4 Sanitarno inženirstvo / International Journal of Sanitary Engineering Research   Vol. 14  1/2020
SANITARNO INŽENIRSTVO / International Journal of Sanitary Engineering Research 2020;14(1):4-16
DOI: 10.2478/ijser-2020-0002
An evaluation of the 
effectiveness of nudge 
techniques in improving 
hygiene behaviours in 
Kindergartens 
1 Faculty of Health Sciences, University of 
Ljubljana, Zdravstvena pot 5,  
1000 Ljubljana, Slovenia 
2 Kindergarten Kekec Grosuplje, Trubarjeva 
cesta 15, 1290 Grosuplje, Slovenia
*	Corresponding author
Natalija Rozman, MSc Sanitary 
Engineering 
Currently at National Institute of  
Public Health, Trubarjeva 2,  
1000 Ljubljana, Slovenia 
E-mail: natalija.rozman1@gmail.com
 © 2020 Natalija Rozman, Branka Strah, 
Mojca Jevšnik. This is an open access 
article licenced under the Creative 
Commons Attribution NonCommercial-
NoDerivs license as currently displayed on 
http://creativecommons.org/licenses/
by-nc-nd/4.0/.
Natalija ROZMAN1*, Branka STRAH2, Mojca JEVŠNIK1
ABSTRACT
Good hygiene practice is an important element in terms of preventing the 
spread of infections, but it is not always carried out according to instructions 
among employees in hygienically sensitive work processes. To improve this, 
tools for nudging hygienic behaviour have been developed, which 
subconsciously encourage the individual to perform the desired hygienic 
behaviour. Examples of activity where employees and children constantly come 
into contact with pathogenic microorganisms are educational institutions 
(kindergartens). By observing the working process in the selected kinder-
gartens, we wanted to determine the time, technique, and frequency of 
handwashing among childcare workers and children. In the case of the first 
ones, we wanted to find out whether they also wear personal protective work 
equipment. Based on the findings, we wanted to implement the selected 
nudging tools for better hygiene behaviour. In the first half of the observation, 
we found that the hygienic behaviour regarding handwashing of childcare 
workers and children is poor. After setting the nudging tools, hygienic behaviour 
improved in all the observed groups. The results suggest that the use of 
nudging tools in kindergartens can significantly contribute to the better 
implementation of hygienic behaviour (especially handwashing) in childcare 
workers and children. Consequently, we conclude that with the tools for 
promoting hygiene behaviour, the incidence of infectious diseases in kinder-
gartens can be reduced. We can direct children towards the healthier and 
hygienically appropriate way of life by means of the appropriate hygiene 
behaviour.
Key words: preschool education; handwashing; hand hygiene; behaviour; 
nudging tools
POVZETEK 
Dobra higienska praksa je pomemben element v smislu preprečevanja širjenja 
okužb, vendar se med zaposlenimi v higiensko občutljivih delovnih procesih ne 
izvaja vedno po navodilih. Za izboljšanje le-tega so se oblikovala orodja 
spodbujanja higienskega vedenja, ki podzavestno spodbudijo posameznika k 
Original scientific article
Received: 3. 09. 2020 
Accepted: 2. 12. 2020 
Published: 31. 12. 2020
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N. ROZMAN, B. STRAH, M. JEVŠNIK: AN EVALUATION OF THE EFFECTIVENESS OF NUDGE TECHNIQUES IN IMPROVING HYGIENE BEHAVIOURS IN KINDERGARTENS   
izvajanju želenega higienskega vedenja. Primer dejavnosti, pri kateri zaposleni 
in otroci pogosto prihajajo v stik s patogenimi mikroorganizmi, so vzgojno 
varstveni zavodi (vrtci). Z opazovanjem delovnega procesa v izbranih vrtcih 
smo želeli ugotoviti čas, tehniko in pogostost umivanja rok pri strokovnih 
delavkah in pri otrocih. Pri prvih tudi ali uporabljajo osebna zaščitna sredstva. 
