***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND The purpose of this educational project was to assess the effect of several interventions on the frequency of h and washing  among elementary public school children . METHODS Participants in this project were first- grade rs and fourth- grade rs from jurisdictions within a mid-Atlantic metropolitan area . Phase I included a baseline assessment of bathroom cleanliness as well as adequacy of supplies for h and washing in each school . During phase 2 , the frequency of h and washing before lunch or after bathroom use was monitored and recorded during a 2-month period . The schools were separated into four groups : a peer education group , a h and wipes and instructional poster group , a combination of the education and h and wipes/poster groups , and a ( control ) comparison school . RESULTS Overall , a significant increase occurred in the proportion of h and washing frequency from preintervention to postintervention for each intervention group ( wipes : 0.50 vs 0.66 , p = 0.03 ; education only : 0.64 vs 0.72 , p = 0.02 ; and education and wipes : 0.45 vs 0.67 , p = 0.03 ) but not in the control group ( 0.42 vs 0.46 , p = 0.26 ) . When the first 3 weeks and the last 3 weeks after intervention were compared , h and washing frequency remained unchanged in the wipes only group ( 0.66 vs 0.66 , p = 0.96 ) , decreased in the education group ( 0.77 vs 0.65 , p = 0.006 ) , and increased in the education and wipes group ( 0.58 vs 0.75 , p = 0.003 ) , as well as in the control group ( 0.37 vs 0.52 , p = 0.01 ) . CONCLUSION Education combined with accessible convenient h and hygiene may result in a sustainable increase in the frequency of h and washing among elementary school children Elementary school-age children are particularly vulnerable to infections . While h and washing is the best method of preventing infections , many elementary schools are housed in buildings that have barriers to effective h and hygiene . The purpose of this study was to determine the effectiveness of an alcohol gel as an adjunct to h and washing in reducing absenteeism secondary to infectious illness .  Two-hundred and fifty-three elementary school children were r and omized by classroom into an experimental or control group . With a crossover design , all children participated in both groups , with a one-week washout period between phases . A 45-minute “ Germ Unit ” was taught to all children as they started the experimental phase and a st and ard unit on h and hygiene was taught as they started the control phase . Sixty-nine children were absent due to illness while in the control group . Thirty-nine children became ill while in the experimental group . Alcohol gel as an adjunct to h and washing was shown to be effective in reducing absenteeism due to infectious illness by 43 % Background Day care center attendance has been recognized as a risk factor for acquiring gastrointestinal and respiratory infections , which can be prevented with adequate h and hygiene ( HH ) . Based on previous studies on environmental and sociocognitive determinants of caregivers ’ compliance with HH guidelines in day care centers ( DCCs ) , an intervention has been developed aim ing to improve caregivers ’ and children ’s HH compliance and decrease infections among children attending DCCs . The aim of this paper is to describe the design of a cluster r and omized controlled trial to evaluate the effectiveness of this intervention . Methods / design The intervention will be evaluated in a two-arm cluster r and omized controlled trial among 71 DCCs in the Netherl and s. In total , 36 DCCs will receive the intervention consisting of four components : 1 ) HH products ( dispensers and refills for paper towels , soap , alcohol-based h and sanitizer , and h and cream ) ; 2 ) training to educate about the Dutch national HH guidelines ; 3 ) two team training sessions aim ed at goal setting and formulating specific HH improvement activities ; and 4 ) reminders and cues to action ( posters/stickers ) . Intervention DCCs will be compared to 35 control DCCs continuing usual practice . The primary outcome measure will be observed HH compliance of caregivers and children , measured at baseline and one , three , and six months after start of the intervention . The secondary outcome measure will be the incidence of gastrointestinal and respiratory infections in  600 children attending DCCs , monitored over six months by parents using a calendar to mark the days their child has diarrhea and /or a cold . Multilevel logistic regression will be performed to assess the effect of the intervention on HH compliance . Multilevel poisson regression will be performed to assess the incidence of gastrointestinal and respiratory infections in children attending DCCs . Discussion This is one of the first DCC intervention studies to assess HH compliance of both caregivers and children , as well as the incidence of gastrointestinal and respiratory infections in children , as outcome measures . When an effect of the intervention on improving HH compliance and /or reducing incidence of infections is shown , (inter)national dissemination of the intervention in other DCCs may be considered . Trial registration Netherl and s trial registry : OBJECTIVES Improving school water , sanitation and hygiene ( WASH ) conditions reduces pupil absence and illness . However , these benefits may depend on the conditions of the latrines and availability of consumables . We sought to determine whether a low-cost , policy-relevant , environmental-level latrine cleaning intervention could improve latrine cleanliness , increase its use and reduce absenteeism . METHODS In a three-arm , cluster-r and omized trial we assessed absence via periodical roll-call among 17 564 pupils in 60 schools that had previously received WASH improvements as part of the SWASH+ project .  Latrine conditions and use were also assessed using structured observation . Latrine cleanliness increased significantly during the post-intervention period among schools receiving the latrine cleaning package compared to controls , as did h and washing with soap . We found no difference in latrine use and absence across arms . CONCLUSIONS The additive impact of cleaning may not have been strong enough to impact absence above and beyond reductions attributable to the original WASH infrastructure improvements and basic hygiene education the schools previously received . Improving latrine conditions is important for the dignity and well-being of pupils , and investments and strategies are necessary to ensure that school toilets are clean and pupil-friendly OBJECTIVE This research aim ed to examine the effectiveness of an And roid mobile game application called Arbi Care as a means to prevent diarrhea and build self-efficacy in h and washing among preschool children . METHOD This research used a pre- and post-test control group and time series design approach . Respondents were chosen r and omly from a group of four to six years children . The intervention group ( n = 60 ) received Arbi Care intervention for 25 minutes , twice a week , for five weeks while the control group ( n = 60 ) received st and ard education .  