'Use 123 to get Germ Free': Extending the Reach and Impact of a Hand Hygiene Intervention

Context
In the previously funded project ('Lifting the Lid on Bacteria') children devised many interesting ideas to help communicate the importance of hand hygiene to their peers when in school toilet spaces. The final overall concept developed was 'Use 123 to get germ free' and this message, and associated messages/graphics were placed imaginatively in cubicles, on washing devices and around the wall areas. The areas where the designs were installed (in 3 primary schools and in Eureka! Museum) became much more colourful, engaging and helped improve hand hygiene by increasing the use of soap by between 41% and 60%. The designs were very well received by the children who helped create them the people that used the space and other stakeholders. The project won the 'Best Education and Research Award' at the E-Bug Conference, London in January 2019 and we have given invited presentations in Denmark and Nepal. We have also published 3 journal articles and have 3 articles under review as part of the previous project.

Aims and Objectives
This project aims to enhance the commercial viability of our wall-based graphics. In the previous research, through interviews with teachers and children, 3 areas were identified that would exploit the 123 concept further - 1) the need for a classroom-based introduction to the designs, 2) an element of the design that teachers could easily customise or alter when there are outbreaks of infection and 3) a take-home pack for parents to ensure the message moves from school to the home. We propose to carry out these extensions to the concept to create a more desirable '123' package for schools to use and we will work with a partner school, through co-design workshops with teachers, children and parents, to ensure ideas match their needs. Once finalised, the package will be made available to download at minimal cost through a University fast-licensing system and we will identify a reliable printer/materials to recommend to schools.

We also aim to share our designs with a wider audience. In the previous project the graphics were placed in 3 schools and a children's museum and we wish to extend their use both to other schools and to tailor the concept for new audiences. Through attendance at a national head teachers conference and by running an event for local schools, we hope to raise awareness of the 123 concept and disseminate the designs further. In terms of new audiences we propose to work with a pre-school to tailor the designs for children under 5 and to develop a script to aid understanding. We also intend to install the designs in the Thackray Medical Museum and understand, through liaison with the museum staff, how to tailor the concept for their visitors. We also will test out and tailor how the design concept works in a new international context, working in a school in Uganda. Two short films will be created that will help bring the concept to life for potential new users. The final stage of the activities involves targeted promotion of the product and contacting potential new organisations who may wish to use the product. Downloads of the product will be monitored and follow-up feedback sought.

Potential Application and Benefits
Evidence gathered from the previous project highlights an increase in soap usage and reduction in instances of dirty hands. The designs therefore play an important role in infection reduction, improving cleanliness standards overall and enhancing the appeal of spaces. By widening the audience for the designs and developing add-on components to exploit the concept further, more schools, children and parents will benefit, in health terms, from improved hand hygiene. By introducing the work to 3 new audiences we will be able to instil better awareness of hand hygiene at pre-school age, we will be able to customise the designs for adults and broaden the dissemination of the concept and lastly, impact positively upon hygiene habits in a Global South context.

The main beneficiaries of the activities are schools, children and parents.

Schools will benefit from the work since they will have the potential to download a resolved package of designs at minimal cost. Given the evidence we have gathered - the designs leading to a reduction in dirty hands (by hand swab testing) and an increase in soap usage (through soap count) - it is likely that schools using the product will see a decrease in infection spread and in turn a decrease in absenteeism. Given education pressures, it is important for schools to retain attendance to avoid children falling behind through sickness. The school in Uganda will benefit from direct improvement to their toilet facilities - from the installation of soap dispensers in the toilet areas to colourful designs placed on the walls and in the classroom. Given the life-threatening/serious nature of the diseases in Uganda caused by poor hand hygiene, it is likely that the designs in this context will have a tangible and positive impact on health quality in the area.

Children, whether at primary or pre-school, will benefit where the designs are installed. The graphics enhance the appeal and colourfulness of the spaces making them more likely to visit the spaces. Children taking part in the co-design workshops will also benefit from being more involved in the creative generation of ideas, leading to a sense of empowerment and learning more about the design process and problem solving.

Parents, both those taking part in workshops and those receiving the packs, will benefit from learning more about hand hygiene which in turn, should reduce the spread of infection in the home. The packs will help them to reflect on their own hand hygiene practices, not just their child's behaviour. The designs include simple and rhyming messages about why all 3 elements - soap, water and drying - are needed and thus wider dissemination of this message will enable people in homes to make a more informed choice about whether to wash hands or not.

The installation of the designs at Eureka! Museum in the previous project provoked much positive feedback from visitors. Of particular note were comments related to the fact that the designs continued their child's learning experience from the galleries into more public service spaces. Recorded comments include "I think they're brilliant - they should be everywhere" and "I recently visited Eureka with my two children aged 3 and 8. We found the most inspirational and thought provoking toilet facilities for young children we have ever seen. My 3 year old recalled her visit to family members last night and mainly talked about the toilets". We therefore have reason to believe that the designs installed in the newly refurbished Thackray Medical Museum have definite potential to enhance the visitor experience and reflect positively on the museum itself and the feedback they receive.