It's in our hands: a rapid, international initiative to translate a hand hygiene song during the COVID-19 pandemic.

Sir,

The novel coronavirus disease 2019 (COVID-19) continues to affect the global community deeply and rapidly, with more than 200 countries impacted at the time of writing (May 2nd, 2020). In order to manage the extent of this pandemic, there is a need to develop, disseminate, and implement infection prevention and control strategies in healthcare settings and in the community. Early on in the outbreak, there were general recommendations to frequently wash hands to reduce the spread of infection. With the current, relentless global scale of COVID-19, international compliance with handwashing frequency and technique is more important than ever.

A prominent strategy to improve hand hygiene, developed by the World Health Organization (WHO), includes an effective six-step handwashing technique which has had broad uptake through the use of a multi-modal approach; however, encouraging consistent compliance can be challenging [1]. In addition to needing to remember all six steps of the technique and needing to wash hands for the required duration of time, there may be a lack of awareness regarding the importance of handwashing technique on reducing the microbial burden on hands. This lack of awareness may not be surprising, as most hand hygiene promotion campaigns focus on indications for action (‘when to clean hands’) rather than on technique (‘how to clean hands’) [2]. Thus, continuing to promote correct handwashing technique is currently of utmost importance to the world population, especially given the disproportionate burden of COVID-19 on older adults, and emerging evidence of asymptomatic shedding [3,4].

In order to assist children with remembering the effective six-step technique, we recently published a musical mnemonic to the tune of the well-known nursery rhyme Frère Jacques, or Brother John [2,5]. This memory aid reinforces inclusion of all six handwashing steps using self-instruction, via engaging with the familiar melody and singing (or imagining singing) the lyrics (Figure 1 A). In the context of the evolving COVID-19 pandemic, the near-ubiquitous melody of Brother John provided an opportunity for international, interdisciplinary collaboration to translate and rapidly disseminate the musical mnemonic globally. On March 19th, drawing on our combined network of music neuroscience researchers, music education specialists, and healthcare professionals, we invited approximately 40 international colleagues to create a new version of the handwashing song that (a) included all six WHO handwashing steps; (b) worked musically in the new language; and (c) had been checked by a healthcare professional for accuracy. Each translator was also invited to submit an audio or video file of the translated song. We received an overwhelmingly positive and creative response. Within one week, 26 songs meeting the criteria were gathered. Alongside the original English and French versions, this led to 28 versions for immediate dissemination (Figure 1B). The songs cover languages from all five continents and range from very close (e.g. Punjabi) to creative (e.g. Czech) translations. All translators gave informed consent for their versions to be disseminated, as a starting point and inspiration for further development into other languages.

Figure 1

World Health Organization (WHO) six-step handwashing technique (an adaption of an original work, ‘How to handwash’; 2009; https://www.who.int/gpsc/5may/How_To_HandWash_Poster.pdf) and handwashing song lyrics, set to the tune of Brother John. (A) Visual handwashing aid, lyrics, and musical notes for each step. (B) The handwashing song in twenty-eight languages. d, r, m, f, s, l = do, re, mi, fa, so, la (sI = so below d). ∗Handwashing steps are sung in a different order from the original English version.

Brother John is an ideal tune to use in this context: it is widely known across cultures; the melody involves very simple, repeating patterns; the vocal range centres around a small interval of a sixth (e.g. middle C to A), which is easy to sing for children; and the duration, when sung at a steady tempo, is between 20 and 25 s. Singing is a highly sequential, structured activity and has been used throughout history to remember text or coordinate movement, from ballads and religious scriptures to work songs and children's action songs. Experimentally, music has been shown to facilitate verbal and motor learning in a variety of contexts, likely using neural resources shared between music, language and motor networks [[6], [7], [8]]. In practice, we have observed that, once the handwashing song becomes highly familiar through repetition and rehearsal, a missed step is immediately noticed, leading to important self-correcting behaviour.

A clear advantage of this six-step handwashing song is that it highlights the importance of correct technique, in addition to the recommended 20 s duration (such as singing Happy birthday twice – another popular approach). A demonstration, prior to introducing the song, will ensure full understanding of each step. In launching these translated songs during a pandemic that underlines our global interconnectedness, and to highlight 2020 World Hand Hygiene Day on May 5th, we have made these songs available at www.CleanHandsSaveLives.org/hand-washing-song/, hoping that this mnemonic will inspire individuals to take matters into their own hands and reduce their risk of acquiring or spreading COVID-19. Music is known to have the capacity to entertain, bring joy, and be a powerful, positive shared experience; the 28 languages included here allow access to this musical mnemonic to more than half of the world's population in their native language.

Acknowledgements

We thank the following individuals for their extraordinary efforts in quickly creating these handwashing songs: F. Alnaji (Arabic); D. Roučová and F. Rouča (Czech); P. Vuust and B. Peterson (Danish); R. Schaefer (Dutch); M. Paas (Estonian); M. Pazoki and A. Sannaee (Farsi); P. Villeneuve and M. Paquette (French); E. MacLeod (Gaelic); S. Koelsch (German); F. Gyftopoulou (Greek); B. Prasaad (Hindi); B. Furka and L.N. Nemes (Hungarian); E. Ferretti and M. Majno (Italian); A. Hirano (Japanese); S. Hong (Korean); M. Mickevičius (Lithuanian); N. Merican (Malay); P. Nie (Mandarin); W. Jajdelska and K. Bogdanowicz (Polish); T. Sampaio (Portuguese); N. Hussain (Punjabi); T. Jarret (Russian); A.S. García and C. Soni (Spanish); L. Kailaheimo-Lönnqvist (Swedish); P. Lin, A. Chen, and P. Kí (Taiwanese); S. Evans (Welsh); and O. Oludare (Yoruba). Additional thanks go to T. Howey for the artwork and to G. Avanzini for sparking this initiative.

Conflict of interest statement

None declared.

Funding sources

None.