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Comparing Hand Washing to Hand Sanitizers in Reducing Elementary


									                                        Comparing Hand Washing to
                                        Hand Sanitizers in Reducing
Practice                                Elementary School Students'
Applications                            Ahsenteeism
of Research
                                       Judith A. Vessey
 Janice S. Hayes, PhD, RN
                                       Jessie J. Sherwood
                                       Dorothy Warner
                                       Diane Clark
Purpose: To compare the efficacy of an alcohol-based hand sanitizer to standard hand washing in reducing
illness and subsequent absenteeism in school-age children.
Method: A randomized cross-over design was used with 18 classrooms of 2nd and 3rd grade students
(n = 383) from 4 elementary schools. Half of the classes from each school used an anti-microbial gel hand
sanitizer while the other half used soap and water for regular hand hygiene for 2 months, then, the students
switched cleaning methods for the following 2 months.
Results: No significant differences in absenteeism rates were demonstrated. A follow-up focus group com-
prised of teachers and school nurses indicated that hand sanitizers were preferred over soap and water.
Conclusion: Hand sanitizers are an appropriate alternative to hand washing for hand cleansing and may
offer additional benefits in the school setting.

         chool nurses are responsible for minimizing bealth         Review of the Literature
         threats that interfere with student's learning and staff
         participation (Rodriguez, 2002). Hand cleansing is an      Illness, Absenteeism, and Academic Performance
         effective method for preventing the spread of infection        Everyone is susceptible to the transmission of disease, but
and reducing illness-related absenteeism (Morton & Schultz,         children are one group that is at greater risk (Hezel, Bartlett,
2004). Although the benefits of hand cleansing are clearly rec-     Hileman, Dillon, & Cessna, 2000). Upper respiratory infec-
ognized, initiating and sustaining appropriate hand-washing         tions, influenza, intestinal illnesses, conjunctivitis, and other
practices among elementary school children is difficult due to      communicable diseases occur frequently among students.
the students' developmental level and constraints in school         Crowded settings, shared objects, and inadequate self-care
settings. Anti-microbial gel hand sanitizers appear to be a         skills all contribute to the transfer of pathogenic microorgan-
viable alternative to soap and water and offer other distinct       isms, particularly in elementary schools where current peda-
advantages in the school setting. The purpose of this study         gogical techniques require close and cooperative interaction
was to compare the efficacy of a hand sanitizer to standard         among children. Microorganisms are readily transmitted either
hand washing in reducing illness and subsequent absenteeism         directly or by inanimate objects serving as vectors, and cont-
in school-age children.                                             aminated hands are implicated in this process. When the
                                                                    organisms are pathogenic, the secondary spread of commu-
                                                                    nity-acquired infections among students is inevitable (White,
Judith A. Vessey, PhD, FAAN, Is Leiia Hoiden Carroli Professor in   Shinder, Shinder, & Dyer, 2001).
iNursing, Boston College, William F. Conneii School of Nursing,         Community-acquired infections are a major reason for
Chestnut Hill, MA.                                                  absenteeism among elementary school students (Dyer,
Jessie J. Sherwood, BSN, RN, is Chronic Illness Care Manager,       Shinder, & Shinder, 2000; Hammond, Ali, Fendler, Dolan, &
Maine Medical Center Physician - Hospital Organization, Portland,   Donovan, 2000; McGuckin, & Ali, 2002). Absenteeism from
ME.                                                                 communicable illnesses is estimated to range from 70 to 164
Dorothy Warner, MS, BSN, RN, is Elementary School Nurse,            million lost school days annually (Adams, Hendershot, &
Butte School District #1, Butte, MT.                                Marano, 1999), with absenteeism usually higher during winter
                                                                    months due to influenza and other infectious illnesses.
