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Journal of Applied Behavior Analysis 2020, 53, 1219–1224 NUMBER 3 (SUMMER)

Increasing handwashing in young children: A brief review

Rachel L. Jess and Claudia L. Dozier
Department of Applied Behavioral Science, University of Kansas

Personal hygiene is critical for preventing the spread of infection. One important component of
personal hygiene is handwashing. This review summarizes research on behavioral strategies to
address handwashing in children, offers areas for additional research, and suggests a treatment
package to teach handwashing to young children.
Key words: children, COVID-19, handwashing, healthy behavior

On March 11th, 2020, the World Health water is the most effective method for decreas-
Organization (WHO) declared the outbreak of ing transmission of infection (Aiello et al.,
COVID-19, a severe respiratory disease caused 2008; WHO, 2020b). Specifically, proper han-
by a novel coronavirus, a pandemic (WHO, dwashing reduces acute respiratory illnesses in
2020a). The virus that causes COVID-19 is the general population by at least 20% (Aiello
currently understood to spread through respira- et al., 2008). Recent research suggests individ-
tory droplets produced when an infected person uals with COVID-19 may spread the virus
coughs or sneezes (Centers for Disease Control even without showing any symptoms
and Prevention [CDC], 2020). These respira- (Mizumoto & Chowell, 2020); thus, han-
tory droplets can land on an infected person’s dwashing is important even after interacting
hands and transfer after touching various sur- with people who are symptom-free. According
faces (e.g., doorknobs and light switches). to the CDC (2020), it is important to use
Thus, a healthy individual could become water and soap to vigorously scrub all areas of
infected by touching a surface containing the the hands (i.e., palms, tops, between fingers,
virus and then touching their own mouth or and fingernails) for at least 20 s. Alcohol-based
nose. Young children are prone to acquiring hand sanitizers may be used when soap and
infections (e.g., acute respiratory illness) for water are unavailable, but washing hands with
several reasons, including the tendency to put soap and water is more effective at removing
items and their hands in their mouths and most types of infectious particles (Charbonneau
noses (Aronson & Shope, 2019). Infected chil- et al., 2000).
dren are often carriers of infection to family Caregivers should ensure children engage in
members due to frequent hands-on contact “everyday preventive behaviors” (CDC, 2020),
with caregivers, resulting in parents becoming including handwashing, to keep themselves
sick in more than 30% of child acute respira- healthy and avoid spreading infection. Many
tory illness episodes (Sacri et al., 2014). community agencies have developed resources
Hands are the most common mode of trans- to support caregivers and families in teaching
mission of pathogens (Rabie & Curtis, 2006), children handwashing and other healthy behav-
and washing hands thoroughly with soap and iors (Sesame Street, 2020; UNICEF, 2020).
Additionally, researchers have evaluated several
Address correspondence to: Claudia L. Dozier, Depart- strategies, including antecedent and conse-
ment of Applied Behavioral Science, 4001 Dole Human quence interventions, to teach proper han-
Development Center, 1000 Sunnyside Ave., Lawrence, KS
66044. Email: cdozier@ku.edu dwashing in young children. The purpose of
doi: 10.1002/jaba.732 this brief review is to summarize research on
© 2020 Society for the Experimental Analysis of Behavior
1219
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1220 Rachel L. Jess and Claudia L. Dozier

antecedent and consequence strategies to teach scrub to prompt washing all areas of their
handwashing in children, offer areas for addi- hands for an appropriate duration. Other stud-
tional research, and suggest strategies to teach ies have provided vocal reminders of how and
handwashing. when to wash hands. Nandrup-Bus (2009)
trained teachers to remind elementary students
to wash their hands at specified times of the
Antecedent Strategies school day (i.e., upon arrival, following bath-
Various antecedent strategies for teaching room use, prior to eating). Visual prompts,
handwashing in young children include provid- such as posters depicting areas of the hands to
ing rationales and instructions, modeling scrub (e.g., Lee & Lee, 2014) and physical
proper handwashing, and providing vocal and paths to handwashing stations (e.g., Grover
visual prompts. Some studies have involved dis- et al., 2018) have also been successful in evok-
cussing the importance of handwashing ing handwashing in elementary school children.
(e.g., washing hands can remove germs that get Studies evaluating various prompting strategies
you sick; Harrison, 2012) and describing cor- suggest vocal and visual prompts can increase
rect handwashing (e.g., telling children when handwashing quality and frequency.
and how to wash hands; Rosen et al., 2006).
Unfortunately, handwashing rationales and
education are generally ineffective when Consequence Strategies
implemented alone, and should be used in con- Consequence strategies used to teach han-
junction with other intervention components dwashing to young children include providing
(Staniford & Schmidtke, 2020). visual feedback, implementing error correction,
Other studies have used various modeling and providing rewards. Providing visual feed-
modalities to teach handwashing to young chil- back indicating how well children are washing
dren, including in-person (e.g., Rosen et al., their hands has been evaluated in several stud-
2011) and video models (e.g., Deochand et al., ies. For example, some studies have used Glo
2019; Jess et al., 2019). Rosen et al. (2011) Germ™, a UV-sensitive simulated germ lotion,
implemented a package intervention that to show children how well they washed their
included a nurse modeling correct handwashing hands. The removal of Glo Germ™ during
for preschool children. Following the interven- handwashing simulates the removal of actual
tion, children’s handwashing quality increased germs from hands; remaining Glo Germ™ fol-
and maintained during monthly observations. lowing handwashing indicates areas that were
Deochand et al. (2019) presented a commer- not adequately cleaned. Snow et al. (2008)
cially available handwashing video to three chil- implemented a one-time hands-on Glo
dren with developmental disabilities. All Germ™ exercise to increase handwashing com-
children required individualized feedback fol- pliance with elementary school children. The
lowing the video model to increase han- Glo Germ™ demonstration more effectively
dwashing duration and effectiveness. Overall, promoted handwashing compliance compared
these studies suggest that modeling, when com- to instructions and modeling alone. Similar
bined with other strategies, can increase proper demonstrations have been effective with pre-
handwashing by children. school children (e.g., Au et al., 2009; Dingman
Researchers have also evaluated different et al., 2020) and children in a pediatric waiting
prompting strategies to improve handwashing. room (Fishbein et al., 2011). Researchers have
For example, Lee et al. (2015) taught children also used common household products
a 20-s song that described areas of the hand to (e.g., nutmeg and petroleum jelly, glitter) to
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Handwashing in Children 1221

