PHWR Public Health Weekly Report

Schools are collective environments where the introduction of infectious diseases can lead to group outbreaks within a short period. Therefore, systematic prevention and management of infectious diseases are crucial in these environments. In addition, the incidence of respiratory infectious diseases, such as pertussis and scarlet fever, has been increasing markedly, particularly among infants, school-aged children, and adolescents [1]. Accordingly, continuous infectious disease prevention education for students has become necessary, which led to the implementation of this project. In 2024, the Chungnam Center for Infectious Diseases Control and Prevention (CNCIDC) conducted an infectious disease prevention education program (Title: Dream Tree Infectious Disease Safe School), targeting elementary school students at small schools with fewer than 50 students in the Chungnam Province, where no school nurse was assigned. (According to Article 15(2) of the School Health Act, schools are required to appoint a school nurse responsible for student health education and management, but schools below a certain size may instead be served by a visiting school nurse.) Thus, this article presents the results of the infectious disease prevention education at such small schools and proposes ways to utilize those results effectively.

1. Selection of Target Institutions

The infectious disease prevention education was conducted for approximately seven months, from May 2024 to November 2024. Among 413 elementary schools in Chungnam Province (as of March 2024; data provided by the Chungnam Office of Education), 93 schools (22.5%) did not have an assigned school nurse. Among these, 74 schools (17.9%) with fewer than 50 students were selected as the target schools [2]. Official letters introducing the project and requesting participation were sent to the target schools, and 15 schools that expressed willingness to participate were finally selected as the participating institutions.

2. Education Program and Evaluation of Its Effects

1) Education program

The education program included mandatory instruction on handwashing and cough etiquette. The program consisted of viewing a handwashing education video, conducting an adenosine triphosphate (ATP) surface test practice (measuring microbial contamination on environmental surfaces such as desks and chairs and on the hands of participating elementary school students using a 3M Clean-Trace ATP measuring device), and practicing handwashing using fluorescent lotion. As optional education, one topic was selected from the following: understanding the transmission of infectious diseases (respiratory, waterborne, and foodborne infectious diseases), common infectious diseases among children (varicella, mumps, and scarlet fever), and an infectious disease prevention quiz. Each education session was conducted within 60 minutes. Since the total number of students in each school was fewer than 50, the educational sessions were conducted with all grade levels gathered together in the auditorium or a classroom.

2) Evaluation of the effects of handwashing education

To assess the outcomes of the education, a survey on handwashing awareness (ten items) and attitudes (five items) was administered to participating students before the education, immediately after the education, and 3 months after the education. The handwashing awareness and attitude survey items were developed by simplifying the awareness and attitude items (16 and six items, respectively) from the questionnaire “Survey on Handwashing Practices and Public Awareness (Student Version)” used in the research project “Survey on Handwashing Practices and Development of Strategies to Improve Handwashing Compliance for Infectious Disease Prevention” (Korea Centers for Disease Control and Prevention, 2013) to ten and five items, respectively. Survey responses were structured as binary responses (“yes” or “no”) [3]. The survey was self-administered by each student. For lower-grade students (grades 1–3), the survey items were read aloud, when necessary, to obtain responses. The handwashing surveys conducted before and after the education were administered to all participating schools and students. The handwashing survey was conducted 3 months after the education targeted schools that had received the education and had voluntarily agreed to participate. For these schools, experiential teaching materials using hand-shaped badges to check bacterial contamination on hands were provided so that the activity could be conducted independently prior to administering the survey. To verify the internal consistency of the survey instrument, Cronbach’s alpha was calculated using the pre-education data. The results showed that Cronbach’s alpha values for the handwashing awareness (ten items) and attitude items (five items) were 0.72 and 0.56, respectively.