Diane Clark, RN, is Elementary School Nurse, Butte School           Because attendance is predictive of academic success,
District # 1, Butte, MT.                                            repeated absences disrupt students' learning processes and
Acknowledgement: This research study was supported by an            academic performance. Frequent, shorter absences—^the pat-
unrestricted grant from GoJo Industries awarded to the National     tern associated with repeated communicable diseases—is
Association of School Nurses. The assistance of Linda Boland,       more detrimental than a singular, longer absence (Hezel,
RN, also is noted.                                                  Bartlett, Hileman, Dillon, & Cessna, 2000; Kimel 1996;
                                                                    Ohiund & Ericsson, 1994). Student learning also is disrupted
  The Practice Applications of Research section pre-                by unplanned teacher absenteeism, which in turn, interferes
sents reports of research that are clinically fccused and           with curriculum coordination and delivery.
discuss the nursing application of the findings. If you are
Interested in author guidelines and/or assistance, con-                 Student absenteeism affects more than student academic
tact Janice S. IHayes, PhD, RN; Section Editor; Pediafric           performance. Because public school funding formulas are
Nursing; East Holly Avenue Box 56; Pitman, NJ                       based on attendance numbers, increased absenteeism direct-
08071-0056; (856) 256-2300 or FAX (856) 256-2345.                   ly translates to fewer federal and state dollars for school pro-

                                                                                               ;/July-Augusf 2007/Vol. 33/No. 4
grams. When sick students need to be cared for at home, par-        When multiplied by four times over the course of the school
ents are absent from the workplace which in turn, negatively        day, 2 hours—or a third of the school day—is taken from ped-
affects the economy (Master, Hess, & Dickson, 1997). Student        agogical activities (White et al., 2001). In some schools, the
and staff absenteeism also results in increased school admin-       time required for a class to wash their hands is the entire lunch
istrative costs (e.g., student tracking, hiring substitutes) and    break.
greater health-care expenditures.                                       Environmental obstacles include the placement and num-
                                                                    ber of sinks. They are often too few in number, too high, or
Efficacy of Hand Cleansing                                          located outside the classroom where supervision is limited.
    Skin fiora contains resident and transient flora. Resident      Faucets are rarely operated by foot pedals or sensors, result-
fiora refers to colonizing microorganisms not readily removed       ing in hand recontamination when turning off the water. The
through the mechanical friction associated with hand washing.       inability to control the water temperature, frequently only cold
Transient flora, noncolonizing and present on hands due to          water is available, is objectionable. Soap and paper towels are
contamination, is more likely to cause illness and are of           frequently in short supply, sometimes misguidedly removed
greater concern. Hand-cleansing techniques are aimed at sig-        by custodians to eliminate mess.
nificantly reducing the amount of transient flora on hands.             Hand sanitizers. The use of anti-microbial gel hand sanitiz-
Although data fi^om schools are not available, studies con-         ers appears to provide an effective, convenient, and simple
ducted on hospital personnel as to the impact of hand wash-         alternative to hand washing. A comparison of traditional hand
ing on illness are compelling. These studies have shown that        washing with soap and water versus gel hand sanitizers has
the bacteria found on the hands of hospital personnel caused        shown that using a hand sanitizer is effective at disinfecting
21% of the nosocomial infections, but hand-washing can sig-         hands of health care personnel as well as reducing the irrita-
nificantly (p<.05) decrease the nosocomial infection rates          tion associated with the regular use of the soap and water
among hospital patients (Conly, Hill, Ross, Lertzman, & Louie,      (Boyce, 2000; Boyce & Kelleher, 2000; Kimel, 1996). The
1989;Larson,1981).                                                  most effective regimens use antimicrobial gel sanitizers in
    Hand-cleansing education leading to improved hand               combination with either anti-microbial or plain soap and water
hygiene helps reduce the spread of infections (Kimel, 1996;         for hand cleansing (Paulson, Fendler, & Dolan, 1999; Boyce &
Niffenegger, 1997; Wilson, 1985). Unfortunately, formal             Pittet, 2002).
