The prevalence of frequent headache among adolescents increases with decreasing SES. This socio-economic inequality has been persistent among adolescents in Denmark from 1991 to 2014. Clinicians should be aware of this social inequality.

BackgroundInfectious illnesses such as influenza and diarrhea are leading causes of absenteeism among Danish school children. Interventions in school settings addressing hand hygiene have shown to reduce the number of infectious illnesses. However, most of these studies include small populations and almost none of them are conducted as randomized controlled trials. The overall aim of the Hi Five study was to develop, implement and evaluate a multi-component school-based intervention to improve hand hygiene and well-being and to reduce the prevalence of infections among school children in intervention schools by 20% compared to control schools. This paper describes the development and the evaluation design of Hi Five.Methods/designThe Hi Five study was designed as a tree-armed cluster-randomized controlled trial. A national random sample of schools (n = 44) was randomized to one of two intervention groups (n = 29) or to a control group with no intervention (n = 15). A total of 8,438 six to fifteen-year-old school children were enrolled in the study. The Hi Five intervention consisted of three components: 1) a curriculum component 2) mandatory daily hand washing before lunch 3) extra cleaning of school toilets during the school day. Baseline data was collected from December 2011 to April 2012. The intervention period was August 2012 to June 2013. The follow-up data was collected from December 2012 to April 2013.DiscussionThe Hi Five study fills a gap in international research. This large randomized multi-component school-based hand hygiene intervention is the first to include education on healthy and appropriate toilet behavior as part of the curriculum. No previous studies have involved supplementary cleaning at the school toilets as an intervention component. The study will have the added value of providing new knowledge about usability of short message service (SMS, text message) for collecting data on infectious illness and absenteeism in large study populations.Trial registrationCurrent Controlled Trials ISRCTN19287682, 21 December 2012.

The Hi Five study was a three-armed cluster randomized controlled trial designed to reduce infections and improve hygiene and well-being among pupils. Participating schools (n = 43) were randomized into either control (n = 15) or one of two intervention groups (n = 28). The intervention consisted of three components: (i) a curriculum (ii) mandatory daily hand washing before lunch (iii) extra cleaning of school toilets. The aim of this study was to evaluate the implementation and to identify challenges to program implementation. Several data sources were used, including observations of school toilets, semi-structured interviews with school coordinators (n = 4), focus groups with pupils (n = 6) and teachers (n = 5), and questionnaires among pupils (n = 5440), teachers (n = 387) and school coordinators (n = 28). This study indicates that the curriculum was successfully implemented at most schools, and that teachers and pupils reacted positively to this part of the intervention. However, daily hand washing before lunch seems to be difficult to implement. Overall, the implementation process was affected by several factors such as poor sanitary facilities, lack of time and prioritization and objections against the increasing tendency to place the responsibility for child-rearing tasks on schools. This study reveals the strong and weak parts of the Hi Five study and can guide program improvement.

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