successful in fulfilling both of these requirements. We wanted to

make sure that the powder was visible under the UV light, but easy enough to wash off for the

children.

Research was done on effective ways to teach kids a new topic, such as hand washing.

An outline was designed to determine talking points and order of the health campaign. Everyone

wanted to participate in different ways, so this was a good way to determine what every group

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member would do. The campaign was scheduled for Friday, April 18, 2014 at the CHC. We

conducted the campaign with two groups of students. The first group was five year olds and the

second group was four year olds.

Our group decided on having a class activity to begin with to show the children how

easily germs can spread. A ball was covered in the GlitterBug powder to show all of the germs

that people can share just by using the same toy. During this activity, we asked the students what

they thought germs were and what they did to a person. We wanted to get a feel for their

understanding and clarify any questions that they had. After every child got a chance to roll the

ball, we used the UV light to show them the “germs” on their hands. Next, we did a

demonstration of how germs can be spread by sneezing. One of the group members covered her

hands in GlitterBug powder and had five volunteers gather around her. Everyone held out their

hands to see if they would get any of the “germs” from the sneeze. She blew the powder,

imitating a sneeze. We then used the UV light to show the children how easily they got the

“germs” on their hands and even on their clothes. With the second group of students, we asked

them to line up in a single-file line and asked them to high-five a group member’s hand. This

was another way to show how germs are spread.

Next, we utilized the posters made to tell the children how to wash their hands. We went

through the five steps of proper hand washing with the students and made sure they understood

what was going to happen next when they went to wash their hands. For the younger group of

children, we demonstrated exactly what to do for each step, as well as tell them. They even

mimicked our hand motions and sang the ABCs with us. The teacher had everyone line up in

preparation for going to the bathroom to practice the correct hand washing procedure we just

taught. Two group members stood at the sinks to help students remember the process, as well as

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to sing the ABC’s. A third group member stood at the entrance of the bathroom to ensure that all

students dried their hands and lined back up at the door to return to the classroom.

When everyone returned to the classroom, we asked for the students to sit in a circle to

see how well they did at washing their hands. We went around to every student and used the UV

light to allow them to see any remaining germs on their hands. Next, we went over the list of

when to wash hands. Then we got ready for story time. Everyone sat in a circle around the

reading chair to hear the story. The children were told that there was a prize of stickers at the

end if they were able to sit quietly and listen to the story. At the end of the story, we reviewed

the concept taught during the health campaign. We reviewed when it is important to wash your

hands and how to wash your hands. At the end of the campaign, each student was able to receive

a sticker of their choice as a prize for participating in the presentation.

Results/Discussion

This health campaign was intended to teach young students, between the ages of three

and five, the importance of hand washing. It was conducted at the Child Enrichment Center on

GVSU’s Allendale campus on Friday, April 18, 2014. The campaign was created around

showing the children that germs can be spread easily via fomites, people or bodily functions such

as sneezing.

The main goal for our campaign was to be more informative than anything. We hope the

kids will remember our campaign based upon our visual aids, activates and story. It’s a much

more difficult task trying to get these ideas across to younger children than college students, but

we believe we succeeded.

Before we decided upon the Glitterbug powder we also tried the Glitterbug lotion. Both

of these substances glow bright white underneath a black light, and can be used as tools to

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demonstrate the importance of hand washing. We exposed our hands to the substances and

washed our hands the way we’d normally do so. To our shock our hands were still coated with

the lotion/powder and glowed bright white with the black light. We were college students that

have spent the last 20 or so years learning the importance of hand washing, yet we were doing it

incorrectly. We developed a step by step system and utilized a picture that shows frequently

missed places on hands during hand washing. To our experience the image was almost spot on,

we made sure to include it with the campaign

During our presentation we rolled a ball coated in the Glitterbug powder towards the

participants and they rolled it amongst each other and us. Effectively coating all of our hands,

team and participant alike, is a great tool to actually get an idea as to what is occupying the skin

of a hand. How many desks, door knobs, vending machines, or hands does the average Grand

Valley Student come into contact with? There are 23,000 students at GVSU, and this campaign

depicted why hand washing is important.

