Effectiveness of VR on the Sustainability of Hand Hygiene Compliance: School-based RCT With 10-month Follow-up

Official title

Effectiveness of Immersive and Embodied Enhancement Via "Virtual Reality" on the Sustainability of Hand Hygiene Compliance: School-based RCT With 10-month Follow-up

Overview

This study aims to evaluate the effectiveness of a VR intervention on teaching handwashing skills which are promoted by the Centre for Health Protection, Department of Health, HKSAR. A 7-step handwashing approach will be taught through a customized VR game in secondary schools in Hong Kong. Participant's handwashing skills and prolonged effects on handwashing habits and hygiene level will be assessed. The main questions it aims to answer are: * Does an intervention of our VR handwashing game enhance handwashing skills amongst junior secondary students? * What are the factors hinder or enhance students' learning of handwashing skills in the intervention? Participating students will be assigned into 3 groups. Each group will receive two sessions of educational training with different kinds of intervention throughout one school year (9 months). The first intervention group will participate in two VR-game sessions on handwashing skill; the second intervention group will participate in one VR-game session and one video session about handwashing; the baseline group will participate in two sessions of other VR activities unrelated to hand hygiene and view a handwashing skill poster. The research will compare the handwashing performance between the three groups. Participants will: * participate into a VR handwashing game intervention, or a video-based intervention, or placebo VR activities as stated hereinafter; * perform handwashing in the VR game, and their hand-motion data will be captured; * participate a UV lighting test after handwashing away fluorescent lotion; and, * fill up questionnaires

Detailed description

Schools are often the site of infection outbreaks, including COVID-19, influenza and other infectious diseases. COVID-19 pandemic has accelerated the need to enhance hygiene levels at primary and secondary schools and, specifically, nurturing and enforcing students' regular handwashing practices is one of the key components of a preventive strategy to reduce the transmission of infectious illnesses. Meanwhile, Virtual Reality (VR) intervention has been shown to be an efficacious tool for behavioural change. It manipulates an array of behavioural and environmental variables to construct an immersive virtual environment for changing certain human behaviours. VR handwashing education system may be more helpful than conventional verbal explanation in encouraging school children to wash their hands thoroughly, especially overcoming difficult to wash areas including wrists. Nevertheless, a school-based VR intervention on handwashing education is lacked in Hong Kong.

Objective:

This study aims to evaluate the effectiveness of a VR intervention on teaching handwashing skills which are promoted by the Centre for Health Protection, Department of Health, HKSAR. A 7-step handwashing approach will be taught through a customized VR game in secondary schools in Hong Kong. Participant's handwashing skills and prolonged effects on handwashing habits and hygiene level will be assessed.

Methods:

A 3-arm randomized controlled trial will be adopted. About 500 students will be assigned into 3 groups which will be randomly assigned on class-basis. Each group will receive two sessions of educational training with different kinds of intervention throughout one school year (9 months). The first intervention group will participate in two VR-game sessions on handwashing skill; the second intervention group will participate in one VR-game session and one video session about handwashing; the baseline group will participate in two sessions of other VR activities unrelated to hand hygiene and view a handwashing skill poster. Comparison of pre- and post-intervention hand-images of participants will serve as primary measurement. Ultraviolet-sensitive fluorescent lotion will be applied to the participants' hands and digital photos will be taken under UV lighting environment. Image comparisons will adopt quantitative method of calculating the percentage of fluorescent pixels over total hand areas. Post-intervention hand-images will be collected 3 months after the second intervention in order to capture any prolonged effect on handwashing over the whole intervention period. The secondary measures will be deployed through pre-invention, immediate post-intervention and follow-up (3 months after intervention) surveys. The survey will comprise scales measuring self-efficacy, knowledge on hand hygiene, handwashing habits and intentions, attitudes, subjective norms, and perceived behavioral control, VR embodiment and VR experience.

Results:

The project has already commenced in March 2026. The data collection period of the randomized controlled trial will be started from Sep 2026 and will end in May 2027. Data will be analyzed during June and August 2027, and the results are expected to be released in September 2027.

Conclusion:

This study contributes to existing knowledge about infection prevention strategy through VR game as well as the hand hygiene of the student population in Hong Kong and elsewhere. The study fills a number of research gaps in the field by (1.) developing evidence-based and executable VR hand hygiene programmes in school settings; (2.) addressing the ill-solved sustainability issue of hand hygiene intervention effects; (3.) identifying factors underlying the pathway of behavioural changes on hand hygiene and issues related to barriers to change, and (4.) identifying handwashing patterns through hand motion data shaping the hand hygiene level. The experiences and results from this VR game project can be also transferable to develop other programme regarding public health by adopting VR devices.

