Demographic Characteristics, Experiences, and Beliefs Associated With Hand Hygiene Among Adults During the COVID-19 Pandemic

United States, June 24-30, 2020

Mark É. Czeisler; Amanda G. Garcia-Williams, PhD; Noelle-Angelique Molinari, PhD; Radhika Gharpure, DVM; Yiman Li, MPH; Catherine E. Barrett, PhD; Rebecca Robbins, PhD; Elise R. Facer-Childs, PhD; Laura K. Barger, PhD; Charles A. Czeisler, PhD, MD; Shantha M.W. Rajaratnam, PhD; Mark E. Howard, MBBS, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(41):1485-1491. 

In This Article

Abstract and Introduction

Introduction

Frequent hand hygiene, including handwashing with soap and water or using a hand sanitizer containing ≥60% alcohol when soap and water are not readily available, is one of several critical prevention measures recommended to reduce the spread of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19).* Previous studies identified demographic factors associated with handwashing among U.S. adults during the COVID-19 pandemic;[1,2] however, demographic factors associated with hand sanitizing and experiences and beliefs associated with hand hygiene have not been well characterized. To evaluate these factors, an Internet-based survey was conducted among U.S. adults aged ≥18 years during June 24–30, 2020. Overall, 85.2% of respondents reported always or often engaging in hand hygiene following contact with high-touch public surfaces such as shopping carts, gas pumps, and automatic teller machines (ATMs). Respondents who were male (versus female) and of younger age reported lower handwashing and hand sanitizing rates, as did respondents who reported lower concern about their own infection with SARS-CoV-2§ and respondents without personal experience with COVID-19. Focused health promotion efforts to increase hand hygiene adherence should include increasing visibility and accessibility of handwashing and hand sanitizing materials in public settings, along with targeted communication to males and younger adults with focused messages that address COVID-19 risk perception.

During June 24–30, among 9,896 eligible U.S. adults, 5,412 (54.7%) completed Internet-based surveys administered by Qualtrics, LLC, as part of The COVID-19 Outbreak Public Evaluation (COPE) Initiative.** The Monash University Human Research Ethics Committee of Monash University (Melbourne, Australia) reviewed and approved the study protocol on human subjects research. This activity was also reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.†† Respondents were informed of study purposes and provided electronic consent before commencement, and investigators received anonymized responses. The 5,412 participants who completed surveys during June included 3,683 (68.1%) first-time respondents and 1,729 (31.9%) respondents who were recontacted after having been recruited to participate in The COPE Initiative during April 2–8, 2020.§§ Complete data for explanatory variables included in the analysis were obtained from 5,000 (92.4%) respondents. Among these respondents, 4,817 (96.3%) reported having been in public during the previous week and were included in this analysis (3,243 [67.3%] first-time respondents and 1,574 [32.7%] recontacted respondents). Quota sampling and survey weighting were employed to improve sample representativeness of the adult U.S. population by gender, age, and race/ethnicity. Hand hygiene frequency was assessed on a five-item Likert scale from "Never" to "Always" using the following questions: "In the last week, how frequently did you use hand sanitizer after touching high-touch surfaces in public?" and "In the last week, how frequently did you wash your hands with soap and water after touching high-touch surfaces in public?" Bivariate chi-squared analyses identified covariates associated with frequency of hand hygiene.

With handwashing and hand sanitizing frequency as dependent variables for separate models, adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for hand hygiene frequency were estimated using weighted ordered logistic regressions with the following explanatory variables: gender, age, race/ethnicity, 2019 household income, U.S. Census region,¶¶ rural/urban residence,*** whether respondents knew someone who had positive test results for SARS-CoV-2 or who was hospitalized for or died from COVID-19, and concern for personal risk for infection with SARS-CoV-2 (from "Not at all" to "Extremely"). Statistical analyses were conducted in R (version 4.0.2; The R Foundation) with the R survey package (version 3.29).

Among 4,817 U.S. adults, 85.2% reported frequent (always or often) use of at least one form of hand hygiene after contact with high-touch public surfaces, including handwashing (78.5%) and hand sanitizing (70.7%) (Table). Frequent handwashing and hand sanitizing were least prevalent among adults aged 18–24 years (64.6% and 59.8%, respectively, with 72.4% reporting at least one form of hand hygiene); frequency increased with age and was highest among persons aged ≥65 years (83.3% and 73.3%, respectively, with 89.4% reporting at least one form of hand hygiene). Frequent hand sanitizing was more prevalent among respondents with a 2019 household income ≥$100,000 (72.6%) compared with those with a household income <$25,000 (62.5%). Regarding concern for personal risk for SARS-CoV-2 infection, frequent handwashing and hand sanitizing were least prevalent among those not at all concerned (68.0% and 54.0%, respectively, with 72.1% reporting at least one form of hand hygiene); prevalence increased with level of concern and was most prevalent among those extremely concerned (89.5% and 83.1%, respectively, with 93.7% reporting at least one form of hand hygiene).

The aORs and 95% CIs reflect significant differences in odds of more frequent handwashing associated with gender, age, race/ethnicity, whether the respondent knew someone who had received a positive SARS-CoV-2 test result, and concern for personal risk for SARS-CoV-2 infection (Figure 1). Odds of more frequent handwashing were lower for males than for females (aOR = 0.65; 95% CI = 0.57–0.74) and higher among older than among younger respondents (e.g., aOR = 2.36; 95% CI = 1.85–3.01 for persons aged 45–64 years compared with those aged 18–24 years). Odds of more frequent handwashing were 66% higher among non-Hispanic Asian respondents than among non-Hispanic White (White) respondents (aOR = 1.66; 95% CI = 1.34–2.06) and were 30% higher among those who knew someone who received a positive SARS-CoV-2 test result than among those who did not (aOR = 1.30; 95% CI = 1.10–1.53). Compared with those who were not at all concerned about SARS-CoV-2 infection, those who were moderately, very, and extremely concerned had 35% (aOR = 1.35; 95% CI = 1.07–1.72), 77% (aOR = 1.77; 95% CI = 1.36–2.31), and 209% higher odds (aOR = 3.09; 95% CI = 2.38–4.01), respectively, of more frequent handwashing.