The first literature review focused greatly on the connection between a health campaign

and the Health Belief Model. It was interesting to see that even though the campaigns were on

different topics, the application of the model was still relevant. When there is a lower level of

perceived susceptibility, it is harder for an individual to adopt a new health behavior because

there is also no perceived benefit. In our campaign, the children understood that germs can make

them sick, and no one wants to be sick. At the beginning of the campaign, their perceived

susceptibility was low because germs are not a tangible object that a child can hold, they are very

abstract. But once we started talking about what germs can do and how easily they spread, it

started to grab their attention. The most influential pieces of the campaign were the activities

with the GlitterBug powder. This was something that mimicked germs, but the children could

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visualize it. They saw that just by playing with a ball or giving someone a high-five that hasn’t

washed their hands can easily pass germs from one person to another. The activity of washing

the GlitterBug powder off of the hands and being able to see their results also helped to increase

their susceptibility as well as the perceived benefits. A perceived barrier for the children at the

CHC was the access to reminders to wash hands. Other than the teachers reminding the children

when they needed to wash their hands, there weren’t any posters or reminders in the center to

spark their memory to wash their hands. If there were more reminders or triggers for the

children, the health behavior of washing hands when necessary would be retained easily and

quickly.

It was interesting how in the second article by Pettitt & Simon not all physicians felt it

was necessary or felt they were decent role models for hand hygiene. Therefore, by starting to

teach correct and sufficient hand washing at a young age and promoting these types of health

behaviors it will become a habit at a young age. Once something is taught at a young age and is

repeated throughout a person’s lifetime it tends to stick with them and it done over and over

again. Therefore by teaching and promoting about why hand washing is so vital at such a young

age as our campaign targeted 3-5 year olds it will carry on through one’s life. In hope that for all

people including physicians, it will become a habit and that it is done repeatedly and often at

health care related practices like the Geneva hospitals. If risks and reasons as to why we need to

wash our hands are promoted to the public and to health care providers it becomes more of an

emergent need to wash our hands. It was also discussed in the questionnaire given to

participants in the Geneva hospital research that only 35% of them knew the recommended

guidelines on hand hygiene. In our campaign we taught the correct and proper way to wash your

hands and we felt this was a very vital concept of our campaign because anybody can wash their

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hands but it needs to be done correctly for it to be most efficient. Like our campaign, this article

was partly framed from using the Health belief Model as well especially with the questions

focused on asking about their perception of risk of cross-transmission or in other words, if they

were at risk of the disease and if hand washing would help prevent it. Another question from the

article that was related to the HBM was about difficulty of adherence to hand washing, and if it

was difficult for participants because of the placement of hand sanitizer or soaps and sinks. In

other words, what barriers were in their way of not being able to wash their hands. These were

some of the constructs that our hand washing campaign had focused on as well.

The hand washing campaign conducted on the college campus reduced the risk of illness

and student absenteeism. Hand washing is such a simple task, but it can be informative at any

age. We believe it is important to educate young children on the importance of hand washing so

they have an idea of the proper way to do it and the harmful side effects it can cause. A health

campaign about hand washing for college students and young children varies greatly. Our

campaign was targeted at three to five year olds. We gave them basic information about germs

and simple hand washing steps. In the article, college kids were given brochures and talked with

one of the authors about the benefits of hand washing. This technique wouldn’t have worked for

our campaign because the children would have had a hard time comprehending the material.