Self-efficacy was measured by using question naire and observation . Measurement was carried out three times in the sixth , eight , and tenth week post-intervention . The data was analyzed using the GLMRM test . RESULTS There was a significant increase in the average score of self-efficacy in h and washing for the intervention group versus the control group . Moreover , there were significant differences in the results of average scores in which the intervention group showed much better self-efficacy improvement over the control group during the first , second , and final post-test after the intervention was given ( p < 0.001 ) . CONCLUSIONS An And roid-based educational game can be an effective medium to improve h and washing self-efficacy among preschool children , thus helping to prevent diarrhea BACKGROUND We assessed the effectiveness of a h and washing program using h and sanitizer to prevent  school absenteeism  due to upper respiratory infections ( URIs ) . METHODS This was a r and omized , controlled , and open study on a sample of 1341 children 4 - 12 years old , attending 5 state schools in Almería ( Spain ) , with an 8-month follow-up . The experimental group ( EG ) washed their h and s with soap and water , together with using h and sanitizer , and the control group followed their usual h and washing procedures .  Absenteeism rates due to URIs were compared between the 2 groups through a multivariate Poisson regression analysis . The percent of days missed in both groups were compared with a z test . RESULTS Overall , 1271 cases of school absenteeism due to URIs were registered . Schoolchildren from the EG had a 38 % lower risk of absenteeism due to URIs , incidence rate ratio : 0.62 , 95 % confidence interval : 0.55 - 0.70 , and a decrease in absenteeism of 0.45 episodes/child/academic year , p < .001 . Pupils missed 2734 school days due to URIs and the percentage of days absent was significantly lower in the EG , p < .001 . CONCLUSIONS Use of h and sanitizer plus h and washing with soap accompanied by educational support is an effective measure to reduce absenteeism due to URIs Evidence of the impact of water , sanitation , and hygiene ( WASH ) in schools ( WinS ) interventions on pupil absence and health is mixed . Few WinS evaluations rigorously report on output and outcome measures that allow for comparisons of effectiveness between interventions to be made , or for an underst and ing of why programs succeed . The Water , Sanitation , and Hygiene for Health and Education in Laotian Primary Schools ( WASH HELPS ) study was a r and omized controlled trial design ed to measure the impact of the United Nations Children ’s Fund ( UNICEF ) Laos WinS project on child health and education . We also measured the sustainability of intervention outputs and outcomes , and analyzed the effectiveness of group hygiene activities on behavior change and habit formation . Here , we present the design and intermediate results from this study . We found the WinS project improved the WASH environment in intervention schools ; 87.8 % of schools received the intervention per design . School-level adherence to outputs was lower ; on average , schools met 61.4 % of adherence-related criteria . The WinS project produced positive changes in pupils ’ school WASH behaviors , specifically increasing toilet use and daily group h and washing . Daily group hygiene activities are effective strategies to improve school WASH behaviors , but a complementary strategy needs to be concurrently promoted for effective and sustained individual h and washing practice at critical times From October 1981 to September 1984 , the authors conducted a three-year longitudinal study of diarrhea among infants and toddlers attending day care centers in Maricopa County , Arizona . In the third year of study , they evaluated the effects on diarrhea rates of staff training without external monitoring and of active surveillance conducted throughout the study . From 21 study day care centers , they r and omly selected 10 ( " intervention day care centers " ) to receive staff training in procedures  to reduce transmission of infectious diarrhea . Continuing active surveillance in the 10 intervention and 11 control day care centers found no difference between diarrhea rates in intervention day care centers in the pre- and posttraining years and no difference between diarrhea rates in the two groups of centers either before or after the training intervention . Biweekly family-based surveys during the two months after training also demonstrated no difference between infant-toddler diarrhea rates in intervention and control day care centers . These surveys found the 21 study day care centers to have significantly higher diarrhea rates than did day care homes or households not using day care , but significantly lower rates than day care centers not included in the active surveillance . Continuous surveillance without training was associated with a significant decrease in diarrheal illness during the course of longitudinal study . One-time staff training without subsequent monitoring did not result in additional decreases and did not lower day care center diarrhea rates to the levels observed in day care homes and households not using day care The objective of this study was to assess the effectiveness of a hygiene program in reducing the incidence of respiratory and diarrheal diseases in toddlers attending day care centers . A r and omized field trial was conducted in 52 day care centers in Quebec , Canada , between September 1 , 1996 and November 30 , 1997 . Absences for any reasons and the daily occurrence of colds and /or diarrhea in toddlers were recorded on calendars by the educators . The number of fecal coliforms on children 's h and s and on educators ' h and s was measured during three unannounced visits . Overall , 1,729 children were followed in 47 day care centers for a total of 153,643 child-days . The incidence rate of diarrhea was considerably reduced by the effect of monitoring ( IRR = 0.73 , 95 % CI = 0.54,0.97 ) , and the intervention reduced the incidence rate of upper respiratory tract infections ( IRR = 0.80 , 95 % CI = 0.68,0.93 ) . Monitoring alone also had an important effect in reducing the level of bacterial contamination on children 's and educators ' h and s. The results indicate that both an intervention program and monitoring alone play a role in reducing infections in children attending day care centers SUMMARY Gastrointestinal and respiratory infections in children attending daycare centres ( DCCs ) are common and compliance with h and hygiene ( HH ) guidelines to prevent infections is generally low . An intervention was developed to increase HH compliance and reduce infections in DCCs . The objective of this paper was to evaluate the effectiveness of this intervention on HH compliance . The intervention was 
    Output:
    
The findings of this review may have identified a small yet potentially beneficial effect of rinse-free h and washing regimes on illness-related absenteeism .