Bringing Healthcare-Level Hand Hygiene Skills to Children Through Iterative App Design

Handwashing is an effective and low-cost practice that offers protection against a host of infectious diseases, both respiratory and gastrointestinal-but only when it is done at the appropriate time, with proper technique, and consistently when indicated. Public health efforts that emphasized access to clean water, soap, and towels, were combined with public messaging through flyers, posters, and videos with prompts to wash hands. Yet despite these efforts to raise awareness, the public health achievement gap has remained intractably wide. One problem is technique: teachers and parents are not commonly taught proper handwashing skills, which translates into imperfect technique being transferred to children in their care. Another is healthy habit formation: despite years of pandemic, heightened awareness, and sincere efforts by adults and children alike, durable handwashing practices have not taken hold. To address this unmet public health need, we developed an interactive digital trainer for touchscreen devices commonly found in schools and at home. Teacher co-developers, domain experts, students, and parents participated throughout the project, through rapid and frequent cycles of design, build, test, and refine. The trainer 1) conveys proper technique with accurate hand anatomy for high-fidelity learning; 2) provides critical visual feedback of germs remaining, so that players learn to use the appropriate scrub motion to address specific areas on each hand; 3) simulates infection transmission schoolwide, for experiential learning on when handwashing is indicated; 4) fosters habit formation, over several sessions, for lifelong gains in hand hygiene. This approach to game design, development, and evaluation was critical to the success of this project and is broadly applicable to many other learning domains.