Na osnovi ugotovitev smo želeli uvesti izbrana orodja spodbujanja higienskega 
vedenja in ugotoviti, ali ta izboljšajo higiensko vedenje opazovancev. V prvi 
polovici opazovanja smo ugotovili, da je higiensko vedenje glede umivanja rok 
strokovnih delavk in otrok na nizki ravni. Po namestitvi spodbujevalnih orodij se 
je higiensko vedenje izboljšalo pri vseh opazovancih. Rezultati nakazujejo, da 
lahko uporaba spodbujevalnih orodij na področju umivanja rok v vrtcih bistveno 
pripomore k boljšemu izvajanju higienskega vedenja (predvsem umivanje rok) 
strokovnih delavk v oddelkih in otrok. Posledično sklepamo, da lahko z orodji 
spodbujanja higienskega vedenja zmanjšamo pojavnost nalezljivih bolezni v 
vrtcih ter hkrati otroke z ustreznim higienskim vedenjem usmerjamo k bolj 
zdravemu in higiensko ustreznemu načinu življenja.
Ključne besede: predšolska vzgoja; umivanje rok; higiena rok; vedenje; spod-
bujevalna orodja
INTRODUCTION
Nowadays, there are many theoretical and practical training courses on 
good hygiene practice (referred as GHP) such as proper hand hygiene. 
According to the scientific literature, such implementation is a constant 
challenge [1, 2, 3, 4] due to poor knowledge, superficiality, overload 
and/or employee disinterest and skin irritation. The fact is that an 
individual’s behaviour in the field of hygiene practices affects the health 
of everyone, that he or she comes into contact with. For more consistent 
implementation of hygiene practices, nudging tools have been 
developed to encourage the individual to perform the desired action 
(e.g. handwashing) [3]. Nudging tools in the field of hand hygiene are 
important, as many studies shows an association between improved 
hand hygiene and a reduction in the number of diseases [2, 5, 6]. An 
example of an activity in which employees and children often come into 
contact with infections are educational institutions (kindergartens). 
There, regular and proper exercise of handwashing is crucial, as 
otherwise the health of employees, children and parents is at stake. 
Simple, cost-effective tools for promoting hygienic behaviour can help 
target behaviours to be improved and motivated by childcare workers 
and children [3, 7].
The term “nudge” was first described by the authors Thaler and 
Sunstein (8) as a “gentle push” with the main goal of directing people’s 
behaviour towards a better decision. This definition has been labelled in 
scientific circles as too broad and imprecise. Therefore, they stipulated 
that incentives must meet certain requirements. Nudges must be low-
cost, simple, easy to reject (without coercion) and nudges need to help 
people make better decisions (safer and healthier).
The health hygiene regime in kindergarten is based on ensuring a safe 
and healthy environment. An important factor is regular and proper 
Nudges must be low-cost, 
simple, easy to reject 
(without coercion) and 
nudges need to help people 
make better decisions (safer 
and healthier).
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handwashing. The main purpose of handwashing is to prevent the 
transmission of microorganisms that are applied to the skin of the hands 
in contact with surfaces and other persons, objects and the environment. 
This prevents the contact spread of infectious diseases. Handwashing of 
children and childcare workers in kindergarten is essential: before entering 
the playroom, before preparing meals, before and after meals, after 
outdoor activities, after using the toilet, after nose cleaning, coughing, 
sneezing and after changing diapers. During the handwashing process 
itself, in addition to the time and technique of washing, the encouragement 
(supervision) of children is also crucial [9, 10].
The aim of the research was to determine: a) time, technique and 
frequency of handwashing among childcare workers and children, b) in 
the case of the first ones, we wanted to find out whether they comply 
with hygiene tidiness criteria and wear personal protective work 
equipment and c) based on the findings, we wanted to implement the 
selected nudging tools for better hygiene behaviour and measure its 
improvement. 
METHODS
Type of research methodology, techniques and methods of data 
collection
In the research a qualitative methodology and descriptive method of 
work were used. The method of data collection is open observation of 
childcare workers and children in the practice of handwashing (time, 
technique and frequency), in the case of the first ones, also the hygienic 
tidiness and whether they wear personal protective work equipment.
For observation, we created and used an observation list with criteria 
for proper handwashing (time, technique, frequency) of all observers 
and with criteria for hygienic tidiness and use of personal protective 
work equipment of childcare workers.
