Child care institutions have always been the focus of attention from all walks of life, and more and more reports that the hand hygiene of child care institutions can cause a series of related infectious diseases, and the incidence rate is increasing year by year. Institutional hand hygiene has become a hot research topic for current scientists. This paper refers to relevant literatures at home and abroad, summarizes the impact of hand hygiene on the hand hygiene of child care institutions, the current status of hand hygiene and its influencing factors, hand health interventions and effects, and proposes appropriate Hand hygiene interventions improve hand hygiene compliance, reduce the outbreak and incidence of hand, foot and mouth disease, and promote healthy growth of children. At the same time, it provides a theoretical basis for relevant research on hand hygiene in the future, and provides scientific basis for relevant departments to formulate and introduce hand hygiene standards suitable for child care institutions.
Infants and young children are in the stage of growth and development, and their resistance is weak. It is a high-risk group for infectious diseases. Child care institutions (kindergartens) are densely populated, have poor air circulation, and have close contact with children. They are high-risk places for infectious diseases, which can easily cause clustering diseases [1, 2]. Hand, foot and mouth disease seriously threatens the health of infants and young children. And the hand plays an important role in the process of its dissemination, so the hand hygiene problem has become a hot spot for current scientists. A lot of researches have been carried out at home and abroad, including the epidemiological characteristics of hand-foot-mouth disease and its influencing factors in child care institutions, the influence of children and their hand washing behavior on the occurrence of foot and mouth disease, and the hand health intervention research in child care institutions. This article will review the hand hygiene research of child care institutions from the following four aspects.
1. Child care institutions hand, foot and mouth disease epidemic
In child care institutions, hand hygiene behavior is an important part of the epidemic of hand, foot and mouth disease. A study in 2014 showed that children with poor hand hygiene were more likely to develop hand, foot and mouth disease than children without disease . At the same time, many studies showed that children sucked their fingers and did not wash their hands and nails before and after meals. Dirty and unhealed hand hygiene behaviors such as washing hands and playing are all risk factors for hand, foot and mouth disease. Conversely, good hand washing behavior is a protective factor [10,11].
2. Current status and influencing factors of hand hygiene in child care institutions
2.1 Types of child care institutions and hand hygiene status In domestic care institutions, they can be divided into different types according to the nature, level and geographical location. According to the nature of the start-up, it is divided into: public kindergartens, higher-income private kindergartens and private kindergartens for floating population; divided into: demonstration parks, first-grade kindergartens and second-level kindergartens by level; divided into: urban, rural and urban-rural joint kindergartens .
There are significant differences between different childcare institutions in terms of hardware facilities, service providers and guardians. There are no major differences in conditions and facilities in public kindergartens, higher-income private kindergartens, demonstration parks, primary kindergartens, and urban kindergartens. The health care room is fully equipped, equipped with adequate health care personnel and trained in specialized health knowledge. The various physical examination, common disease management, infectious disease management and sanitation management systems are relatively sound and perfect. The kindergarten teacher has a high quality and can correctly guide children to develop good hand washing habits. The requirements for the nurses are stricter. The toys, doors and windows, door handles and towels in the classroom are regularly disinfected to reduce the chance of children’s hands touching the bacteria, which fundamentally reduces the occurrence of related diseases. The survey on the quality of public and private kindergartens in Shenzhen, Zhuhai, Tianjin and other regions shows that [12-14], the pass rate of children’s hands, preschool hands, surface of objects, door handles, toys, etc. in public kindergartens are all Significantly higher than private kindergartens. The floating population private kindergartens, secondary kindergartens, rural and urban-rural joint kindergartens are in poor condition in all aspects due to restrictions on funds and venues. Some floating population private kindergartens do not have a dedicated health care room, and health care equipment is not perfect. For example, according to a survey conducted by Zheng Jinliang et al. , only 25% of child care institutions meet the criteria for the basic conditions of kindergartens in Jiangxi Province. 》. The quality of kindergarten teachers and childcare workers is low, lack of health knowledge, and lack of attention or inability to pay attention to hand hygiene. See the results of a survey conducted by private kindergartens in Zhengzhou . In addition, the general economic conditions of guardians are not good. Health knowledge is relatively inadequate and it is difficult to perform hand health work.
