ArticleBMC pediatrics2026
Impact of hand hygiene on infection-related symptoms in school-aged children: a cross-sectional study on the moderating effect of depression.
Article in BMC pediatrics, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundWhile hand hygiene is a primary defense against infection-related symptoms, the specific dose-response relationship and the influence of psychological factors (e.g., depression) on this association in children are not well understood. PURPOSE: To examine the dose-response relationship between multi-scenario hand hygiene behaviors and infection-related symptoms and to test the moderating effects of depression in school-aged children in China.
methodsThis multicenter, cross-sectional study enrolled 22,602 students from 54 schools. Hand hygiene was assessed using a composite score (0-3) across three key scenarios. Infection-related symptoms was defined by the 14-day incidence of seven predefined symptoms (e.g., respiratory, gastrointestinal). Depression was assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. Three-level mixed-effects logistic regression models were employed to examine dose-response relationships, accounting for county- and school-level clustering. To ensure the robustness of our findings, we calculated E-values to quantify potential unmeasured confounding and performed subgroup analyses across infection-related symptoms types and demographics to assess the stability of the association. Additionally, a moderation analysis examined the interaction between hand hygiene and depression, specifically among secondary school students.
resultsMultilevel analysis revealed a significant nonlinear dose-response relationship, with a threshold at score 3 compared to scores 0-2 (adjusted odds ratio [AOR] = 0.676, 95% confidence interval [CI]: 0.633-0.721, P < 0.001). The association remained robust after subgroup analyses, and E-values ≥ 1.73 indicated resilience to potential unmeasured confounding. In the moderation analysis for secondary-school students, depression significantly moderated the association between hand hygiene and infection-related symptoms (P
conclusionsMaintaining hand hygiene across all three scenarios (score = 3) was associated with a lower risk of infection-related symptoms in school-age children. However, the presence of depression may attenuate this association. School-based infection control may need to transition from purely behavioral interventions (e.g., reinforcing hygiene) in primary schools to an integrated approach that includes mental health support in secondary schools. CLINICAL TRIAL NUMBER: Not applicable.
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