Hand Hygiene and Absenteeism in Primary Schools

Transcription

1 Hand Hygiene and Absenteeism in Primary Schools Alexandra Nicholson Research Associate, University of Bristol

2 Background Effective hand hygiene can reduce the spread of infection Children often implicated in spread of infection Trial evidence for the effectiveness of hand washing interventions in schools is of poor quality with mixed results

3 Hands up for Max! Developed by the former Health Protection Agency Educational resource to promote effective hand hygiene practice in primary schools

4 Hands up for Max! Lesson plans DVD animation Posters and stickers

5 Evaluation: cluster randomised controlled trial Outcome measures Pupil and staff absence Sub-study Absence due to infectious illness Questionnaires: knowledge, attitudes, behaviour

6 Recruitment and Randomisation 613 primary schools in 6 local authorities in SW invited to participate 178 schools consented Randomised Intervention 88 schools receive Hands up for Max! Control 90 do not receive Hands up for Max! (until trial complete)

7 Baseline characteristics Characteristic All schools n=175* Intervention n=85 Control N=90 Mean school size (no. of pupils) Mean pupil age Percentage female Percentage entitled to free school meals Percentage of children with English as main language Mean number of pupil half days of absence per 100 half days * 3 special schools were excluded from analysis

8 Intervention delivery 85.2% of schools reported delivering the intervention (75/88) Autumn 2009 (term 1&2) Spring 2010 (term 3&4) Summer 2010 (term 5&6) Term not reported Total Delivered (%) 51 (68.0) 21 (28.0) 2 (2.7) 1 (1.3) 75 (100)

9 Pupil absence Mean number of pupil half days of absence per 100 half days at follow-up Intervention n=84* Control n=88* *Data were not available for special schools and schools that had merged or closed post baseline. Adjusted analysis: -0.05, (95% CI to 0.21) p=0.70

10 Teacher sickness absence Mean number of teacher sickness days per teacher per year at follow-up Intervention n=87* Control n=87* * Data were not available for schools that had merged or closed post baseline Adjusted analysis: (95% CI to 0.88) p=0.74

11 Null result why? Intervention is not effective Variation in intervention delivery Influenza pandemic Outcome measure flawed

12 Absence due to infectious illness Data on 14 common symptoms collected Algorithm developed to identify infectious illness Number of infectious illnesses compared across trial groups no significant pupil or staff differences

13 Pupil questionnaires Developed for the trial Tests applied to assess how valid and meaningful the data are Factor analysis suggests 3 factors: When, how, why Role modelling Facilitators and barriers

14 Insights from the process evaluation Factors influencing hand hygiene Structure Time Facilities Societal norms Agency Encouragement and reminders Education and information Awareness and knowledge

15 Summary Hands up for Max! was not effective at reducing absence in trial population Challenge to make hand washing part of a sustained routine in schools A more comprehensive approach to hand hygiene in schools may be needed

16 Funding This presentation presents independent research commissioned by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

17 DECIPHer Acknowledgement The work was undertaken with the support of The Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), a UKCRC Public Health Research Centre of Excellence. Joint funding (MR/KO232331/1) from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the Welsh Government and the Wellcome Trust, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged.

18 Pupil absence: School level analysis Difference in mean rates: half days per 100 days 95% confidence intervals p- value Crude to Adjusted a to Adjusted plus to weighted b a Adjusted for baseline rates of absence, school size, proportion of pupils taking FSM, LA area, mean age of pupils, proportion of females in the school, proportion of pupils recorded with ethnicity white, proportion of pupils with English as their first language, school level deprivation score indices. b Inverse variance weights, using total numbers of pupils, added to adjust for differences between schools in terms of size.

19 Teacher sickness absence: School level analysis Difference in mean rates: days of absence per year 95% confidence intervals p- value Crude to Adjusted a to Adjusted plus weighted (no. of pupils) b to a Adjusted for baseline rates of absence, school size, proportion of pupils taking FSM, LA area, mean age of pupils, proportion of females in the school, proportion of pupils recorded with ethnicity white, proportion of pupils with English as their first language, school level deprivation score indices. b Inverse variance weights, using total numbers of pupils, added to adjust for differences between schools in terms of size.

20 Symptom algorithm 1. Gastrointestinal infectious illness Where the following combinations of symptoms are reported: Vomiting + Diarrhoea + Fever Vomiting + Fever Diarrhoea + Fever Vomiting + Diarrhoea Vomiting Diarrhoea 3. Other infectious illness Fever + one or more of the following: Headache, Red/Gritty eyes, Rash/skin spots Fever alone Rash/skin spots alone Red/Gritty eyes alone 2. Respiratory tract infections Fever + one or more of the following: Sneezing, Runny/stuffy nose, Cough, Sore throat, Ear pain/infection Two or more of the following: Sneezing, Runny/stuffy nose, Sore throat Ear pain/infection 4. Other non-infectious illness Any other combination of symptoms.