3. Statistical Analysis

Statistical analyses were conducted using Excel (Microsoft) and the statistical program R (version 4.5.2; R Foundation for Statistical Computing). The frequencies (number, %) of elementary schools and students participating in the education were presented by city/county, by the five regions of Chungnam Province (Cheonan area, Hongseong area, Seosan area, Gongju area, and Nonsan area), and by sex and grade group (grades 1–3 and grades 4–6). Changes in handwashing awareness and attitudes before the education, immediately after the education, and 3 months after the education were calculated by assigning ten points to “yes” and zero point to “no” for each of the ten handwashing awareness items and assigning 20 points to “yes” and zero point to “no” for each of the five handwashing attitude items, and converting the scores to a scale ranging from 0 to 100 points. Each score was presented as mean±standard deviation and percent change (%). For each item, the percentage (%) of respondents answering “yes” and the percent change (%) were recorded. Changes in handwashing awareness and attitudes among education participants were presented as mean±standard deviation by sex, grade group, and city/county groups. Comparisons between groups at the same time point were performed using an independent samples t-test. Because personal identification information was not collected, changes across the three time points (before the education, immediately after the education, and 3 months after the education) were analyzed using one-way analysis of variance for independent samples, followed by post hoc tests. The level of statistical significance was set at less than 0.05. In addition, Cohen’s d effect size was presented as a measure of the effect size of mean differences (d≤0.2, small effect size; d=0.5, medium effect size; and d≥0.8, large effect size).

1. Characteristics of Participating Schools and Education Participants

Among the 74 elementary schools in Chungnam Province with fewer than 50 students and without an assigned school nurse, 15 schools and 353 students participated in this infectious disease prevention education program. At the school level, eight schools (53.3%) from cities and seven schools (46.7%) from counties participated, and schools from all five regions of Chungnam were represented. Among the participating students, 176 were male (49.9%), and 177 were female (50.1%). By grade group, 167 students were in grades 1–3 (47.3%) and 186 were in grades 4–6 (52.7%) (Table 1). Seven of the 15 schools (46.7%) also participated in the handwashing survey conducted 3 months after the education, and 122 of the 353 students (34.6%) participated in the follow-up survey.

Table 1 Characteristics of elementary schools and students participating in the 2024 infectious disease education program in Chungnam Province, the Republic of Korea

Category			Participation in the pre- and post- handwashing survey (Step 1)	Step 1+Participation in the handwashing survey 3 months after (Step 2)
Participating elementary schools	All		15 (100)	7 (100)
	City county	City	8 (53.3)	2 (28.6)
		County	7 (46.7)	5 (71.4)
	Area	Cheonan area (Cheonan, Asan)	4 (26.7)	1 (14.3)
		Hongseong area (Boryeong, Hongseong, Yesan, Cheongyang)	5 (33.3)	3 (42.9)
		Seosan area (Seosan, Dangjin, Taean)	1 (6.67)	1 (14.3)
		Gongju area (Gongju, Buyeo)	2 (13.3)	0 (0.0)
		Nonsan area (Nonsan, Gyeryong, Seocheon, Geumsan)	3 (20.0)	2 (28.5)
Participating elementary students	All		353 (100)	122 (100)
	Sex	Male	176 (49.9)	60 (49.2)
		Female	177 (50.1)	62 (50.8)
	Grades	Grades 1–3	167 (47.3)	53 (43.4)
		Grades 4–6	186 (52.7)	69 (56.6)
	City county	City	219 (61.9)	24 (19.7)
		County	134 (38.1)	98 (80.3)
	Area	Cheonan area (Cheonan, Asan)	133 (37.6)	11 (9.0)
		Hongseong area (Boryeong, Hongseong, Yesan, Cheongyang)	74 (21.0)	39 (32.0)
		Seosan area (Seosan, Dangjin, Taean)	13 (3.7)	13 (10.7)
		Gongju area (Gongju, Buyeo)	50 (14.2)	0 (0.0)
		Nonsan area (Nonsan, Gyeryong, Seocheon, Geumsan)	83 (23.5)	59 (48.3)

Unit: number of schools, number of students (%)..