represent germs during handwashing demon- may initially maintain following an intervention,
strations (e.g., Witt & Spencer, 2004). rewards should be provided intermittently dur-
Together, these studies suggest that demon- ing follow-up observations to promote
strating effective handwashing using various maintained responding over time. Future
products to provide feedback may promote research should evaluate the use of various forms
appropriate handwashing in young children. of rewards and reinforcement schedules on chil-
Other studies have provided ongoing vocal dren’s acquisition and maintenance of correct
and visual feedback for children’s handwashing handwashing.
performance. Jess et al. (2019) provided pre-
school children with visual and vocal feedback
regarding the amount of simulated germ lotion Discussion
remaining on hands following handwashing. Overall, results of studies examining inter-
Specifically, experimenters showed children pic- vention strategies for handwashing with young
tures of their Glo Germ™ illuminated hands children suggest that a combination of both
and described the areas where germs were not antecedent and consequence strategies should
scrubbed. Following the intervention, han- be used to teach and maintain appropriate han-
dwashing performance and hand cleanliness dwashing. Given the importance of frequent
(i.e., accuracy of procedure, effect on Glo and effective handwashing during the current
Germ™ removal) improved. Similar procedures COVID-19 pandemic, we suggest a treatment
have been evaluated with elementary school package that involves demonstrating han-
children (e.g., Oncu et al., 2018) and children dwashing effectiveness along with ongoing per-
with emotional and developmental disabilities formance feedback, teaching a handwashing
(e.g., Deochand et al., 2019). song, and providing frequent and immediate
With respect to error correction, Deochand consequences (e.g., feedback, rewards) after
et al. (2019) provided visual feedback follow- handwashing. Caregivers could provide visual
ing initial handwashing attempts and then feedback of handwashing effectiveness using
offered children the opportunity to rewash commercial products, such as Glo Germ™, or
their hands. Although this procedure was common household products, such as nutmeg
implemented in a package intervention that and lotion. Various handwashing songs (see
included visual feedback and reinforcement for Appendix) may prompt best-practice han-
clean hands, results suggest error correction dwashing by describing where to scrub for an
may be an important component for increas- appropriate duration. Frequent and immediate
ing hand cleanliness and handwashing dura- feedback regarding handwashing accuracy
tion. That is, visual feedback regarding initial should be provided until correct handwashing
handwashing performance and an opportunity occurs independently across several opportuni-
to rewash hands may serve as a prompt to ties. Finally, incorrect handwashing technique
scrub specific areas of the hands with better should result in an opportunity to rewash
quality in the future. hands to address the components performed
Some studies have included rewards for cor- incorrectly. Interventions to teach and maintain
rect handwashing, such as stamps, stickers, and handwashing should include consequence-based
edible items. Nandrup-Bus (2009) provided strategies in conjunction with antecedent
children with a small reward following teaching manipulations.
correct handwashing; however, rewards were not Although several studies have demonstrated
provided for correct handwashing in subsequent effective strategies to improve handwashing
observations. Although correct handwashing with young children, additional research is
 19383703, 2020, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jaba.732 by INASP/HINARI - INDONESIA, Wiley Online Library on [11/12/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1222 Rachel L. Jess and Claudia L. Dozier

needed. Many studies teaching handwashing to Health Education, 110(1), 5–16. https://doi.org/10.
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(2000). A method of assessing the efficacy of hand
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targeted concurrently. based, blacklight handwashing program can improve
handwashing quality and knowledge among pre-
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1224 Rachel L. Jess and Claudia L. Dozier

Appendix Scrub under your nails, scrub under your

Handwashing Resources nails,
Now again, now again.
The Centers for Disease Control and Pre- Top and bottom, top and bottom,
vention (CDC) recommend the following han- In between, in between,
dwashing steps: Scrub under your nails, scrub under your
1. Wet your hands with clean, running water nails,
(warm or cold), turn off the tap, and Now you’re clean, squeaky clean!
apply soap. Other handwashing resources:
2. Lather your hands by rubbing them CDC Handwashing- A Family Activity
together with the soap. Lather the backs of https://www.cdc.gov/handwashing/
your hands, between your fingers, and handwashing-family.html
under your nails. JAMA Pediatrics- What Does the Coronavi-
3. Scrub your hands for at least 20 seconds. rus Disease 2019 (COVID-19) Mean for Fami-
4. Rinse your hands well under clean, run- lies? https://jamanetwork.com/journals/
ning water. jamapediatrics/fullarticle/2763176
5. Dry your hands using a clean towel or air Sesame Street- “H is for Handwashing” story
dry them. https://sesamestreetincommunities.org/topics/
health/?activity=h-is-for-handwashing
Sing a handwashing song: (to the tune of Sesame Street- Handwashing Steps coloring
“Frere Jacques”). page https://sesamestreetincommunities.org/
Top and bottom, top and bottom, topics/health/?activity=teaching-handwashing
In between, in between,