Research strategy, sample and data analysis
We used a case study. The units of study are two kindergartens. We 
selected purposeful and non-random samples consisting of two wards 
of children with first age range (2-3 years), two wards of children with 
second age range (4-6 years) and childcare workers from each ward. 
The whole observation took place for eight weeks and simultaneously in 
both kindergartens with the prior given oral consent by the kindergarten 
principals. Then we asked childcare workers to give their written consent. 
When they agreed to participate, we also informed children’s parents 
about the research process in written statement. The kindergarten health 
and hygiene regimen staff then confirmed to us through e-mail the 
participation of all childcare workers and children in the survey.
In the first kindergarten, we firstly observed the ward of the first age 
range for two weeks. After that, we have selected several nudging tools 
to promote hygienic behaviour, set and tested them in a childcare work 
The main purpose of 
handwashing is to prevent 
the transmission of 
microorganisms that are 
applied to the skin of the 
hands in contact with 
surfaces and other persons, 
objects and the environment. 
This prevents the contact 
spread of infectious diseases.
During the handwashing 
process itself, in addition to 
the time and technique of 
washing, the encouragement 
(supervision) of children is 
also crucial.
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environment. The observing time (2 weeks) after the installation of 
nudging tools was the same as the observing time before the installation 
of those tools. The ward of the second age range was then observed in 
the same kindergarten for two weeks, followed by the installation of the 
same tools as in the first age ward, and then observed for another two 
weeks. The same procedure was then repeated in the second kinder-
garten, where the selected groups were observed half the time less than 
those in the first kindergarten. All observation data were marked in the 
observation list. 
The selected nudging tools were: 
• a poster made in A4 size, showing (hygiene requirements) when the 
handwashing is necessary;
• plasticized rectangular pictures, measuring approximately 8 × 6,5 
cm. The first picture showed handwashing with running water and 
soap. Second picture showed a cheerful smile, which was used as a 
hint for a well done job (thumbs up). Both images were placed next 
to the soap dispensers in the selected observed groups/wards;
• the story of a tractor that illustrates proper handwashing technique, 
which was introduced in the morning round (an educational work 
process in which children and childcare workers sit on cushions and 
learn new concepts) [11];
• poster created on A0 format. Handwashing technique, shown step by 
step with pictures of hand movements, mowing and hay harvesting 
with tractor. The poster was hung in the washrooms above the sinks;
• practical learning of handwashing at the sink for each child individually.
In the end, an analysis of all the obtained data was made and a 
comparison with the observation results before and after the introduction 
of the nudging tools. The analysis of the data was prepared in summary 
form so that the individual cannot be recognized and thus the anonymity 
of all participants was guaranteed. The data were analysed using an Excel 
computer program. The Equation 1 was used to calculate consistency of 
proper handwashing of childcare workers.
Equation 1. Basic consistency calculation of handwashing [12]:
For analysing children’s results, we used the scaling method to compare 
the results before and after the use of nudging tools (Equation 2). 
Equation 2. Scaling calculation:
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   N. ROZMAN, B. STRAH, M. JEVŠNIK: AN EVALUATION OF THE EFFECTIVENESS OF NUDGE TECHNIQUES IN IMPROVING HYGIENE BEHAVIOURS IN KINDERGARTENS
In this way, we adjusted the results of the number of all present children 
for all observed parameters so that the groups of children before and 
after the nudging tools were identical. The scaling results were then 
inserted into the consistency equation for performing handwashing by 
children (Equation 3).
Equation 3. Consistency calculation of children’s handwashing using scaling:
RESULTS 
In the practical part of the research, we made a total of 60 observations 
of hygiene behaviour through the elaborated observation list. Of these, 
30 observations were made before the introduction of nudging tools 
and 30 observations after the introduction of nudging tools. Table 1 
and 2 show the observation results of the hygiene tidiness and 
handwashing of children and childcare workers. The results in table 1 
and 2 are shown by the number of observations of proper hygiene 
behaviour and by percentages (%). A 100% share means that the 
observed parameter out of a total of 30 observations or opportunities 
has been correctly (appropriately) performed each time. The most 
common causes (disruptive factors) of inadequate hygiene behaviour 
are also listed. Figure 1 shows two of the selected nudging tools, that 
were used during practical part of the research.