2. Changes in Handwashing Awareness and Attitudes Before, After, and 3 Months after the Education among Participants in the Student Infectious Disease Education Program

1) Handwashing awareness

Handwashing awareness (0–100 points) among elementary school students (n=353) who participated in the Infectious Disease Safe School program showed an increasing trend after the education (353 students, 93.5±12.4) compared with before the education (353 students, 85.7±17.3). Three months after the education (122 students, 89.7±15.7), awareness levels remained higher than before the education (Tables 2, 3, Figure 1). Cohen’s d effect size was 0.52 (medium effect size), 0.24 (small effect size), and −0.29 (small effect size; higher after the education) when comparing before and after the education, before and 3 months after the education, and after and 3 months after the education, respectively. The level of handwashing awareness was higher after the education than before the education across sex, grade group, and city/county groups. Among male students and students in county areas, handwashing awareness remained higher even 3 months after the education compared to before the education (Tables 2, 3, Figure 2). For the ten individual items measuring handwashing awareness, awareness increased across all items after the education. However, 3 months after the education, awareness decreased across all ten items (Table 2). Handwashing awareness scores were consistently higher than attitude scores before, after, and 3 months after the education; however, the difference was significant only after the education (Table 3, Figure 1). By sex, handwashing awareness was higher among females than males both before and after the education (before the education: males 83.1±18.6, females 88.3±15.5; after the education: males 92.0±14.5, females 95.1±9.54). By grade group, handwashing awareness after the education was higher among upper-grade students (grades 4–6) than among lower-grade students (grades 1–3) (lower grades: 91.5±13.1; upper grades: 95.4±11.4) (Table 3, Figure 2).

Figure 1. Changes in handwashing awareness and attitudes among participants in the 2024 infectious disease education program in Chungnam Province, the Republic of Korea

Figure 2. Changes in handwashing awareness by participant characteristics in the 2024 infectious disease education program in Chungnam Province, the Republic of Korea

Table 2 Changes in handwashing awareness and attitudes among participants in the 2024 infectious disease education program in Chungnam Province, the Republic of Korea

Category		Before education (n=353)	After education (n=353)	% Change after educationa)	After 3 months (n=122)	% Change after 3 months of educationb)
Handwashing awareness questions (10 items)	Knowledge points conversion (0–100 points, mean±SD)	85.7±17.3	93.5±12.4	9.10	89.7±15.7	−4.06
	1. Germs on the hands are removed through handwashing (%).	88.4	94.6	7.01	93.4	−1.27
	2. Germs on the hands can be removed by washing thoroughly with soap (%).	91.2	94.3	3.40	93.4	−0.95
	3. Washing hands with running water helps prevent infectious diseases (%).	69.4	85.0	22.47	77.9	−8.35
	4. Frequent handwashing is effective in preventing epidemic conjunctivitis (%).	70.5	87.8	24.54	80.3	−8.54
	5. When washing hands, the palms, backs of the hands, interlaced fingers, spaces between fingers, and under the fingernails should be rubbed for at least 30 seconds and rinsed thoroughly (%).	92.6	96.6	4.32	95.1	−1.55
	6. Handwashing should be performed after using the restroom (%).	90.4	97.2	7.52	95.9	−1.34
	7. Handwashing should be performed before meals (%).	93.8	98.0	4.48	95.9	−2.14
	8. Handwashing should be performed after coughing, sneezing, or blowing one’s nose (%).	77.9	91.5	17.46	82.8	−9.51
	9. Handwashing should be performed after returning from the outside (%).	92.6	95.2	2.81	93.4	−1.89
	10. Handwashing should be performed after physical education classes or outdoor activities at school (%).	89.8	95.2	6.01	88.5	−7.04
Handwashing attitudes questions (5 items)	Attitudes points conversion (0–100 points, mean±SD)	85.2±21.2	91.7±17.8	7.51	88.6±19.2	−3.28
	1. Handwashing helps prevent illness (%).	91.2	95.5	4.71	91.8	−3.87
	2. Hands should be washed frequently to prevent infectious diseases (%).	92.1	94.1	2.17	96.7	2.76
	3. Hands should be dried completely after handwashing (%).	66.6	85.8	28.82	73.0	−14.91
	4. Handwashing should be established as a habit from an early age (%).	88.7	93.2	5.07	91.8	−1.50
	5. Hands should be washed even if they do not appear dirty (%).	87.3	89.8	2.86	89.3	−0.56

Unit: points (0–100), %. ^a)% Change calculated as [(After education–Before education)/Before education]×100 (%). ^b)[(After 3 months of education–After education)/After education]×100 (%)..

