Effectiveness of Handwashing Education Among Orang Asli Kids

Introduction

Handwashing is a core hand hygiene practice that involves the use of plain or antimicrobial soap and water to physically remove dirt, destroy transient microorganisms, and reduce resident flora. Hands often serve as an essential vector in many infectious diseases, such as gastrointestinal infections like diarrhoea and respiratory illnesses like pneumonia. Therefore, handwashing is considered one of the most efficient and cost-effective approaches to breaking the chain of disease transmission, thereby reducing disease occurrence.

Promoting handwashing enhances basic sanitation and prevents the spread of infectious diseases among populations, particularly in developing countries. Nonetheless, on a global scale, around three in ten individuals, or 2.3 billion people, lack access to handwashing facilities with water and soap in their homes. The lack of handwashing facilities poses a significant challenge in maintaining proper sanitation and hygiene, which potentially leads to adverse health effects, especially in children. Globally, diarrhoeal diseases are one of the leading causes of death among the child population aged 0 to 14 years, responsible for one in every 10 deaths within this age group. In fact, childhood diarrhoea is found to be significantly associated with handwashing without using soap. Moreover, respiratory infections are not only the leading cause of infectious disease burden worldwide but also responsible for half of all child deaths annually.

Access to hygiene infrastructure is often worse in rural areas. Individuals residing in rural regions frequently face greater challenges in accessing basic handwashing facilities than those living in urban areas. In Malaysia, the Aboriginal people, also known as “Orang Asli,” predominantly live in rural and remote areas. They are often disadvantaged in terms of socioeconomic status, education, and health. Consequently, the prevalence of diseases among the Orang Asli community, particularly among kids, is greater compared to the general population. Most diseases occurring among Aboriginal kids are attributed to poor handwashing practices.

One of the key barriers to effective handwashing among Orang Asli kids is a lack of knowledge, appropriate attitudes, and consistent practices. Research has consistently shown that handwashing education can significantly reduce the incidence of infectious diseases and contribute to maintaining school health. Proper handwashing also reduces school absenteeism among children, which indirectly improves their academic performance and eventually contributes to the nation’s development. Therefore, healthcare providers and researchers should conduct comprehensive and sustained handwashing training programmes, especially in schools serving vulnerable populations, such as the Orang Asli. This is particularly important because Orang Asli kids are more susceptible to infectious diseases due to overcrowded environments and limited access to basic handwashing facilities.

Primary school age is a critical developmental stage for forming lasting personal hygiene habits. At this stage, children are more open to adopting new behaviours, making it an ideal period for intervention. Handwashing programmes specifically designed for young school-aged children have been shown to produce positive results in terms of both behaviour and health outcomes. Despite these findings, most existing studies have focused on children living in urban areas in Malaysia or Aboriginal communities in other countries. As a result, there is a lack of available literature regarding the KAP of handwashing among Orang Asli kids in Malaysia.

In light of this context, this study aims to evaluate the Aboriginal kids’ KAP regarding handwashing before and after the handwashing education intervention. The findings from this study will aid in enhancing the delivery of handwashing education within the community, ultimately leading to improved perceptions and behaviours regarding handwashing.

Also Read: Modern IT Applications For Project Planning And Management

Methods

Study Population

The interventional study was conducted among 61 Orang Asli students from Sekolah Kebangsaan Pasir Linggi, Gua Musang, Kelantan, aged 7 (Year 1) to 12 years old (Year 6). The study was conducted from June 2024 to August 2024. This school was chosen because it catered not only to students from nearby Orang Asli villages but also to those from other areas in the Gua Musang district, such as Kampung Kuala Koh and Kampung Aring, which are 100 km from the school. Students from distant areas were staying at the school hostel. The broad catchment area enabled the study’s findings to better represent the broader Orang Asli student population in Gua Musang.

In addition to its diverse student base, the school was chosen due to ongoing public health concerns previously reported among the Orang Asli communities in Gua Musang. Several studies and health reports have documented a high prevalence of hygiene-related illnesses in the area, particularly among children. For instance, during the 2019 measles outbreak in Kampung Kuala Koh, which resulted in multiple deaths, healthcare workers noted widespread fungal skin infections and weakened immunity, conditions that are often linked to insufficient hygiene practices. Moreover, research focusing on Orang Asli preschool children in Gua Musang reported a high prevalence of malnutrition and soil-transmitted helminth infections, indicating inadequate hygiene practices and poor sanitation in the area. Although there have been reports of hygiene issues in the Gua Musang district, there is still limited information about Sekolah Kebangsaan Pasir Linggi, which made it a suitable choice for this handwashing intervention.