instruction on hand cleansing is not universal in schools and           To date, multiple studies have studied the effects of hand
even when taught, not all students practice hand cleansing          sanitizers on school children. In a randomized clinical trial of
regularly (Day, St. Arnaud, & Monsma, 1993; Kimel, 1996).           6,000 elementary schools comparing groups using hand san-
School nurses, accountable for minimizing health threats that       itizers paired with control groups (p < .05) receiving no inter-
interfere with learning, must promote regular hand cleansing        vention, the data showed an overall reduction in infection-
by students and staff (Kimel, 1996).                                related absenteeism of 19.8% (Hammond, Ali, Fendler, Dolan,
    Varieties of hand-cleansing programs have been imple-           & Donovan, 2000). Dyer (2000) and colleagues' 10-week
mented in schools and have met with mixed success. The              crossover study involving 420 elementary school children
Scrubby Bear Program, initiated in 1986, was found to be            using an alcohol-free hand sanitizer support these findings.
effective with teaching 4-year-olds in day-care centers to wash     Illness-related absences were decreased by 41.9% when stu-
their hands and has been used in many day-care centers and          dents were supervised throughout the school day and used
elementary schools since its origination (Glasby & Snow,            hand sanitizer in addition to regular hand washing. White
 1986; Eliason & True, 2004). Since then, other hand-cleans-        (2001) and colleagues conducted a double-blind, placebo-
ing curricula have been disseminated. Studies of the effective-     controlled study to evaluate the effectiveness of adding a hand
ness of all these curricula report positive short-term findings     sanitizer to routine hand washing. FYior to conducting this
(Master, Longe, & Dickson, 1997; Pete, 1986). But in cases          study, students received a half-hour educational program on
where long-term behavior change was tracked, evidence indi-         the transmission or germs, their relationship to illness, the
cates that that students did not routinely wash their hands         importance of hand washing, and how to use a hand sanitizer.
without periodic verbal reinforcement accompanied by other          All students were supervised in the use of the hand sanitizer or
reminders (Monsma, Day, & St. Arnaud 1992). Consistent              placebo six times per day and were allowed to wash their
adult supervision and incorporating hand cleansing into daily       hands at will without supervision. The results indicated a
routines are needed to help children maintain consistent hand-      31.1% difference in student absences related to illness for the
cleansing habits.                                                   hand sanitizer group (N = 381) compared to the control group
                                                                    (N = 388). Finally, Morton and Schultz (2004) demonstrated a
Hemd Cleansing Techniques                                           43% reduction in illness-related absenteeism over a 3-month
                                                                    period in their crossover-design study of elementary students
    Soap and water. Mechanical friction, soap, and water
                                                                    (N = 253) when hand sanitizers were used as an adjunct to
removes most transiently acquired organisms and is a highly
effective techniques for hand cleansing. To be effective,
experts recommend using warm running water and soap;                   Meadows and Le Saux (2004) conducted a critical review
applying 30 seconds of friction between hands; drying hands         of these studies using criteria published in the Cochrane
witji a paper towel; and turning off the faucet with a paper        Reviewers' Handbook, the leading authority in evaluating the
towel to avoid hand-to-surface contact (Centers for Disease         quality of research evidence for practice. Collectively, the find-
Control, 2003). Warm water, while making hand washing eas-          ings from these studies were deemed to be of low quality and
ier and more pleasurable, is not essential to removing most         should be interpreted with caution. Additional, well-controlled
microorganisms from hands.                                          randomized clinical trials were recommended.
    Developmental and physical barriers impede the imple-
mentation of this seemingly simple skill (Pete, 1986).              Barriers to Hand Cleansing
Children's limited psychomotor coordination and the inability          Neither soap and water or hand sanitizer will be effective in
to easily estimate a 30-second time period often result in insuf-   reducing micro-organisms if they are not used. Placement of
ficient scrubbing. For the entire class of 30 students to wash      wash stations and sanitizers, frequency and duration of hand
their hands appropriately, it requires approximately one-half       washing, ease of product use, and verbal prompts have all
hour when there is only one sink available in the classroom.        been positively correlated with improved adherence and

PEDIATRIC NURSING/July-August 2007/VoL 33/No. 4
reduced infection risk (Early et al.,1998; Morton & Schultz,           tional formal education was provided.