Figure 1. 
Two of selected, set and tested 
nudging tools
Note: 
Two of selected, set and tested nudging 
tools are hint pictures, placed next to the 
soap dispensers and poster of 
handwashing technique, hung above the 
sinks.
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Table 1. Observation results of hygienic tidiness of childcare workers before and after the use of nudging tools and causes 
for their inadequate hygiene behaviour
Observation  
criteria
Before using NT After using NT Causes of inadequate  
hygiene behaviourA (n) A (%) B (n) B (%)
1. Unvarnished and trimmed 
nails
19 63 21 70
Not complying the prescribed health 
and hygiene regimen (subjective cause).
2. Absence of wearing jewellery 20 67 19 63
Not complying the prescribed health 
and hygiene regimen (subjective cause).
3. Appropriate health condition 30 100 30 100 /
Note: NT – nudging tools; A (n) – the number of observations of proper hygiene tidiness before the introduction of NT; A (%) – the 
number of observations of proper hygiene tidiness before the introduction of NT, shown as a percentage (%); B (n) – the number of 
observations of proper hygiene tidiness after the introduction of NT; B (%) – the number of observations of proper hygiene tidiness after 
the introduction of NT, shown as a percentage (%).
Table 2. Observation results of handwashing of childcare workers and children under certain hygiene requirements and 
causes for their inadequate handwashing
Observation  
criteria
Before using NT After using NT
Causes of inadequate  
hygiene behaviour
A (n) A (%) B (n) B (%)
T Tq S T Tq S T Tq S T Tq S
1. Washing children’s 
hands after 
entering the 
playroom
parents 0 0 0 0 0 0 0 0 0 0 0 0 There were no sinks available.
childcare 
workers
2 0 2 7 0 7 0 0 0 0 0 0
Superficiality, rushing, unattended 
children.
2. Handwashing 
before meal 
preparation
childcare 
workers
6 3 19 20 11 68 5 9 19 18 31 68 Rushing, superficiality.
3. Handwashing 
before meal
childcare 
workers
1 2 19 2 7 64 8 9 20 27 30 66 Rushing, superficiality.
children 3 3 11 10 10 37 21 21 27 70 70 90
Rushing (on the command of 
childcare workers) and superficiality.
4. Handwashing after 
meal
childcare 
workers
1 1 7 2 2 23 6 8 14 20 27 47
Rushing, superficiality.
children 4 3 11 13 10 37 21 21 27 70 70 90
5. Handwashing after 
completed activities 
childcare 
workers
3 3 12 10 10 40 11 11 18 37 37 60
Rushing, superficiality and belief 
that they have enough clean hands.
children 6 4 15 20 13 50 23 21 26 77 70 87 Rushing, superficiality.
6. Supervision and 
assistance in 
washing children’s 
hands
childcare 
workers
6 6 11 20 20 37 7 13 16 23 43 53
Lack of encouragement and only 
verbal referral to children for wash 
their hands.
7. Handwashing after 
changing diapers
childcare 
workers
4 2 10 24 13 67 4 6 10 24 40 67 Rushing, superficiality.
children 16 4 16 53 13 53 19 15 20 63 50 67
Rushing (on the command of 
childcare workers) and superficiality.
8. Handwashing after 
cleansing nose 
childcare 
workers
2 0 1 15 0 8 0 0 2 0 0 15 Superficiality.
children 3 1 6 10 3 20 3 1 3 10 3 10
Lack of encouragement, rushing and 
superficiality.
9. Handwashing after 
using the toilet
children 3 3 11 10 10 37 21 21 27 70 70 90
Rushing (on the command of 
childcare workers) and superficiality.
Note: NT – nudging tools, T – time of handwashing, Tq– handwashing technique, S – use of soap; A (n) – the number of observations of 
proper handwashing before the introduction of NT; A (%) – the number of observations of proper handwashing before the introduction of 
NT, shown as a percentage (%); B (n) – the number of observations of proper handwashing after the introduction of NT; B (%) – the 
number of observations of proper handwashing after the introduction of NT, shown as a percentage (%).
