{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,20]],"date-time":"2026-08-20T16:36:49Z","timestamp":1787243809952,"version":"build-2736575974"},"reference-count":26,"publisher":"American Society of Tropical Medicine and Hygiene","issue":"2","license":[{"start":{"date-parts":[[2025,8,6]],"date-time":"2025-08-06T00:00:00Z","timestamp":1754438400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,8,6]]},"abstract":"<jats:title>ABSTRACT.<\/jats:title>\n                  <jats:p>Hand hygiene (HH) can prevent the spread of infectious diseases and school absenteeism. However, limited data exist on HH practices at schools. Our study assesses the impact of a pilot HH intervention in 12 schools in Belize during the coronavirus disease 2019 (COVID-19) pandemic. After a national assessment of existing water, sanitation, and hygiene resources (December 2021\u2013January 2022), 12 pilot schools were selected to evaluate an HH intervention, which included environmental nudges and HH education. Baseline assessments occurred in March 2022, the HH intervention was implemented during October 2022\u2013May 2023, and follow-up assessments were conducted in June 2023. Student knowledge, attitudes, practices (KAP), and hand dirtiness were assessed at baseline and follow-up. There were no changes in overall KAP median scores between the baseline and the follow-up surveys (knowledge: 3 of 4; attitudes: 11 of 12; practices: 8 of 8). There was an increase in the proportion of students who reported cleaning hands during critical moments, such as before eating and after using the restroom. Observations showed that 83% of students at baseline and 71% of students at follow-up washed their hands with soap after using the restroom. The median hand dirtiness score was seven at baseline and five at follow-up (lower score corresponds to dirtier hands). We did not observe improvements in HH after the intervention. It is possible that the decrease in perceived risk of infection as COVID-19 protocols from baseline to follow-up were reduced in schools contributed to the decrease in HH practices.<\/jats:p>","DOI":"10.4269\/ajtmh.24-0617","type":"journal-article","created":{"date-parts":[[2025,5,27]],"date-time":"2025-05-27T13:25:58Z","timestamp":1748352358000},"page":"427-436","source":"Crossref","is-referenced-by-count":3,"title":["Hand Hygiene Knowledge, Attitudes, Practices, and Hand Dirtiness of Primary School Students Before and After a Behavioral Change Intervention During the COVID-19 Pandemic, Belize 2022\u20132023"],"prefix":"10.4269","volume":"113","author":[{"given":"Anh N.","family":"Ly","sequence":"first","affiliation":[{"name":"Department of Pediatrics, National School of Tropical Medicine, Baylor College of Medicine and Texas Children\u2019s Hospital, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christina","family":"Craig","sequence":"additional","affiliation":[{"name":"Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kelsey","family":"McDavid","sequence":"additional","affiliation":[{"name":"Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dian","family":"Maheia","sequence":"additional","affiliation":[{"name":"Belize Ministry of Education, Culture, Science, and Technology, Belmopan, Belize;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yolanda","family":"Gongora","sequence":"additional","affiliation":[{"name":"Belize Ministry of Education, Culture, Science, and Technology, Belmopan, Belize;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francis","family":"Morey","sequence":"additional","affiliation":[{"name":"Belize Ministry of Health and Wellness, Belmopan, Belize;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Russell","family":"Manzanero","sequence":"additional","affiliation":[{"name":"Belize Ministry of Health and Wellness, Belmopan, Belize;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexandra","family":"Medley","sequence":"additional","affiliation":[{"name":"Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Allison","family":"Stewart","sequence":"additional","affiliation":[{"name":"Division of Global Health Protection, Global Health Center, Centers for Disease Control and Prevention\u2014Central America Region, Guatemala City, Guatemala;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Allison","family":"Lino","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, National School of Tropical Medicine, Baylor College of Medicine and Texas Children\u2019s Hospital, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ramiro","family":"Quezada","sequence":"additional","affiliation":[{"name":"Centro de Estudios en Salud, Universidad del Valle de Guatemala, Guatemala City, Guatemala;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rosalva","family":"Blanco","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, National School of Tropical Medicine, Baylor College of Medicine and Texas Children\u2019s Hospital, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vickie","family":"Romero","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, National School of Tropical Medicine, Baylor College of Medicine and Texas Children\u2019s Hospital, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gerhaldine","family":"Morazan","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, National School of Tropical Medicine, Baylor College of Medicine and Texas Children\u2019s Hospital, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ella","family":"Hawes","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, National School of Tropical Medicine, Baylor College of Medicine and Texas Children\u2019s Hospital, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Oluwadara","family":"Okeremi","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, National School of Tropical Medicine, Baylor College of Medicine and Texas Children\u2019s Hospital, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kanako","family":"Ishida","sequence":"additional","affiliation":[{"name":"Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew","family":"Lozier","sequence":"additional","affiliation":[{"name":"Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;"},{"name":"United States Public Health Service, Silver Springs, Maryland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kristy O.","family":"Murray","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, National School of Tropical Medicine, Baylor College of Medicine and Texas Children\u2019s Hospital, Houston, Texas;"},{"name":"Emory University and Children\u2019s Healthcare of Atlanta, Atlanta, Georgia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2795","reference":[{"key":"b1","series-title":"Am J Public Health","first-page":"1372","article-title":"Effect of hand hygiene on infectious disease risk in the community setting: A meta-analysis","volume":"98","author":"Aiello","year":"2008"},{"key":"b2","series-title":"Am J Infect Control","first-page":"682","article-title":"The effect of hand-hygiene interventions on infectious disease-associated absenteeism in elementary schools: A systematic literature review","volume":"45","author":"Wang","year":"2017"},{"key":"b3","series-title":"Arch Dis Child","first-page":"42","article-title":"Effectiveness of hand hygiene interventions in reducing illness absence among children in educational settings: A systematic review and meta-analysis","volume":"101","author":"Willmott","year":"2016"},{"key":"b4","article-title":"Advice for the Public: Coronavirus Disease 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Hyg","first-page":"1166","article-title":"A cluster-randomized controlled trial evaluating the effect of a handwashing-promotion program in Chinese primary schools","volume":"76","author":"Bowen","year":"2007"},{"key":"b24","series-title":"BMJ Paediatr Open","first-page":"e000543","article-title":"How are behavioral interventions delivered to children (5\u201311 years old): A systematic mapping review","volume":"3","author":"Brigden","year":"2019"},{"key":"b25","article-title":"The Behavioral Drivers Model","year":"2019"},{"key":"b26","series-title":"BMJ Open","first-page":"e053320","article-title":"How community participation in water and sanitation interventions impacts human health, WASH infrastructure, and service longevity in low-income and middle-income countries: A realist review","volume":"11","author":"Nelson","year":"2021"}],"container-title":["The American Journal of Tropical Medicine and 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