Behavioural Determinants of Hand, Foot and Mouth Disease Incidence Among Preschool Children in Urban Southeast Asia: A Systematic Literature Review

Hand, Foot and Mouth Disease (HFMD) is a communicable viral disease that commonly affects young children and can spread rapidly in childcare centres, nurseries, kindergartens, and other community settings. Preschool children may be particularly exposed to infection because of frequent close contact with peers, shared toys and equipment, and the development of personal hygiene habits. Understanding the factors associated with HFMD incidence is important for identifying opportunities to improve infection prevention and control in preschool environments. This systematic literature review aims to identify and synthesise the determinants associated with HFMD incidence among preschool children in urban areas of Southeast Asia. The review will examine behavioural factors, including handwashing practices, personal hygiene, hand-to-mouth behaviour, toy-sharing, cleaning and disinfection practices, contact behaviour, and compliance with infection prevention and control measures. In addition, it will consider relevant environmental and facility-level factors, such as the availability of hygiene facilities, infrastructure constraints, cleaning resources, and exposure to shared community environments, where these are investigated in relation to HFMD transmission. The review will include eligible studies conducted in urban settings across Southeast Asian countries, including Malaysia, Singapore, Thailand, Indonesia, Vietnam, the Philippines, Brunei, Cambodia, Laos, Myanmar, and Timor-Leste. Studies involving preschool-aged children, preferably defined as children aged 3–6 years, will be considered. Studies involving wider age groups may also be included when findings specific to preschool children can be extracted. The review will focus on studies reporting HFMD incidence, occurrence, new cases, transmission, or outbreak frequency, using clinical diagnosis, laboratory confirmation, or clearly defined surveillance records. Peer-reviewed studies published in English within the specified publication period will be considered, with studies published before 2015 excluded according to the proposed eligibility criteria. The review will systematically identify, assess, and synthesise relevant evidence to determine which behavioural and other investigated factors are associated with HFMD incidence among preschool children in urban Southeast Asia. It will also examine how preschool facility conditions and environmental exposures may contribute to transmission patterns and outbreak occurrence. Where sufficient evidence is available, the findings will be compared across studies and settings to identify consistent associations, differences in reported determinants, and gaps in the existing literature. The expected outcomes are a comprehensive overview of the determinants associated with HFMD incidence in the target population, identification of potentially modifiable behavioural and environmental risk factors, and recognition of gaps requiring further epidemiological research. The findings may inform the development of targeted hygiene education, improved cleaning and disinfection practices, strengthening of preschool infection prevention and control measures, and more effective public health strategies. Ultimately, this review aims to provide evidence that can support efforts to reduce HFMD transmission and improve disease prevention among preschool children in urban Southeast Asian communities.