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   N. ROZMAN, B. STRAH, M. JEVŠNIK: AN EVALUATION OF THE EFFECTIVENESS OF NUDGE TECHNIQUES IN IMPROVING HYGIENE BEHAVIOURS IN KINDERGARTENS
Table 3 shows whether childcare workers used personal protective 
work equipment appropriately. The results in table 3 are shown by the 
number of observations of proper hygiene behaviour and by percentages 
(%). A 100% share means that the observed parameter out of a total of 
30 observations or opportunities has been correctly (appropriately) 
performed each time. The most common causes (disruptive factors) of 
inadequate hygiene behaviour are also listed.
DISCUSSION
Hygienic tidiness and handwashing of childcare workers before 
the use of nudging tools and causes for their inadequate 
hygiene behaviour
Hygienic tidiness of childcare workers is important for the protection of 
children’s health and to avoid potential health hazards (e.g. long nails and 
jewellery can injure children and at the same time allow the retention of 
microorganisms and their spread to children and objects) [12]. Prior to 
any use of nudging tools, childcare workers performed best in their health 
condition that was adequate throughout the observation (did not pose a 
health risk). Obervers performed worse in the first two observation 
criterias (Unvarnished and trimmed nails; Absence of wearing jewellery). 
The causes of inadequate hygiene behaviour of these two criterias are 
difficult to determine and are mostly of subjective origin (superficiality, 
rushing and thinking that long and varnished nails and wearing jewellery 
do not pose a health risk). The fact is that in this regard, childcare 
workers do not follow the kindergarten’s health hygiene regime, which 
stipulates that nails must be trimmed and unvarnished and jewellery 
must be removed before starting childcare work [9].
Obtained results also shows that childcare workers do not perform 
handwashing for a sufficient amount of time, with proper technique, and 
not often enough with every hygiene requirement. The lowest results 
Table 3. Observation results of the use of personal protective work equipment of childcare workers before and after the use 
of nudging tools and causes of their inadequate hygiene behaviour.
Observation  
criteria
Before using 
NT
After using 
NT Causes of inadequate  
hygiene behaviour
A (n) A (%) B (n) B (%)
1. Wearing work clothes and shoes
25 83 25 83 
Same footwear for indoor and outdoor 
playroom areas → superficiality.
2. Wearing hygienic apron to distribute 
food
9 30 10 33
Childcare workers at one kindergarten did not 
have an apron available (not provided).
3. For the first age range only: Use of 
protective gloves (diaper changing of 
children in the event of illness and potty 
cleaning)
10 67 15 100 Rushing, superficiality.
Note: NT – nudging tools; A (n) – the number of observations of proper hygiene behaviour before the introduction of NT; A (%) – the 
number of observations of proper hygiene behaviour before the introduction of NT, shown as a percentage (%); B (n) – the number of 
observations of proper hygiene behaviour after the introduction of NT; B (%) – the number of observations of proper hygiene behaviour 
after the introduction of NT, shown as a percentage (%).
Childcare workers do not 
follow the kindergarten’s 
health hygiene regime, which 
stipulates that nails must be 
trimmed and unvarnished and 
jewellery must be removed 
before starting childcare work.
Obtained results also shows 
that childcare workers do not 
perform handwashing for a 
sufficient amount of time, with 
proper technique, and not 
often enough with every 
hygiene requirement.
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were technique and time of handwashing (less than 20 seconds). The 
most common causes for inadequate behaviour are rush, superficiality 
and the assumption that the hands are already clean enough. They also 
performed poorly in supervision and assistance in washing children’s 
hands. In most cases, encouragement was present only as a verbal 
referral to children for washing their hands, but not in detail in terms of 
their control over appropriate timing and washing techniques and the use 
of soap. As there is no other research available on observing handwashing 
of childcare workers, we can compare our findings with those in the field 
of health. Lack of hand hygiene (handwashing and hand disinfection) has 
been identified in a number of studies in healthcare professionals [4, 13, 
14]. They, like the observers in our study, performed handwashing/hand 
disinfection with lacking frequency (they did not comply with hygiene 
requirements). Due to their rush and superficiality, they also performed in 
some cases inappropriate time and technical execution of handwashing /
disinfection. Studies around the world, therefore, suggests that hand-
washing is insufficiently controlled in hygienically sensitive institutions 
(even in developed countries). At the same time, too few measures have 
been put in place to properly and regularly implement it.
