title: Video surveillance captures student hand hygiene behavior, reactivity to observation, and peer influence in Kenyan primary schools.
abstract: BACKGROUND
  In-person structured observation is considered the best approach for measuring hand hygiene behavior, yet is expensive, time consuming, and may alter behavior. Video surveillance could be a useful tool for objectively monitoring hand hygiene behavior if validated against current methods.
  
  
  METHODS
  Student hand cleaning behavior was monitored with video surveillance and in-person structured observation, both simultaneously and separately, at four primary schools in urban Kenya over a study period of 8 weeks.
  
  
  RESULTS
  Video surveillance and in-person observation captured similar rates of hand cleaning (absolute difference <5%, p = 0.74). Video surveillance documented higher hand cleaning rates (71%) when at least one other person was present at the hand cleaning station, compared to when a student was alone (48%; rate ratio  = 1.14 [95% CI 1.01-1.28]). Students increased hand cleaning rates during simultaneous video and in-person monitoring as compared to single-method monitoring, suggesting reactivity to each method of monitoring. This trend was documented at schools receiving a handwashing with soap intervention, but not at schools receiving a sanitizer intervention.
  
  
  CONCLUSIONS
  Video surveillance of hand hygiene behavior yields results comparable to in-person observation among schools in a resource-constrained setting. Video surveillance also has certain advantages over in-person observation, including rapid data processing and the capability to capture new behavioral insights. Peer influence can significantly improve student hand cleaning behavior and, when possible, should be exploited in the design and implementation of school hand hygiene programs.
authors.affiliation: Woods Institute for the Environment, Stanford University, Stanford, California, United States of America; Environment and Water Studies, Civil and Environmental Engineering, Stanford University, Stanford, California, United States of America.
authors.forename: Amy J
authors.initials: AJ
authors.lastname: Pickering
authors.affiliation: Environment and Water Studies, Civil and Environmental Engineering, Stanford University, Stanford, California, United States of America.
authors.forename: Annalise G
authors.initials: AG
authors.lastname: Blum
authors.affiliation: Global Disease Detection Program, Kenya Office of the Centers for Disease Control and Prevention, Nairobi, Kenya; Global Disease Detection Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Robert F
authors.initials: RF
authors.lastname: Breiman
authors.affiliation: Social and Preventative Medicine, State University of New York at Buffalo, Buffalo, New York, United States of America.
authors.forename: Pavani K
authors.initials: PK
authors.lastname: Ram
authors.affiliation: Woods Institute for the Environment, Stanford University, Stanford, California, United States of America; Environment and Water Studies, Civil and Environmental Engineering, Stanford University, Stanford, California, United States of America.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Davis
mesh_terms: D001294:Attitude to Health; D005260:Female; D063373:Hand Hygiene; D015438:Health Behavior; D006801:Humans; D007630:Kenya; D008297:Male; D000067074:Peer Influence; D062486:Public Health Surveillance / Q000379:methods*; D012574:Schools; D013334:Students; D014741:Video Recording