2004). Education, accessible and convenient hand hygiene                   Data collection then took place in two phases: January and
methods, and verbal prompts will result in a sustainable               February (phase 1) and March and April (phase 2). These
increased hand washing and sanitizer use and in the reduction          time periods were selected because they minimized the effects
of illness and absenteeism among elementary school children            of holidays and vacations on illness communicability. During
(Early et al., 1998; Rodriguez, 2002). Although teachers rec-          the data collection phase and following standard educational
ognize the importance of hand cleansing, little is known               practices, teachers, nurses, and other school personnel
regarding their preferences regarding soap and water or hand           reminded all students to clean their hands as they normally
sanitizers. Yet, they are in the position of providing ongoing         would. This included regular reminders, such as before going
messages regarding the importance of hand cleansing and for            to lunch and after using the bathroom, and episodic reminders,
modeling correct hand-cleansing behaviors to their students.           such as after activities that resulted in soiled hands. A strict
Direct comparisons of hand sanitizers to soap and water used           reminder protocol was not used; rather the intent was for
and their effect on absenteeism are not in evidence.                   teachers to give the reminders they normally would through-
                                                                       out the school day.
Methods                                                                    The classrooms were divided into two cohorts. Cohort 1 (n
    The study consisted of two parts. Part 1 included a con-           = 191) consisted of 9 classes, four 2nd grade classes from
trolled clinical trial designed to compare the efficacy of soap        schools A and B andfive3rd grade classes from schools C and
and water to hand sanitizers in reducing illness-related absen-        D. Cohort II (n = 192) consisted of 9 classes, four 2nd grade
teeism. Part II used a qualitative focus group technique to            classes from schools C and D and five 3rd grade from four
ascertain school personnel's preferences and insights into             schools A and B. Classes in cohort I/phase 1 were assigned to
product selection.                                                     treatment 1 (hand washing) and classes in cohort ll/phase 1
                                                                       were assigned to treatment 2 (hand sanitizing). The appropri-
Parti                                                                  ate product—soap or hand sanitizer—was made available in
    Design. A randomized cross-over design was chosen to               their classrooms and restrooms during this period. The cohorts
control for the seasonality of illness and treatment order.            switched treatments for phase 2 after 2 months. At the con-
    Site. The Butte, Montana school district was chosen for this       clusion of data collection, all students were given a certificate
study as there was district administrative support, qualified          of appreciation.
school nurses available to help design and execute the study,              Absentee data were forwarded each week to the
and support personnel who collected the data. Moreover, 4 of           researchers at Boston College where it was entered, cleaned,
the 7 elementary schools in the district were similar in size and      and analyzed. No identifying information for individual stu-
demographics needed for the research design.                           dents was provided. Demographic information and enrollment
    Sample. The sample consisted of the 2nd and 3rd grade              and absentee data were only reported in the aggregate.
student population of the participating schools. The total con-
sisted of 383 elementary students drawn from 18 classes, 8             Findings
classes of 2nd grade students and 10 classes of 3rd grade stu-             All 18 classes and 360 students completed the study. Of the
dents. The classroom size ranged from 15 to 27 students.               3 students who withdrew, 2 did so because the soap was too
Grades 2 and 3 were chosen as younger students have a high-            irritating and 1 because both soap and hand sanitizer were too
er rate of communicable disease than older students.                   irritating. Absentee data are presented in Table 1. Data fi-om
Kindergarten students and 1st grade students were not includ-          cohort A, phase 1 and cohort B, phase 2 were combined to
ed because they attend only half-day sessions or were less             form the Soap and Water Group. Data from cohort A, phase 2
familiar with school routines. All students in the designated          and cohort B, phase 1 were combined to form the Hand
grades were eligible to participate. Those who did not give            Sanitizer Group. Absentee data from these two treatment
consent had allergies to soap, sanitizers, or one of their             groups are presented in Table 1. Both groups had 18
components. This sample size assumed a medium effect size              absences. The students' f-test was then applied. No significant
(.50) = .05, and power = .80.                                          differences were noted between the groups, indicating that the
    Measure: Absentee rates. School secretaries collected              number of student absences was not appreciably affected by
absentee information and specifically asked whether the                the hand-cleansing technique used.