Use of personal protective work equipment of childcare 
workers before the use of nudging tools and causes of their 
inadequate hygiene behaviour
We also wanted to find out if childcare workers use personal protective 
work equipment in the work process. They performed best when 
wearing work clothes and shoes. However, the most common causes of 
poor hygiene behaviour were wearing the same footwear in the indoor 
and outdoor playroom areas (e.g. when children were playing on the 
patio, childcare workers wore the same footwear as in the indoor 
playroom). With that, they enable the pollution of the indoor playroom 
and also possible transfer of microorganisms from the outside to the 
inside of the playroom. The use of protective gloves was observed only 
in first age range (ward), as there were no longer daily diapers changing 
in the older age ranges (wards) (except in the case of illnesses, which 
were not discovered in the time of observation). In comparison with the 
childcare assistants, the childcare teachers performed better. The 
reason for the incorrect use of protective gloves was because of the 
rushing to the following tasks. Observers performed worst when 
wearing an apron to distribute food. When distributing food, we come in 
contact with it and wearing an apron is absolutely essential. Also, in 
one of the two selected kindergartens observers used an apron for 
distributing food while in the other it was not possible (the kindergarten 
did not provide it). Poor and/or lack of knowledge of the importance of 
personal hygiene and the use of personal protective work equipment of 
workers in the food industry has identified many similar studies 
worldwide. They all came to the conclusion that in order to protect the 
health of consumers and employees and to prevent cross-contamination, 
the knowledge of workers who comes in food contact, needs to be 
constantly upgraded, repeated and verified [15, 16, 17]. Knowledge 
The most common causes for 
inadequate behaviour are 
rush, superficiality and the 
assumption that the hands are 
already clean enough.
The most common causes of 
poor hygiene behaviour were 
wearing the same footwear in 
the indoor and outdoor 
playroom areas.
With that, they enable the 
pollution of the indoor 
playroom and also possible 
transfer of microorganisms 
from the outside to the inside 
of the playroom.
The reason for the incorrect 
use of protective gloves was 
because of the rushing to the 
following tasks.
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and awareness of the importance of good hygiene practice in food 
management is essential to reduce food-related outbreaks/poisonings 
[18].
Handwashing of children under certain hygiene requirements 
before the use of nudging tools and causes for their inadequate 
hygiene behaviour
Regarding children’s handwashing, all children together and also as 
individual age classes (wards), performed best when using soap during 
handwashing, while time and technique of handwashing were poorer. 
Nevertheless, the share of soap use was still low or below 50%. One of 
the most common causes for inadequate washing of children ‘s hands is 
the rush on command of childcare workers. During the observation, we 
found out that children do not know that after sneezing, coughing and/
or cleansing their nose, they should always wash their hands. Dreibelbis 
et al. [6] found out that children with the absence of the nudging tools 
do not perform proper hygiene behaviour (especially handwashing). 
They were aware that children with new hygiene habits would be able 
to live healthier also in adult life. From the obtained results, we can also 
conclude that a higher age of children (greater ability to think) does not 
yet mean a better handwashing practice. Results indicate that children 
of the first age ward performed better handwashing practice. A similar 
finding was made by Au et al. [2], who concluded that for children (4-6 
age), improved theoretical knowledge of proper handwashing does not 
necessarily mean improved practical handwashing knowledge.
Given the obtained results before any use of nudging tools, we found out 
that both theoretical and practical knowledge of handwashing at selected 
kindergartens were low. Therefore, we have chosen simple and affordable 
tools to promote hygienic behaviour. We sat in a morning circle (round) in 
the playroom with children and childcare workers. Then we began with a 
detailed explanation and meaning of the poster, pictorially showing when 
to wash hands (after coughing, after using the toilet, after playing, before 
cooking, etc.) and placed it in a visibly place in the playroom and at the 
height of children. For the proper handwashing, we introduced the story 
of mowing and hay harvesting with tractor to all observers. Through it, 
we learned together the time (at least 20 seconds) and technical 
implementation of handwashing, including the use of soap. In order to 
better remember the story, we transferred it pictorially to a poster (A0) 
and hung it in the washrooms above the sinks. 