Interventions

• Other VR Handwashing Game (2 sessions)
  The intervention will be a VR game taught about the '7-Steps approach' of hand-washing promoted by Centre for Health Protection, HKSAR. The game is comprised of two parts: Training Mode and Challenge Mode. In Training Mode, students will be guided with text and voice feedback. A pair of 'ghost hands' will demonstrate what to do. Students follow the movements of the 'ghost hands' to complete the handwashing tasks. In the Challenge Mode, students are requested to perform all the steps at once by t
• Other VR Handwashing Game (1 session) + Video on hand hygiene (1 session)
  For Intervention Group 2, participants will attain one VR game session and 1 video-instructed session.

Primary outcome measures

• Hand-imaging Data [Time frame: Hand-imaging data will only be collected before the 1st intervention and at the end of the data collection period (about 9 months after the 1st intervention).]

Secondary outcome measures (3)

• Knowledge on Hand Hygiene and Handwashing [Time frame: This measurement will be collected through questionnaire pre-intervention, immediately after 1st intervention, after 2nd intervention (5 months after 1st intervention) and in the follow-up survey (9 months after 1st intervention).]
• Handwashing Habit [Time frame: This measurement will be collected through questionnaire pre-intervention, immediately after 1st intervention, after 2nd intervention (5 months after 1st intervention) and in the follow-up survey (9 months after 1st intervention).]
• Attitude and Intention [Time frame: This measurement will be collected through questionnaire pre-intervention, immediately after 1st intervention, after 2nd intervention (5 months after 1st intervention) and in the follow-up survey (9 months after 1st intervention).]

Eligibility criteria

Inclusion criteria

• Hong Kong secondary school students studying junior forms

Exclusion criteria

\-

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: Yes

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Double blind

Primary purpose

Prevention

Study locations

Hong Kong · 1 center

• School of Future Media, The University of Hong Kong — Hong Kong

Publications

• Birrenbach T, Zbinden J, Papagiannakis G, Exadaktylos AK, Muller M, Hautz WE, Sauter TC. Effectiveness and Utility of Virtual Reality Simulation as an Educational Tool for Safe Performance of COVID-19 Diagnostics: Prospective, Randomized Pilot Trial. JMIR Serious Games. 2021 Oct 8;9(4):e29586. doi: 10.2196/29586. PMID 34623315
• Sin CS, Rochelle TL. Using the theory of planned behaviour to explain hand hygiene among nurses in Hong Kong during COVID-19. J Hosp Infect. 2022 May;123:119-125. doi: 10.1016/j.jhin.2022.01.018. Epub 2022 Feb 3. PMID 35124145
• O'Boyle CA, Henly SJ, Larson E. Understanding adherence to hand hygiene recommendations: the theory of planned behavior. Am J Infect Control. 2001 Dec;29(6):352-60. doi: 10.1067/mic.2001.18405. PMID 11743481
• Srigley JA, Corace K, Hargadon DP, Yu D, MacDonald T, Fabrigar L, Garber G. Applying psychological frameworks of behaviour change to improve healthcare worker hand hygiene: a systematic review. J Hosp Infect. 2015 Nov;91(3):202-10. doi: 10.1016/j.jhin.2015.06.019. Epub 2015 Aug 4. PMID 26321675
• Gasteiger N, van der Veer SN, Wilson P, Dowding D. Virtual reality and augmented reality smartphone applications for upskilling care home workers in hand hygiene: a realist multi-site feasibility, usability, acceptability, and efficacy study. J Am Med Inform Assoc. 2023 Dec 22;31(1):45-60. doi: 10.1093/jamia/ocad200. PMID 37846147
• Eichel VM, Brandt C, Brandt J, Jabs JM, Mutters NT. Is virtual reality suitable for hand hygiene training in health care workers? Evaluating an application for acceptability and effectiveness. Antimicrob Resist Infect Control. 2022 Jun 25;11(1):91. doi: 10.1186/s13756-022-01127-6. PMID 35752839
• Galvan Debarba H, Bovet S, Salomon R, Blanke O, Herbelin B, Boulic R. Characterizing first and third person viewpoints and their alternation for embodied interaction in virtual reality. PLoS One. 2017 Dec 27;12(12):e0190109. doi: 10.1371/journal.pone.0190109. eCollection 2017. PMID 29281736
• Asadzadeh A, Samad-Soltani T, Rezaei-Hachesu P. Applications of virtual and augmented reality in infectious disease epidemics with a focus on the COVID-19 outbreak. Inform Med Unlocked. 2021;24:100579. doi: 10.1016/j.imu.2021.100579. Epub 2021 Apr 27. PMID 33937503

Identifiers

NCT: NCT07659340 · 23244181

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