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

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.

Inclusion criteria

• Hong Kong secondary school students studying junior forms

Exclusion criteria

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