2.2 Hand hygiene factors
2.2.1 Environmental factors Due to the differences in economic conditions, there are large differences in the hardware facilities of different child care institutions. Judging from the overall environment, the kindergartens with good economic conditions have a beautiful environment, the classrooms are spacious and bright, and the supporting facilities are in place. The child care institutions with poor economic conditions are completely different and the environmental conditions are poor. Some private kindergartens have a multi-purpose room, which is not only a classroom, but also a bedroom or activity room. The classroom area is too small, and the chances of children’s hands coming into contact with infection increase . From the perspective of the bathroom, foreign research has confirmed Whether the area of the bathroom, the number of faucets, the amount of hand sanitizer, the paper towel or the towel directly affect the hand washing behavior and its normative occurrence, the area is large, the number of faucets and hand soap is sufficient, and when the towel is a paper towel , hand hygiene compliance increased significantly [18-19]. Studies have shown , often washing hands or washing hands with soap can cause dry skin and various skin discomfort, thereby reducing the frequency of hand washing, affecting hand washing behavior.
2.2.2 Service providers The service providers of child care institutions mainly include four aspects: directors, teachers, nurses and garden doctors. The first is the head of the school. As a manager, his knowledge and importance are critical. The heads of many private kindergartens are non-medical professionals, lack of knowledge about health and disease prevention, combined with busy work, no energy to take care of this work, so that the sanitation and disinfection work is not completely implemented, and the prevention and treatment of childhood infectious diseases caused by hand hygiene More will not be taken seriously.
Secondly, teachers in kindergartens and kindergartens are of varying quality. The differences in educational level make them more concerned about their children’s requirements and their hand-washing behavior. During the school, the most contact with the children is the teacher and other children. The teacher should not only let the children learn how to pay attention to the hand washing behavior, but also should pay attention to their own hand washing behaviors. Under what circumstances should the hand washing behavior also occur. [21, 22], played a demonstration role. However, some kindergarten teachers lack hygiene awareness and completely ignore the influence of their behavioral habits on children. Children will try to imitate them, so teachers’ good hand washing behavior will help them develop good hand washing habits.
The third is the nurses in the park, most of whom are part-time workers, with a low level of education. They have not undergone formal hygiene knowledge and related disinfection knowledge and skills training, and cannot implement sanitation and disinfection work on surfaces, children’s toys, tableware, toilets, etc. This increases the chance of hand contact infection.
The fourth is health care personnel. The vast majority of health care doctors in child care institutions do not meet the relevant requirements in terms of quantity and quality. For example, according to a survey conducted in Shenzhen, the holding rate of health care practitioners in kindergartens is only 22%, and 66.95% of health workers are secondary and high school graduates.  Many people without medical qualifications are engaged in health care work. Part-time (no medical education) health care personnel have low quality, the concept of health care is vague, and the quality of health care work cannot be guaranteed , related disinfection work (especially on the surface of objects, preschool education, toys, kitchen utensils disinfection project) Without implementation, there are hidden dangers of public health emergencies.
2.2.3 Guardians Children’s family conditions and the quality of parents are closely related to hand hygiene behavior. Parents have high quality, have a good understanding of disease prevention knowledge, and usually pay attention to children’s health behaviors, which is more conducive to the development of children’s good personal hygiene habits. Some children’s parents have lower quality in all aspects, family conditions are relatively poor, and the concept of hand hygiene is insufficient. In addition, they are usually busy with work and pay attention to the development of children’s health habits, so their hand hygiene behavior is relatively poor .
2.2.4 Health Management and Supervision To ensure the implementation of hand hygiene in child care institutions, in addition to their own management, maternal and child health institutions, disease prevention and control institutions and health supervision departments also play a very important role. Judging from the current operational situation, due to institutional reasons, there is still a problem of disconnection and non-implementation of work between several departments. The maternal and child health department only pays attention to child health care, and ignores the training of infectious disease knowledge and disinfection knowledge, while the disease control department is difficult to put in place because of the management system. Health supervision departments are more concerned about law enforcement of major issues, and often ignore routine supervision.
3. Hand hygiene intervention and effect
At home, there are many studies on hand health interventions for medical staff, and there are relatively few hand health interventions in child care institutions. For example, Qiao Hong et al  have shown that it is only necessary to wash hands with mobile water according to the standard, and the microorganisms contaminated on the hands can be effectively removed. According to the three types of environmental sanitation standards of medical institutions, the quality of hygiene can reach more than 80%. Song Xuewen et al  significantly improved the prevention and treatment of his opponent’s foot and mouth disease by conducting health education interventions for parents. Xu Guijuan et al  improved the series of interventions such as hand hygiene training (lectures, special discussions, hand hygiene publicity materials, posters, etc.), hand hygiene training, establishment of sound rules and regulations, evaluation and improvement of hand washing facilities. Hand hygiene awareness and hand washing rate reduce the incidence of infection. Liu Xiuying et al  showed that the closure of the faucet after washing hands has a great impact on the pass rate, and the pass rate of the faucet has increased significantly.