Table 3 Changes in handwashing awareness and attitudes by participant characteristics in the 2024 infectious disease education program in Chungnam Province, the Republic of Korea

Category			Number of students (after 3 months)	Before education (1) handwashing points	After education (2) handwashing points	After 3 months of education (3) handwashing points	p-valuec)	Post hoc testd)
				(Mean±SD)
Handwashing awareness points	All		353 (122)	85.7±17.3	93.5±12.4	89.7±15.7	<0.001	(1)→(2) (1)→(3)
	Sex	Male	176 (60)	83.1±18.6	92.0±14.5	88.5±12.3	<0.001	(1)→(2) (1)→(3)
		Female	177 (62)	88.3±15.5	95.1±9.54	90.8±18.4	<0.001	(1)→(2)
	p-valuea)			0.01	0.02	0.42
	Grades	Grades 1–3	167 (53)	84.0±18.4	91.5±13.1	89.1±12.9	<0.001	(1)→(2)
		Grades 4–6	186 (69)	87.2±16.1	95.4±11.4	90.1±17.6	<0.001	(1)→(2) (2)→(3)
	p-valuea)			0.09	0.00	0.69
	City county	City	219 (24)	86.4±17.5	93.4±12.9	91.3±16.2	<0.001	(1)→(2)
		County	134 (98)	84.5±16.8	93.8±11.5	89.3±15.6	<0.001	(1)→(2) (1)→(3)
	p-valuea)			0.31	0.75	0.60
Handwashing attitudes points	All		353 (122)	85.2±21.2	91.7±17.8	88.5±19.2	<0.001	(1)→(2)
	p-valueb)			0.59	0.01	0.43
	Sex	Male	176 (60)	83.1±23.5	90.0±21.2	89.7±16.3	0.01	(1)→(2)
		Female	177 (62)	87.2±18.5	93.3±13.4	87.4±21.8	<0.001	(1)→(2)
	p-valuea)			0.07	0.08	0.52
	Grades	Grades 1–3	167 (53)	82.9±22.8	89.5±19.4	89.1±18.2	0.01	(1)→(2)
		Grades 4–6	186 (69)	87.2±19.4	93.7±16.0	88.1±20.1	<0.001	(1)→(2)
	p-valuea)			0.06	0.03	0.79
	City county	City	219 (24)	85.4±22.2	92.1±18.1	89.2±16.7	<0.001	(1)→(2)
		County	134 (98)	84.8±19.5	91.0±17.3	88.4±19.9	0.03	(1)→(2)
	p-valuea)			0.79	0.60	0.84

Unit: number of students, points (0–100). ^a)p-values were derived from independent sample t-tests, ^b)p-values were derived from independent sample t-tests comparing handwashing awareness and attitude scores, and ^c)p-values were derived from one-way ANOVA. ^d)Post hoc analyses were performed using the Scheffé method, and only statistically significant results (p<0.05) are presented..

2) Handwashing attitudes

Handwashing attitudes (0–100 points) among elementary school students (n = 353) who participated in the infectious disease prevention education showed an increasing trend after the education (353 students, 91.7±17.8) compared with before the education (353 students, 85.2±21.2) (Tables 2, 3, Figure 1). Cohen’s d effect size was 0.33 (medium effect size) when comparing before and after the education, 0.16 (small effect size) when comparing before the education and 3 months after the education, and −0.18 (small effect size; higher after the education) when comparing after the education and 3 months after the education. Handwashing attitudes were higher after the education than before the education across sex, grade group, and city/county groups (Table 3, Figure 3). For the five individual items measuring handwashing attitudes, attitudes increased for all five items after the education. Three months after the education, attitudes decreased for four of the five items; however, the item “Hands should be washed frequently to prevent infectious diseases” continued to increase even 3 months after the education (92.1%, 94.1%, and 96.7% before, after, and 3 months after the education, respectively) (Table 2). By grade group, handwashing attitude scores after the education were higher among upper-grade students (grades 4–6) than among lower-grade students (grades 1–3) (lower grades 89.5±19.4; upper grades 93.7±16.0).