absence was due to acute, communicable illnesses for stu-
dents in study classrooms. When additional information was             Part II
needed, the school nurse and/or teacher validated the reason
for a student's absence. Absenteeism for reasons other than            Design, Site, and Sample
communicable illness such as injuries, lice infestation, vaca-            At the conclusion of Part I of the study, a focus group of
tions, or exacerbation of chronic conditions were determined           teachers, school nurses, and office personnel (n = 13) was
by parental report and were not included in the data analysis.         conducted to ascertain their observations and preferences.
    Procedure. The study was initially approved by the Boston
College Institutional Review Board and the Butte, Montana              Procedure
School District. Procedures for the waiver of active parental              The primary objective of the focus group was to elucidate
informed consent were followed. A letter describing the study          participants' experiences with soap and water and hand sani-
was sent home to the parents of students in the participating          tizers. The analytic approach was manifest content analysis,
classes. Parents who did not wish for their child to participate       with emphasis on information that was evident and apparent
in the study completed the enclosed form notifying the inves-          in the participants' remarks. Open-ended questions with
tigators of their intent. Children were told about the study in        probes were used to facilitate discussion. Questions such as—
age-appropriate language and their assent was obtained.                "What do you like/dislike about soap and water? hand sanitiz-
    The month prior to data collection, a school nurse with con-       er?"—^were asked. Data were audio-taped, transcribed, and
tent expertise but no affiliation with the school district data col-   coded. Recurring themes were identified.
lectors taught the students in each designated class correct
hand-washing/sanitizing procedures using a standardized cur-
riculum including the video, "Wash those Hands." No addi-

                                                                                                  itiuly-August 2007/Vol. 33/No. 4
Findings                                                                  Table 1. Two-Tailed f-Test Mean Differences of the
     Many of the participants' observations indicated that they          Number of Days Absent Between the Soap and Water
 preferred the use of the hand sanitizer over soap and water as                      and Hand Sanitizer Groups
 it better matched the pragmatics of the school day. The
 amount of time required was a key consideration, as noted in
 these comments.
                                                                       Soap and Water          25.44       10.27       .664         34
     ...they [the students] would try to skip it [hand washing
                                                                       (N = 18)
 with soap and water] or wouldn 't do it properly took up to
 probably an extra 10 minutes to get out to lunch.                                             26.77
                                                                        Hand Sanitizer                      7.00
     I liked the hand sanitizer because it took so long to get the
                                                                        (N = 18)
 kids out to lunch [when hand washing with soap and water]
 and my kids would use it [hand sanitizer] because it was
     Improved adherence and better hand cleansing by students
 during the study period were also noted in teachers' com-              which case no hand-cleansing technique would be used) that
 ments:                                                                 there was insufficient statistical power to detect a significant
     We have the sanitizer by the door and it was funny, the            difference between the groups. Ideally, data would have been
 kids walk by it and subconsciously would just take a                   collected and analyzed by student rather than by classroom,
 squirt.. .Lots of time I don't think they were paying attention to     but logistical issues preclude this from occurring in a natural-
 what they were doing.                                                  istic setting such as a school. Secondly, obtaining accurate
     It [hand sanitizer] was easy, it smelled good. It didn't make      data for absenteeism due to communicable illness was diffi-
 their food taste the lunchroom.                             cult, even when parents were aware of the reason for provid-
     .. .you can't let the water run.. .they touch [the faucet] with    ing accurate information. School personnel noted that fre-
 their dirty hands...touch it again with their clean hands...           quently a parent would report a child's absence as due to ill-
     The ability to observe student behavior and maintain class-        ness but upon questioning the child, a different reason was
 room decorum were other perceived benefits of hand sanitiz-            given. Lastly, this study did not manipulate the environment to
 ers:                                                                   maximize differences between the control and experimental
     We teach them a lot about coughing and sneezing into their        groups, common in other research studies. For example, other
 hands and then to go wash their hands but many times they              studies that reported significantly less absenteeism with the
 are in the classrooms and they can't leave. But if you haue the       use of hand sanitizers were used, additional cues were given to
gel, they can go over and use it.                                      the experimental groups, including throughout the school day
     When you haue them go to in the bathroom with soap and            to use the sanitizer and/or adults supervised sanitizer use
 water you can't tell if they are really using it...                    (Dyer, Shinder, & Shinder, 2000; White, Shinder, Shinder, and
     Equally important was the potential for mess; teachers             Dyer; 2001).
