JMIR Publications

ABSTRACT

Background:

Schools are often the site of outbreaks, including COVID-19, influenza and other infectious diseases. The COVID-19 pandemic has underscored the need to enhance hygiene levels at primary and secondary schools. Specifically, nurturing and sustaining students’ regular handwashing practices is one of the key components of a preventive strategy to reduce the transmission of infectious diseases. Meanwhile, Virtual Reality (VR) intervention has been shown to be efficacious for behavioral change. It manipulates an array of behavioral and environmental variables to construct an immersive virtual environment for changing certain human behaviors. A VR handwashing education system may be more effective 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 lacking in Hong Kong.

Objective:

This study aims to evaluate the effectiveness of a VR intervention of teaching handwashing skills. A 7-step handwashing approach, which is promoted by the Centre for Health Protection, Department of Health, Hong Kong Special Administrative Region, 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 skills; the second intervention group will participate in one VR-game session and one video session reviewing videos captured from participants’ playthrough in the first session; the baseline group will participate in two video sessions about handwashing. Comparison of pre- and post-intervention ultraviolet fluorescence imaging of the participants’ hands will serve as primary measurement. Image comparisons will adopt the 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:

Data collection will be held between September 2026 and May 2027. Data will be analyzed in summer 2027, and the results are expected to be released in September 2027.

Conclusions:

This study contributes to the development of infection prevention strategy through VR game The study fills a number of research gaps in the field by (1.) developing evidence-based and executable VR hand hygiene programs in school settings; (2.) addressing the sustainability issue of hand hygiene intervention effects; (3.) identifying factors underlying the pathway of behavioral 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 project will be transferable to developing other health promotion programs by adopting VR devices. Clinical Trial: NCT07659340