Next to the soap dispensers, we installed a picture of handwashing with 
running water and soap, and a picture of a cheerful smile that indicated a 
well done job (thumbs up). In order to provide the best possible 
visualization and regular handwashing, to each child individually the 
procedure of proper handwashing at the sink (use of running warm water, 
soap and towels) was shown. All of the nudging tools were installed in a 
visibly place at all times, allowing children and childcare workers to 
constantly repeat and learn how to properly wash their hands. After that, 
we began to re-watch all the observers. In addition, during the observation 
A higher age of children 
(greater ability to think) does 
not yet mean a better 
handwashing practice.
All of the nudging tools were 
installed in a visibly place at 
all times, allowing children 
and childcare workers to 
constantly repeat and learn 
how to properly wash their 
hands.
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period in each morning circle, we reiterated the importance of the made 
posters and stories.
Hygienic tidiness and the use of personal protective work 
equipment of childcare workers after the use of nudging tools
After the use of nudging tools, the hygienic tidiness of childcare workers 
in varnished and trimmed nails improved by 6%, while wearing jewellery 
increased by 3%. The health condition remained the same (100%) as 
before the introduction of the nudging tools. Because we did not use 
direct nudging tools to remind observers of their hygienic tidiness, the 
obtained results are not surprising. Nevertheless, after the use of 
nudging tools, the situation could be better, since in the morning round 
with children and childcare workers we told them what the proper 
hygienic tidiness means. Very similar goes for wearing work clothes and 
footwear, and an apron (criteria for personal protective work equipment). 
The opposite result was observed in the use of protective gloves, with 
36% use improved. The reason for this is probably our mention of the 
importance of protecting the health of employees and children, which is 
also reflected in the use of protective gloves when changing diapers.
Handwashing of childcare workers and children under certain 
hygiene requirements after the use of nudging tools
The highest improvement was observed in handwashing of all observers, 
where direct nudging tools were used. Namely, all observers experienced 
nudging tools positive. Handwashing of childcare workers improved about 
20-30%, where they performed best in the technical and timely 
implementation of handwashing. Even more improvement was seen in 
children who washed their hands about 50-60% more appropriately. 
Nudging tools that were used in the research, have advantage in its 
simplicity and affordability. The same conclusion reached also other 
studies, which used nudging tools for improving children's handwashing 
in kindergarten and school [2, 6, 19].
To improve handwashing, we advise childcare workers to practice the 
appropriate time (at least 20 seconds) and technique (to cover all areas of 
the hands) of handwashing and to use a sufficient amount of soap (1 
push or 1 ml of liquid soap per person for a single wash) [20]. In doing 
so, it is crucial to avoid rushing and superficiality and to not encourage 
children to do so. In addition, it is important to finish a certain educational 
process (e.g. playing in a playroom, outdoor activities, etc.) a few minutes 
earlier to instruct children to wash their hands in a timely manner. They 
will therefore have sufficient time to perform handwashing. Also, children 
should be regularly encouraged, taught and assisted in the process of 
handwashing (through various stories, songs, games, folders and posters). 
All of these are affordable and easy to use nudging tools for which there 
should be no excuse for not using them. Despite important findings, the 
survey has some limitations related to the relatively small sample of 
observers in relation to the total number of kindergartens in Slovenia, the 
questionable longevity of nudging tools and the potential bias of the 
After the use of nudging 
tools, the hygienic tidiness of 
childcare workers in 
varnished and trimmed nails 
improved by 6%, while 
wearing jewellery increased 
by 3%.
Handwashing of childcare 
workers improved about 
20-30%, where they 
performed best in the 
technical and timely 
implementation of 
handwashing.