Figure 3. Changes in handwashing attitudes by participant characteristics in the 2024 infectious disease education program in Chungnam Province, the Republic of Korea

In 2024, the CNCIDC conducted infectious disease prevention education for 353 students from 15 elementary schools in Chungnam Province that had no assigned school nurse and had fewer than 50 students. To assess educational outcomes, surveys measuring handwashing awareness and attitudes were conducted before, immediately after, and 3 months after the education. The results showed that students’ handwashing awareness and attitudes both increased after the education compared with before the education, and handwashing awareness remained higher than before the education even 3 months after the education. Handwashing awareness showed a higher trend than attitudes after the education. Previous studies have similarly reported higher levels of handwashing awareness than attitudes [4,5]. This finding can be explained by the knowledge→attitude→practice model, a theoretical framework for health behavior change. While health knowledge can be acquired relatively quickly through education, attitudes are related to individuals’ behavioral habits and beliefs and therefore require more time and repeated education to change. In addition, handwashing awareness and attitudes were higher among female students than male students and higher among upper-grade students (grades 4–6) than lower-grade students (grades 1–3). This finding was consistent with previous studies reporting that handwashing knowledge, attitudes, and practices were higher among females [4,6]. This finding might be attributed to the tendency for female students to demonstrate higher levels of interest in and practice of personal hygiene and health behaviors. The higher levels of handwashing awareness and attitudes among upper-grade students might also be associated with more advanced cognitive development and a greater understanding of the importance of infectious disease prevention.

Due to limitations in the study design, individual-level before–after comparisons could not be performed, and comparisons were conducted at the group level. In addition, the number of participants in the survey 3 months after the education decreased from 353 to 122, introducing potential selection bias. Therefore, the results should be interpreted as exploratory rather than definitive findings. Furthermore, although individuals could not be identified in the statistical analysis, the data involved repeated measurements, which might violate the statistical assumption of independence and therefore limit the ability to statistically confirm the results. Since this survey targeted schools in the Chungnam Province without an assigned school nurse and with fewer than 50 students, the findings cannot be considered representative of all elementary schools in Chungnam. Although schools without an assigned school nurse were prioritized as target institutions for this education program, future follow-up projects will include schools with assigned school nurses in order to examine differences based on the presence of a school nurse, school size, and other related factors. In addition, the reliability index (Cronbach’s alpha) used to assess the internal consistency of the questionnaire was 0.72 for the handwashing awareness items (ten items), indicating acceptable internal consistency, whereas the value for the handwashing attitude items (five items) was 0.56. Therefore, further refinement and development of the handwashing attitude items will be required in the future.

Overall, the results of this survey showed that handwashing awareness and attitudes improved following infectious disease prevention education and that differences in handwashing awareness and attitudes were observed according to sex and grade level. Hence, future infectious disease prevention education programs for students should incorporate tailored education that considers grade level and sex, as well as regular infectious disease prevention education that takes into account the duration of educational effects.

Ethics Statement: Not applicable.

Funding Source: None.

Acknowledgments: None.

Conflict of Interest: The authors have no conflicts of interest to declare.

Author Contributions: Conceptualization: JAL, DHH, OHC. Data curation: JAL, DHH, SOW, SJK. Formal analysis: JAL, DHH. Investigation: JAL, DHH, SOW, SJK. Methodology: JAL, DHH, OHC. Project administration: JAL, DHH, SOW, SJK. Resources: DHH. Software: JAL, DHH. Supervision: JAL, DHH. Writing – original draft: JAL, DHH. Writing – review & editing: JAL, OHC.