21 Pupil absence due to infectious illness Category of illness (number and (%)) *No was recorded for all 14 symptoms. # Data for all 14 symptoms listed were missing Intervention (11 schools, 2282 pupils; 956 absence records) Control (12 schools, 1913 pupils; 1215 absence records) Gastrointestinal infection 274 (28.6) 320 (26.3) Respiratory tract infection 307 (32.1) 417 (34.3) Other infectious illness 56 (5.9) 100 (8.2) Other non-infectious illness 167 (17.5) 204 (16.8) No symptoms listed* 32 (3.4) 36 (3.0) Missing data # 120 (12.6) 138 (11.4)

22 Pupil absence due to infectious illness Intervention Control All categories of infectious illness 637 (67%) 837 (69%) Odds ratio 95% Confidence p-value interval Fully adjusted* to *Adjusted for clustering using robust standard errors, and baseline characteristics as in main trial absence analyses.

23 Staff absence due to infectious illness Category of illness (number (%)) *No was recorded for all 14 symptoms. # Data for all 14 symptoms listed were missing Intervention (11 schools, 411 staff; 67 absence records) Control (12 schools, 330 staff; 79 absence records) Gastrointestinal infection 24 (35.8) 30 (38.0) Respiratory tract infection 24 (35.8) 24 (30.4) Other infectious illness 2 (3.0) 4 (5.1) Other non-infectious illness 14 (20.1) 20 (25.3) No symptoms listed* 2 (3.0) 1 (1.3) Missing data ** 1 (1.5) 0 (0)

24 Staff absence due to infectious illness Intervention Control All categories of infectious illness 50 (75%) 58 (73%) Odds ratio 95% Confidence p-value interval Crude to *Adjusted for clustering using robust standard errors, and baseline characteristics as in main trial absence analyses.

25 Pupil questionnaires Intervention exposure by trial group Item At school we have had lessons about how to wash our hands At school we have pictures on the wall about how to wash our hands Percentage (%) of pupils responding Yes Intervention Control

26 Pupil questionnaires Intervention exposure by trial group Item Percentage (%) answering correctly Intervention Control Max e-bug

27 Pupil questionnaires Intervention Factor one (0-32) When, How, Why? Control Observations Mean (SD) (4.43) (4.30) Median (IQR) 25 (6) 25 (5) Factor two (0-14) Role Modelling Observations Mean (SD) 4.49 (3.53) 3.93 (3.38) Median (IQR) 4 (4) 3 (5) Factor three (0-8) Facilitators/Barriers Observations Mean 2.61 (2.27) 2.56 (2.25) Median (IQR) 2 (3) 2 (3)

28 Role modelling Pupil questionnaires Promoted Statement 39 My friends tell me when to wash my hands 40 I tell my friends when to wash their hands 44 I tell my family when to wash their hands 43 My family tell me when to wash my hands 38 My teacher tells me when to wash my hands Observed 42 At home my family show me how to wash my hands 32 At school my teacher shows me how to wash my hands When,How,Why? Role Modelling Facilitators/Barriers Factor Factor1 Factor2 Factor3 Alpha

29 Pupil questionnaires Factor one (0-32) When, How, Why? Difference in means (intervention minus control) 95% confidence interval p-value Crude to Adjusted for clustering a to Fully adjusted b to Factor two (0-14) Role Modelling Crude to 0.79 < Adjusted for clustering a to Fully adjusted b to Factor three (0-8) Facilitators/Barriers Crude to Adjusted for clustering a to Fully adjusted b to

30 Insights from the process evaluation Intervention implementation The resource was generally well received by teachers and pupils (acceptability) Variation in resource use (dose, fidelity) Curriculum based (sustainability)

31 Process evaluation papers Chittleborough, C. R., Nicholson, A. L., Young, E., Bell, S. & Campbell, R. Implementation of an educational intervention to improve hand washing in primary schools: process evaluation within a randomised controlled trial In: BMC Public Health. 13, p. 757 Chittleborough, C. R., Nicholson, A. L., Basker, E., Bell, S. & Campbell, R. Factors influencing hand washing behaviour in primary schools: process evaluation within a randomized controlled trial. December In: Health Education Research. 27, 6, p p.

32 KS1 female toilets KS1 male toilets 123_03_ _04_001

33 KS2 male toilets 123_08_001, 123_08_002, 123_08_003

34 Explanatory model of hand washing practices in Hands up for max! trial

35 Factors identified as influencing hand washing

36 Summary Agency, through education, may be necessary, but is probably not sufficient to ensure that good hand washing practices are initiated and maintained Structural factors, including being provided with the time, opportunity, and accessible, high quality facilities, also influence how likely hand washing becomes routine.