Figure 1.

Adjusted odds ratios*,† for washing hands after contact with high-touch public surfaces,§ by select respondent characteristics¶,**,††,§§ — United States, June 24–30, 2020
Abbreviations: COVID-19 = coronavirus disease 2019; ref = referent; USD = U.S. dollars.
*Adjusted odds ratios were estimated using an ordered logit model of handwashing on the variables listed in the column with a proportional odds assumption.
95% confidence intervals indicated with error bars.
§Frequency of handwashing was assessed on a 5-point Likert scale from "Never" to "Always" using the following question: "In the last week, how frequently did you wash your hands with soap and water after touching high-touch surfaces in public."
The non-Hispanic, other race, or multiple races category includes respondents who identified as not Hispanic and as more than one race or as American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or Other.
**Region classification was determined using the U.S. Census Bureau's Census Regions and Divisions of the United States. https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf.
††Rural/urban residence was classified as urban or rural based on self-reported ZIP codes according to the Federal Office of Rural Health Policy definition of rurality. https://www.hrsa.gov/rural-health/about-us/definition/datafiles.html.
§§For this question, respondents were asked to rate on a scale from "Not at all" to "Extremely" the extent to which they were concerned about the following statement regarding COVID-19 and infection control measures: "My own risk of infection with COVID-19."

Adjusted odds of more frequent hand sanitizing were similar to those observed for more frequent handwashing (Figure 2), with the following exceptions: those with higher 2019 household income ($25,000–$49,999) had 30% higher odds of more frequent hand sanitizing (aOR = 1.30, 95% CI = 1.04–1.64) than did those with household income <$25,000, and those who knew someone hospitalized for or who died from COVID-19 had 28% higher odds of more frequent hand sanitizing (aOR = 1.28; 95% CI = 1.04–1.59) than did those who did not know someone who had been hospitalized or died from COVID-19.

Figure 2.

Adjusted odds ratios*,† for use of hand sanitizer after contact with high-touch public surfaces by select respondent characteristics¶,**,††,§§ — United States, June 24–30, 2020
Abbreviations: COVID-19 = coronavirus disease 2019; ref = referent; USD = U.S. dollars.
*Adjusted odds ratios were estimated using an ordered logit model of using hand sanitizer on the variables listed in the column with a proportional odds assumption.
95% confidence intervals indicated with error bars.
§Frequency of hand sanitizing was assessed on a 5-point Likert scale from "Never" to "Always" using the following question: "In the last week, how frequently did you use hand sanitizer after touching high-touch surfaces in public after touching high-touch surfaces in public."
The non-Hispanic, other race, or multiple races category includes respondents who identified as not Hispanic and as more than one race or as American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or Other.
**Region classification was determined using the U.S. Census Bureau's Census Regions and Divisions of the United States. https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf.
††Rural/urban residence was classified as urban or rural based on self-reported ZIP codes according to the Federal Office of Rural Health Policy definition of rurality. https://www.hrsa.gov/rural-health/about-us/definition/datafiles.html.
§§For this question, respondents were asked to rate on a scale from "Not at all" to "Extremely" the extent to which they were concerned about the following statement regarding COVID-19 and infection control measures: "My own risk of infection with COVID-19."

*https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html.
Respondents were provided with the following examples as high-touch public surfaces: shopping carts, gas pumps, and ATMs.
§For this question, respondents were asked to rate on a scale from "Not at all" to "Extremely" the extent to which they were concerned about the following statement regarding COVID-19 and infection control measures: "My own risk of infection with COVID-19."
Eligibility to complete a survey during June 24–30, 2020, was determined following electronic contact of potential participants with criteria of age ≥18 years and residence within the United States. Age and residence were assessed using screening questions without indication of eligibility criteria before commencement of the earliest survey (recontacted respondents: April 2–8, 2020; first-time respondents: June 24–30, 2020). Residence was reassessed among recontacted respondents during June 24–30, and one respondent whose primary residence had changed to outside of the United States was excluded from the analysis. Country-specific geolocation verification via IP address mapping was used to ensure respondents were from the United States. Informed consent was obtained electronically during June 24–30, 2020, before enrollment into the study as a participant. All surveys underwent Qualtrics, LLC data quality screening procedures including algorithmic and keystroke analysis for attention patterns, click-through behavior, duplicate responses, machine responses, and inattentiveness. Respondents who failed an attention or speed check, along with any responses identified that failed data quality screening procedures, were excluded from the analysis (6.6%).
**The COVID-19 Outbreak Public Evaluation (COPE) Initiative (https://www.thecopeinitiative.org/) is designed to assess public attitudes, behaviors, and beliefs related to COVID-19 pandemic and to evaluate the mental and physical health consequences of the pandemic. The COPE Initiative surveys included in this analysis were administered by Qualtrics, LLC (https://www.qualtrics.), a commercial survey company with a network of participant pools comprising hundreds of suppliers and with varying recruitment methodologies that include digital advertisements and promotions, word-of-mouth and membership referrals, social networks, television and radio advertisements, and offline mail-based approaches. This analysis focused on questions about hand hygiene behavior during the COVID-19 pandemic.
††45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
§§ https://www.medrxiv.org/content/10.1101/2020.04.22.20076141v1.
¶¶ https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf.
***https://www.hrsa.gov/rural-health/about-us/definition/datafiles.html.

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