Data Collection

During the first visit, the students were given a set of pre-intervention questionnaires assessing their KAP related to handwashing, and they were subsequently trained in proper handwashing techniques. The handwashing steps are based on recommendations from the World Health Organization and the Centers for Disease Control and Prevention (CDC) Guidelines for Hand Hygiene in Healthcare Settings. After three months, the same questionnaires were administered. As most students had difficulties reading, the questionnaire sessions were conducted through face-to-face interviews during both the pre- and post-intervention visits. The researchers asked the questions verbally and recorded the students’ responses.

Inclusion and Exclusion Criteria

All students from Years 1 to 6 at Sekolah Kebangsaan Pasir Linggi who attended classes during both data collection sessions and whose parents provided consent were included. Students who were absent or not proficient in Malay were excluded.

Sample Size Estimation

As no prior studies provided mean or standard deviation estimates, the sample size calculation used an effect size of 0.4 based on Cohen’s d, calculated with G-Power software. The required sample size was 52, and after adding 10% for attrition, the target sample was 65.

Study Instrument

A validated questionnaire adapted from Mohamed et al. and Ramli et al. was used to assess demographic information and KAP.

Knowledge and attitude sections used a 5-point Likert scale. Practices used a three-option scale: yes, no, not sure.

Scoring System

Knowledge/attitudes:
1 = strongly disagree, 2 = disagree, 3 = not sure, 4 = agree, 5 = strongly agree.

Practices:
Yes = 3, Not sure = 2, No = 1.

Statistical Analysis

Data were analysed using SPSS version 27. Descriptive statistics and paired t-tests were used. A P-value < 0.05 was considered statistically significant.

Results

Demographic Characteristics

A total of 61 students participated:

• 35 females (57.4%)
• 26 males (42.6%)

Year distribution ranged from Year 1 to Year 6, with most students in Year 5 (29.5%).

Notably:

• 75.4% reported diarrhoea in the past month
• 77% had previously learned handwashing
• 44.3% lived in hostels
• 98.4% of fathers were employed; 32.8% of mothers were working

Knowledge, Attitudes, and Practices (KAP) Findings

Tables 2 and 3 showed significant improvements across all domains after the intervention.

Knowledge

Before the intervention, students showed limited understanding of:

• disease transmission
• correct handwashing steps
• the link between hygiene and diarrhoea

After the intervention, strong agreement increased dramatically across all six knowledge items (e.g., from 3.3–32.8% rising to 72.1–91.8%).

Attitudes

Strong agreement post-intervention exceeded 86% across all items, showing shifts in:

• recognition of when to wash hands
• understanding of hygiene importance
• awareness of risks linked to shared towels and long nails

Practices

Five of six behaviours improved to 100% compliance post-intervention.
Handwashing after eating was already 100% before the intervention.

Overall Statistical Findings

Paired t-tests showed significant improvements in:

• Knowledge (mean difference: 8.672)
• Attitude (mean difference: 7.787)
• Practice (mean difference: 5.082)

All P < 0.001.

Year-Level Comparisons

Significant improvements were observed in Years 2–6 across knowledge and attitudes.
Year 1 showed no significant improvements, likely due to prior preschool handwashing training (ceiling effect).

Discussion

Proper handwashing reduces the spread of infectious diseases, including multidrug-resistant organisms. Orang Asli communities face limited sanitation, water access, and socioeconomic challenges, contributing to disease prevalence. Multiple prior studies confirm similar disparities and highlight the need for hygiene education. The demographic trends showed low Year 1 enrolment, tied to cultural norms and limited early education awareness. Older children showed higher attendance and greater receptiveness to structured schooling.

Diarrhoea prevalence (75.4%) among participants aligned with global and local studies showing high infection rates in underserved Indigenous populations. More than half of participants had prior handwashing exposure during COVID-19 campaigns, which may have influenced baseline knowledge. The intervention significantly improved KAP scores, consistent with global studies from Rwanda, India, Malawi, and the United States. Year 1 showed limited improvement due to a ceiling effect, but their practices remained strong.

All knowledge metrics improved substantially, particularly regarding disease transmission and correct washing steps. Attitudes also improved, with washing after eating already a strong pre-existing behaviour due to cultural norms of eating with hands. Practices showed major gains, especially handwashing with soap, which was lowest pre-intervention due to limited soap access. Strengths of the study included direct instruction and visual aids, while limitations included a single-school sample. Confounding factors likely included parental hygiene habits and prior COVID-19 hygiene campaigns.

Conclusion

The handwashing education programme significantly improved knowledge, attitudes, and practices among Orang Asli kids, especially those in Years 2–6. Year 1 students showed limited cognitive gains but maintained strong behavioural practices. Future programmes should target younger children with more repetition, hands-on activities, and simplified content. Given ongoing barriers such as limited water access and socioeconomic constraints, culturally tailored interventions are essential.

Sustained handwashing habits can reduce infections, school absenteeism, and disease burden in vulnerable communities. These findings offer guidance for designing effective hygiene programmes in similar Indigenous and resource-limited environments worldwide.