In this section of our report we are going to discuss how the components of our health

campaign are directly related to the components of the Health Belief Model. First we are going

to focus on the component of perceived susceptibility and how the different activities that we

displayed throughout our campaign about washing hands help promote this health behavior. The

first activity that we did with the children was rolling around the “germ dusted” ball to one

another in a circle. This activity left residue of the GlitterBug powder on each person’s hands

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from simply touching the ball. Another activity that we did with the children was to show how

germs could be transferred by sneezing and by high-fives. By showing these different methods

of transmission of germs (fomites, people, bodily functions) it showed how susceptible and how

easily germs can spread from one another. We also made it known that germs can make you sick

and that it is important to wash your hands after daily activities because of the easy transferal of

germs. We had visuals of the germs spreading from object to person and from person to person

by showing them the GlitterBug powder on their own hands under the black light. By doing and

saying all these different actions and methods we wanted to show them that they are very

susceptible to germs and that hand washing is vital in order to keep these bad germs away. By

showing the children how easily germs spread, we are showing them how easily they are able to

get sick. By sharing this information with the children through active participation, we are

letting them know that they are very susceptible to germs because they are everywhere and by

washing our hands it is a great way to get rid of them. In order for an individual to adopt a new

behavior and for it to become natural to them their perceived susceptibility has to be raised. By

telling and showing the children, we were raising their perceived susceptibility about germs

being spread very easily. With hands-on experience and being told that germs can collect on our

hands and by seeing how easily germs can spread, they have a better understanding that without

washing their hands they are more susceptible to getting sick. In retrospect the children think

they are more susceptible to becoming sick if they do not wash their hands so they will want to

adopt this new behavior in order to stay healthy.

Another component that our campaign portrays is one components of the Health Belief

Model, perceived seriousness, of the health behavior of washing your hands. We wanted the

children to begin to understand the seriousness of washing your hands portrays. We wanted

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them to begin to understand the severity that not washing our hands after daily activities like

going to the bathroom, before we eat, after we sneeze and playing with pets can bring us many

illnesses. Also, we wanted the children to understand that washing our hands properly is vital as

well. This is why we went through the hand washing process with the children and then we went

and washed our hands together. We showed them by example and then went and performed the

activity together so they could experience it themselves and see how it is done. By doing it

correctly with the right materials (warm water, soap, clean towel) and for a sufficient amount of

time, washing our hands can stop us from getting multiple diseases. By showing them the

correct way we wanted to increase their perceived seriousness about washing our hands. Also by

telling the children that they can become sick and not feel good they understand that when they

are not sick they cannot go outside and play or go to school and see their friends. This also

triggers them to think that they do not want this to happen, so they get more serious about

washing their hands because they want to be involved in these activities. By understanding that

washing their hands can lessen their chances of getting sick, their seriousness of washing their

hands rises. If they understand what they are not able to participate in if they do not wash their

hands, they become more serious because they are seeing the outcomes of not washing their

hands can do. By seeing the difficulties or realizing the effects of not washing their hands, the

children are more opt to adopt this new health behavior.

This health campaign was also supported by reading material from the COM 410 class.

One particular article “Chapter 4: Health Belief Model” had a lot of information on the model

itself as well as an example of when the model should be applied to a health campaign. All

components of the model are discussed in the article and then applied to a health campaign on

osteoporosis prevention. According to Turner, Hunt, DiBrezzo and Jones (2004), “People are

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most likely to make behavior changes when they perceive that the disease is serious and are less

likely to practice healthy behaviors if they believe that the disease is not severe” (p. 38). We

found this to be true in our campaign as well. Because the children were of a younger age, they

did not necessarily understand the severity of germs, but they understood that germs can make

you sick. With that in mind, the children were very receptive to learn how to properly wash their

hands, and it was more of a reinforcement to see the “germs” under the black light after their

washed their hands. It was either validation of a job well done or a reminder of where they need

to scrub harder the next time. Tuner et al. (2004) states that “Increasing perceived severity,

perceived susceptibility, perceived benefits, self-efficacy and cues to action while decreasing

perceived barriers were actions that encouraged participation” (p. 42). We found this to be true

in our health campaign as well. The more we talked about the topic with the students and

explained the importance of hand washing, the perceived susceptibility, perceived benefits, self-

efficacy and cues to actions all changed so that the students felt more confident in know how to

wash their hands and when.