 viewed hand washing with soap and water as extremely prob-                 The results of this study differ from previous published stud-
 lematic:                                                              ies that all reported significant decreases in absenteeism with
     The floors wereJust covered with water and you know kids          the use of sanitizers. Because of the heterogeneity and low
 were having accidents.                                                quality of reporting in previous studies (Meadows & Le Saux,
     Paper towels were all over the place...                           2004), it is difficult to draw conclusions as to why these differ-
     The soap makes a great missile.                                   ences occurred. Additionally, publication bias in favor of stud-
    Misuse of hand sanitizers was less of an issue but still pos-      ies that demonstrate significant, positive findings for the inter-
sible, limited only by students' creativity as noted by this           vention may play a role. This study addresses some of the
observation:                                                           problems found in earlier studies and provides additional infor-
     The cleaning person put a cup underneath of it [the sani-         mation on the role of hand sanitizers in school to the growing
 tizer dispenser] and you know that got one kid deciding that          body of literature. It is not without its limitations, however. Only
he could Just keep pushing it and see how much it took to fill         one district was used and better measures for determining
it up.                                                                 community-acquired infections than absenteeism rates are
    Although the pros clearly outweighed the cons in teachers'         clearly needed. The results of this study, therefore, need to be
and staff member's views of hand sanitizers over soap and              interpreted cautiously.
water, one drawback of hand sanitizers that was noted was that              Although soap and water needs to be available for frankly
when the sanitizer dripped on to the floor, it removed the wax         soiled hands, teachers and staff clearly favored using hand
fi-om the tile. Teachers observed that maintaining adequate            sanitizers over soap and water as their was less mess, less skin
supplies of soap, paper towels, and sanitizer was an issue. In         irritation, and less time away from classroom activities.
addition to answering the stated objectives, one auxiliary find-       Research conducted in school and health care settings repeat-
ing was noted. Teachers reported that through their participa-         edly supports that personal attitudes and behaviors of author-
tion in the study, they were more were more critical in their          ity figures directly influence hand-cleansing behaviors (Early
decision making when referring students to the school nurse's          et al., 1998; Monsma et al., 1992; Muto, Sistrom, & Farr, 2000;
office for suspected illness. Although no specific teacher train-      Niffenegger, 1997). Although the intent of this study was not
ing in illness detection was included in the study protocol,           to shape attitudes or behavior modification, it is conceivable
teachers were aware that the investigators were tracking               that addressing staff preference could result in greater motiva-
absenteeism. The teachers became more attentive as to which            tion to reinforce frequent hand cleansing. Subsequent long-
students had upper respiratory infections or other illnesses, as       term behavioral change in students would require further
compared to those who were absent for other reasons.                   investigation.
                                                                            In determining whether schools should adopt hand sanitiz-
Discussion                                                             ers, one important factor for consideration is the structure of
    No significant differences in absenteeism were noted               the school. Older schools often do not have sinks in the class-
between the groups. Although this is likely an accurate finding,       rooms, so students must leave class every time their hands
it is possible that since there was no true control group (in          need washing, a significant issue when numerous students

have upper respiratory infections. A second problem is the                Centers for Disease Control (2003). Guideline for hand hygiene in
inability to appropriately adjust the water temperature. This                  health-care settings. Morbidity and Mortality Weekly Report,
may occur because sinks have two faucets or the school may                     53, 431-433.