A series of studies abroad have also confirmed the effectiveness of some hand health interventions. A research team at the Toronto Rehabilitation Association of Canada developed a wearable hand infection prevention system that can monitor and increase the frequency of hand washing . Retrospective studies have shown [31-33] in hepatitis A, cholera, norovirus, Washing hands when an infectious disease such as typhoid fever or Shiga dysentery occurs can be used as a control measure to reduce the outbreak of infectious diseases. Ruan et al  also showed that hand washing can reduce the risk of hand, foot and mouth disease by more than 95%.
In 2009-2013, Erasmus University of the Netherlands conducted the world’s first study to observe the compliance of kindergarten teachers and children’s hand hygiene behaviors, the incidence of gastrointestinal tract infections and respiratory infections in children to evaluate the effects of hand hygiene interventions. The study cost 500,000 euros for 5 years.  This study differs from traditional health education research in the use of compliance and morbidity to quantitatively evaluate research results, and uses social cognitive theory and stepwise behavioral change methods. The development of tailor-made clothing is aimed at the hand hygiene promotion strategy of kindergarten teachers . The research results show that environmental factors and social cognitive factors will affect the hand hygiene behavior of teachers and children, and the intervention strategies are developed for these influencing factors. The Hand Health Promotion Program can significantly improve the hand hygiene behavior of kindergarten teachers and children and reduce the incidence of infectious diseases among kindergarten children . To this end, the Netherlands has adopted the following intervention strategies in kindergartens: the distribution of hand sanitizers; Educational materials; environmental surface cleanliness; health education courses and team training, etc., have achieved remarkable results, effectively reducing the incidence of infectious diseases [21,36]. The study also shows that hand hygiene in the classroom only paper towels In the case, compliance is significantly improved in the case of only towels or both.
4. Child care strategies for child care institutions
4.1 Formulating and promulgating standards Through a series of investigations and studies, the development of relevant hand hygiene standards for child care institutions, including hardware facilities standards, classroom area, number of students per class, per capita area, etc.; hand washing facilities configuration standards: number of restrooms, The number of faucets, the level of installation, the quantity and type of hand soap, the number of dry tissues and the level of installation; the standard of health care room: the size of the health room, the number and quality requirements of health care providers; and the number and quality of cleaning staff.
4.2 Training and Guidance A number of studies have shown [22,36] that team training for teachers and parents in child care institutions can help them and their children to learn more about disease prevention and raise awareness of hand washing. The CDC or maternal and child health care institutions should closely cooperate to strengthen the publicity and training of the health knowledge of the staff of the child care institutions and parents, and take various forms (thematic knowledge lectures, broadcast related videos, hand hygiene knowledge brochures, posters) , stickers and other materials), carry out hand hygiene knowledge publicity and education, or on-site disinfection operation skills training and guidance. Teachers and parents can teach children hand hygiene knowledge through storytelling, drawing, games and other interesting ways, emphasizing the importance of hand washing and raising awareness of hand washing. At the same time, the correct hand washing diagram is posted at the hand washing facility, even in the absence of teacher supervision, the child can be reminded to complete the hand washing behavior independently and effectively, and effectively improve the hand washing norm.
4.3 Supervise the implementation of joint law enforcement in the health and education departments, urge the child care institutions to establish a sound disinfection system, implement special personnel responsible for regular disinfection work , urge them to formulate and improve the health care system, equip adequate health personnel, and strengthen staff And children’s hand hygiene knowledge training, improve the awareness of hand washing, do a good job in cleaning and disinfecting all aspects of environmental goods, reduce the chance of contact with germs, cut off the route of disease, and achieve the purpose of preventing disease. In particular, it is necessary to strengthen the management of private kindergartens, strictly examine and approve the qualifications for running a garden, and those who do not have resolutely banned them. At the same time, it can strengthen the relationship between private and public kindergartens, promote each other, and jointly improve and make progress for children’s physical and mental health.