There were a few barriers to conducting this health campaign. First is the age of the

children. Although they were young, we did not take into consideration their learning style.

With the first group, we conducted the health campaign as practiced, and saw good results, but

the children forgot the five steps as soon as they got to practice washing their hands. We made

an adjustment with the second, and younger, group. We had them imitate us while explaining

the five steps of hand washing, which had a much better outcome after they got to practice

washing their hands. Also, it was beneficial to have group members in the bathroom with the

students washing their hands to ensure they completed the entire process. Another barrier we

took note of was that the posters made for the children were written out with words rather than

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having pictures attached. At a young age, such as the ages of our participants, they learn better

by seeing rather than reading steps. If the campaign were to be conducted again, it would be

beneficial to change the posters to visual aids rather than written steps.

In conclusion, the hand washing health campaign conducted was successful. The

students at the CHC were very receptive to the information and enjoyed the overall process. The

Health Belief Model was applied to the campaign in terms of the components of the model and

the children’s views of hand washing. It is our hope that the children remember this campaign

when they need to make a decision about washing their hands, because they know what germs

can do. There are changes that can be made to a future campaign, but overall the campaign as a

whole was effective in teaching children about hand washing.

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References

Brain pop. (2014, February 2). Washing hands activities for kids. Retrieved April 8, 2014, from

http://www.brainpop.com/educators/community/lesson-plan/washing-hands-activities

-for-kids/

Brinsley, K., Sinkowitz-Cochran, R., & Cardo, D. (April 2005). Assessing motivations for

physicians to prevent antimicrobial resistance in hospitalized children using the health

belief model as a framework. American journal of infection control, 33, 175-181.

Centers for disease control and prevention. (2013, December 11). When and how to wash your

hands. Handwashing: Clean hands save lives. Retrieved April 8, 2014, from

http://www.cdc.gov/handwashing/when-how-handwashing.html

Columbus public health. (2012, July 1). For young children: Teaching handwashing. Retrieved

April 15, 2014, from http://columbus.gov/uploadedfiles%5CPublic_Health%

5CContent_Editors%5CResources_For%5CEducators%5CTeaching%20young%20childr

en%20handwashing.pdf

Maley, M. (2000). Compliance With hand washing. Society for Healthcare Epidemiology of

America, 21, 4.

Pettitt, D., Simon, A., Hugonnet, S., Pessoa-Silva, C., Sauven, V. & Perneger, T. (2004). Hand

Hygiene among Physicians, Performance, Belief and Perceptions. Annals of internal

medicine. Retrieved on April 8, 2014, from: http://graphics8.nytimes.com

/images/blogs/freakonomics/pdf/PittetHandwashingPerceptions(AmerCollegePhys2004).

pdf

The nemours foundation. (2014, January 13). Hand washing. Kids health. Retrieved April 8,

2014, from http://kidshealth.org/teen/your_body/skin_stuff/handwashing.html

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Turner, L.W., Hunt, S.B., DiBrezzo, R., & Jones, C. (2004). Design and implementation of an

osteoporosis prevention program using the health belief model. American journal of

health sciences, 19(2), 115-121. Print.

White, C., Kolbe, R., Carlson, R., & Lipson, N. (2006, August 6). The Impact of a Health

Campaign on Hand Hygiene and Upper Respiratory Illness Among College Students

Living in Residence Halls. Journal of American College Health, 53(4), 175-181.

Retrieved April 19, 2014 from http://search.proquest.com/docview/213032667

/fulltextPDF?accountid=39473

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Appendix A

GlitterBug Powder

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Appendix B

“How to Wash Your Hands” Poster

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Appendix C

“When to Wash Your Hands” Poster

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Appendix D

Most Frequently Missed Areas of the Hands during Hand washing

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Appendix E

Pictures from the Campaign

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