                                                                          Conly, J.M., Hill, S., Ross, J., Lertzman, J., & Louie, T.J. (1989).
have turned off the hot water due to safety and cost concerns.
                                                                               Handwashing practices in an intensive care unit: The effects of
The lack of auto-sensors or foot pedals on sinks also results in               an educational program and its relationship to infection rates.
recontamination of hands when the water is turned off. Staff                   American Journal of Infection Control, 17, 330-339.
were aware that hand sanitizers eliminated these problems.                Day, R., St. Arnaud, S. & Mosma, M. (1993). Effectiveness of a hand
    A variety of hand-sanitizer dispensers are available. Care                 washing program. Clinical Nursing Research, 2, 24-40.
should be taken in selecting a product and dispenser to best              Dyer, D., Shinder, F., & Shinder, A. (2000). Alcohol-free instant hand
meet the needs of the school environment. Ease of installation,                sanitizer reduces elementary school illness absenteeism.
tamper resistant, low malfunctioning rates, and easy determi-                  Family Medicine, 32, 633-638.
nation of refills are needed as all influence the likelihood of           Early, E., Battle, K., Cantwell, E., English, J., Lavin, J.E., & Larson, E.
                                                                               (1998). Effect of several interventions on the frequency of hand
adherence (Kohan, Ligi, Dumigan, & Boyce, 2002). Dispenser
                                                                               washing among elementary public school children. American
placement also is critical. When hand-sanitizer dispensers                     Journai of Infection Control, 26, 263-269.
were placed in a highly visible and readily accessible location,          Eliason, K. &True, A. (2004). Combining health promotion classroom
teachers reported that students frequently "took a squirt" as                  lessons with health fair activities. Journal of School Nursing,
they walked by. Teachers preferred that the dispensers be                      20, 50-53.
placed in the classroom, and if there was a restroom in the               Glasby, C. & Snow, B. L (1986). Scrubby Bear can make an impact
classroom, outside the restroom door. That way they were bet-                  on your community. American Journal of Infection Control, 14,
ter able to monitor and encourage students' usage. In the cafe-                57-63.
teria area, a sufficient number of dispensers should be mount-            Hammond, B., Aii, Y, Fendler, E., Dolan, M., & Donovan, S. (2000).
ed in open areas to encourage use and prevent congestion.                       Effect of hand sanitizer use on elementary school absenteeism.
                                                                               American Journal of Infection Control, 28, 340-346.
                                                                          Hezel, L, Bartlett, C, Hileman, J.W., Dillon, L, & Cessna, T (2000).
Summary                                                                         Effective hand washing in elementary school. School Nurse
     Although additional large, well-designed clinical trials with              News, 77(3), 26-28.
longitudinal follow-up to measure sustained behavioral change             Kimel, LS. (1996). Hand washing education can decrease illness
still need to be conducted, hand sanitizers are a viable alterna-               absenteeism. Journal of School Nursing, 12,14-16,18.
tive to routine hand cleansing using soap and water. As                   Kohan, C, Ligi, C, Dumigan, D.G., & Boyce, J.M. (2002). The impor-
schools are being called upon to increase surveillance for                     tance of evaluating product dispensers when selecting alcohol-
infectious diseases and mount prevention campaigns, hand                        based handrubs. American Journal of Infection Control, 30,
sanitizers can play an important role in this effort.
                                                                          Larson, E. (1981). Persistent carriage of gram-negative bacteria on
                                                                                hands. American Journai of Infection Control, 9, 112-119.
                                                                          Master, D., Longe, S.H., & Dickson, H. (1997). Scheduled hand wash-
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                                                                                PEDIATRIC NURSING/July-August 2007/Vol. 33/No. 4

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