THE EFFECTIVENESS OF HEALTH EDUCATION ON CHANGES IN HANDWASHING BEHAVIOR IN ELEMENTARY SCHOOL CHILDREN

Abstract

Personal hygiene, particularly proper handwashing practices, is the frontline in preventing the transmission of infectious diseases in elementary school-aged children. Recent data from the World Health Organization (WHO) indicate that diseases related to poor sanitation remain the leading cause of morbidity and mortality in this age group, with respiratory infections and diarrhea predominating. Although health education programs have been widely implemented in schools, significant gaps remain in the in-depth understanding, formation of positive attitudes, and adoption of consistent handwashing behavior according to recommended guidelines among elementary school students. This gap indicates the need for a critical evaluation of the effectiveness of existing health education interventions and the development of more targeted strategies. This study aimed to quantitatively evaluate the effectiveness of a structured health education program in increasing knowledge, forming positive attitudes, and inducing changes in correct handwashing behavior in elementary school children, based on social cognitive theory that emphasizes the interaction between individual, environmental, and behavioral factors. The main hypothesis proposed was that the health education intervention would significantly improve the knowledge, attitude, and frequency of correct handwashing behavior in the intervention group compared to the control group. This study used a quasi-experimental design with a pre-test and post-test control group design, which was chosen to compare changes in variables before and after the intervention in the group that received health education (intervention) and the group that did not receive it (control), and to minimize bias due to the lack of full randomization. The study sample consisted of 200 4th and 5th grade elementary school students from two different schools, with each school assigned to an intervention group (n=100) and a control group (n=100), selected through purposive sampling technique based on similarities in demographic and socioeconomic characteristics. Knowledge and attitudes were measured using a valid structured questionnaire (Cronbach's Alpha = 0.85 for knowledge, 0.88 for attitude), and handwashing behavior was assessed through direct observation using a reliable structured observation sheet (Cohen's Kappa = 0.79); the health education intervention was implemented over four sessions, including demonstrations of correct handwashing techniques, interactive games, and group discussions. Data were analyzed using independent t-tests and paired t-tests. The analysis results showed a significant increase in knowledge scores regarding the correct handwashing steps (mean pre-test = 65.2 ± 8.5, post-test = 88.7 ± 5.1, p < 0.001), positive attitude scores towards the importance of handwashing (mean pre-test = 3.8 ± 0.4, post-test = 4.5 ± 0.2, p < 0.001), and frequency of correct handwashing behavior (mean number pre-test = 2.1 ± 0.8, post-test = 4.5 ± 0.6, p < 0.001) in the intervention group, with a very significant difference (p < 0.001) and a large effect size (Cohen's d > 1.5) compared to the control group. Secondary analysis also revealed an increase in collective awareness to remind each other of correct handwashing practices. In conclusion, structured health education has proven highly effective in improving knowledge, attitudes, and correct handwashing behavior in elementary school children. It provides theoretical contributions in the application of social cognitive theory and practical contributions in the form of an adaptable intervention model. It also recommends the continued integration of this program into the school curriculum and the expansion of the study for long-term behavioral sustainability.