It is important to finish a 
certain educational process 
(e.g. playing in a playroom, 
outdoor activities, etc.) a few 
minutes earlier to instruct 
children to wash their hands 
in a timely manner.
Sanitarno inženirstvo / International Journal of Sanitary Engineering Research   Vol. 14  1/202014
   N. ROZMAN, B. STRAH, M. JEVŠNIK: AN EVALUATION OF THE EFFECTIVENESS OF NUDGE TECHNIQUES IN IMPROVING HYGIENE BEHAVIOURS IN KINDERGARTENS
observer, which may have a slight impact on the reliability of the survey. 
To minimize this, we have created an observation list and validated it 
through the observation test of participants before the observation itself. 
In doing so, we achieved repeatability of the research. Regardless of the 
limitations, we have demonstrated that simple and affordable nudging 
tools can improve handwashing of childcare workers and children in the 
kindergartens.
CONCLUSION
Based on the conducted research, we found out that the use of nudging 
tools in kindergartens can significantly contribute to a better 
implementation of hygienic behaviour of childcare workers and children. 
However, we emphasize that installing the nudging tools in wards alone is 
not sufficient or likely to work in the short term. Nudging tools should 
therefore be changed and designed for a limited period of time (e.g. once 
a month) so that they are always attractive, enjoyable and positive for 
children. In addition, the importance of hygiene behaviour (handwashing) 
must be constantly emphasized, encouraged, repeated and taught. Our 
research is the first of its kind to provide insight into the hygienic 
behaviour of childcare workers and children in two selected kindergartens 
in Slovenia, and the first study in which we used nudging tools to improve 
hygienic behaviour in Slovenian kindergartens. 
In order to get a better overview of the actual state of hygiene behaviour, 
more kindergartens should be included in the research and the theoretical 
and practical knowledge of hygiene behaviour of childcare workers should 
be improved. We believe that more emphasis should be placed on pre-
school education in topics that include general hygiene, with an emphasis 
on personal hygiene and the prevention of the spread of infectious 
diseases. In order to ensure proper hygienic behaviour of childcare 
workers and children in the wards, each kindergarten could introduce 
greater control over hygiene requirements. 
Such supervision could be carried out by health and hygiene regimen 
professional staff (e.g. once a month using an observation list). A weak 
point in our study is the comparison of handwashing among children of 
the first and second age groups (wards). Further research would have to 
elaborate more precisely on working methods, identifying and determining 
the same number of children to observe.
Nudging tools used in the research can also be used in home environment 
and in other educational institutions (primary and secondary schools, 
faculties, educational institutions, etc.) for their simplicity and affordability. 
There are no sufficient excuses for their non-use or absence, since the 
nudging tools used in the research can only have a positive response to 
the targeted behaviour. It is also important to emphasize, that our study 
was undertaken before the pandemic COVID-19 was declared. Current 
situation shows even higher importance in complying efficient hygiene 
behaviour (especially handwashing) in kindergartens to control the spread 
of COVID-19.
The use of nudging tools in 
kindergartens can significantly 
contribute to a better 
implementation of hygienic 
behaviour of childcare workers 
and children.
The importance of hygiene 
behaviour (handwashing) 
must be constantly 
emphasized, encouraged, 
repeated and taught.
We believe that more 
emphasis should be placed on 
pre-school education in topics 
that include general hygiene, 
with an emphasis on personal 
hygiene and the prevention of 
the spread of infectious 
diseases.
Nudging tools used in the 
research can also be used in 
home environment and in 
other educational institutions 
(primary and secondary 
schools, faculties, educational 
institutions, etc.) for their 
simplicity and affordability.
Sanitarno inženirstvo / International Journal of Sanitary Engineering Research   Vol. 14  1/2020 15
N. ROZMAN, B. STRAH, M. JEVŠNIK: AN EVALUATION OF THE EFFECTIVENESS OF NUDGE TECHNIQUES IN IMPROVING HYGIENE BEHAVIOURS IN KINDERGARTENS   
We conclude that with nudging tools for hygienic behaviour, we can 
reduce the incidence of infectious diseases in kindergartens, while at 
the same time directing children towards the healthier and hygienically 
appropriate way of life by means of the appropriate hygiene behaviour. 
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