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.

Discussion

Approximately 85% of 4,817 U.S. adults frequently engaged in either handwashing or using hand sanitizer after contact with high-touch public surfaces, including only 72.4% of those aged 18–24 years. These findings highlight the need for continued health communication and outreach promoting hand hygiene. Respondents who were male and of younger age reported less frequent handwashing and hand sanitizing. These findings are consistent with those from previous pandemics^[3] and earlier in the COVID-19 pandemic,^[1] when males and younger adults engaged in less frequent handwashing than did females and older adults.^[2,3] During the COVID-19 pandemic, one study found that Hispanic adults reported more frequent handwashing than did White adults;^[1] however, the current study did not find a difference in handwashing between Hispanic and White adults after adjusting for concern for SARS-CoV-2 infection.

Respondents with lower income reported less frequent hand sanitizing. This could reflect lack of access to hand sanitizer; higher income and access to handwashing infrastructure have been previously found to be associated with adherence to hand hygiene.^[4] Difficulty obtaining hand sanitizer has been documented during the COVID-19 pandemic,^[5] and purchasing hand sanitizer might be prohibitive for persons with low income, particularly given recent reported increases in cost.^††† Strategies to increase hand sanitizing among lower-income populations could apply innovative approaches with regard to the location of signage and contactless dispensers (e.g., the center of a lobby or market or next to or built into gas filling stations) to make hand sanitizer and handwashing materials visible and readily available in public settings and address disparities in access.

Increased concern for personal risk for SARS-CoV-2 infection and personal experience with COVID-19 were both positively associated with handwashing and hand sanitizing. During previous respiratory pandemics, general concern, perceived susceptibility, and perceived severity of illness were found to be positively associated with engagement in hygiene-related prevention behaviors.^[3] During this pandemic, higher perceived risk has been associated with increased handwashing.^[6] In addition to hand hygiene, risk perceptions have been associated with engaging in other protective behaviors such as physical distancing,^§§§ avoiding handshakes and crowds,^[7] and wearing cloth face masks.^[8] Perceived risk for COVID-19 in the United States, when assessed during March–April 2020, was moderately high;^[6] however, some evidence indicates U.S. adults underestimate their risk of becoming ill with COVID-19.^[7] Differences in risk perceptions might partially explain why men and younger adults reported less frequent practicing of hand hygiene compared with women and older adults. Although differences in risk perceptions by gender and age were not assessed in this study, research conducted during the COVID-19 pandemic has found that younger persons^[7,9] and men^[6] had lower COVID-19 risk perceptions compared with older adults and women. For both populations, efforts are needed to further characterize COVID-19 risk perceptions and their relationships to hand hygiene, and to identify how health communication efforts can address risk perceptions in promotion of preventive behaviors. This is particularly important given that only 72.1% of those who were not at all concerned about their risk for SARS-CoV-2 infection frequently engaged in either handwashing or using hand sanitizer after contact with high-touch public surfaces, compared with 93.7% of those who were extremely concerned.

The findings in this report are subject to at least five limitations. First, self-reported data are subject to recall, response, and social desirability biases, and self-reported hand hygiene behavior might be overreported. Survey weighting might not have eliminated nonresponse bias. Second, estimation assumed proportional odds (i.e., that odds are constant across response levels), an assumption that is often violated;^[10] weighted ordered logistic regressions were used for ease of interpretation given that the estimates did not differ substantially from models that did not assume proportional odds. Third, although quota sampling methods and survey weighting were employed to improve sample representativeness of 2010 U.S. Census adult population estimates for age, gender, and race/ethnicity, the Internet-based survey sample might not be fully representative of the 2020 U.S. population for income, educational attainment, and access to technology. Fourth, hand hygiene was self-reported by respondents after contact with high-touch public surfaces; future studies could evaluate hand hygiene within households, workplaces, and other environments. Similarly, although respondents included in this analysis had been in public during the preceding week, adherence to hand hygiene did not account for the number of times respondents contacted high-touch public surfaces, or the number of hand hygiene methods used following contact with such surfaces. Finally, respondents were not asked whether they had access to soap and water or hand sanitizer, which could influence hand hygiene behaviors.

Hand hygiene is part of a multicomponent public health approach, which also includes wearing face masks and maintaining a physical distance of ≥6 feet from others, among additional prevention measures, to prevent and control COVID-19 in community settings. Public health promotional outreach about hand hygiene is needed, given that these findings indicate that hand hygiene adherence could be improved, especially among certain groups. Hand-hygiene–related health promotion strategies should be tailored toward men and young adults. To motivate hand hygiene behavior, health promotion messaging could focus on addressing risk perceptions of COVID-19, which might have shared benefits to promote engagement in additional COVID-19 prevention measures. Finally, increasing visibility and accessibility of handwashing and hand sanitizing signage and materials in public settings could encourage and facilitate hand hygiene to prevent the spread of COVID-19.

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Acknowledgments
Survey respondents; Mallory Colys, Sneha Baste, Daniel Chong, Rebecca Toll, Qualtrics, LLC; The Kinghorn Foundation; Emily Capodilupo, Whoop, Inc.; Alexandra Drane, Sarah Stephens Winnay, Archangels; Australian-American Fulbright Commission.

^††† https://www.npr.org/sections/coronavirus-live-updates/2020/03/25/821513190/stop-price-gouging-33-attorneys-general-tell-amazon-walmart-others.
^§§§ https://psyarxiv.com/dz428/.

Table. Prevalence of frequent hand hygiene* after contact with high-touch public surfaces among adults, by select respondent characteristics — United States, June 24–30, 2020
Characteristic	All respondents	Often or always wash hands		Often or always use hand sanitizer
Characteristic	Weighted no. (%)^†	Weighted no. (%)^†	P-value^§	Weighted no. (%)^†	P-value^§
Overall	4,817 (100)	3,781 (78.5)	—	3,407 (70.7)	—
Demographic characteristic
Sex
Female	2,448 (50.8)	1,971 (80.5)	<0.001	1,800 (73.5)	<0.001
Male	2,369 (49.2)	1,810 (76.4)	<0.001	1,608 (67.9)	<0.001
Age group, yrs
18–24	629 (13.1)	406 (64.6)	<0.001	376 (59.8)	<0.001
25–44	1,685 (35.0)	1,295 (76.8)		1,210 (71.8)
45–64	1,672 (34.7)	1,388 (83.0)		1,212 (72.5)
≥65	830 (17.2)	692 (83.3)		609 (73.3)
Race/Ethnicity
White, non-Hispanic	3,068 (63.7)	2,461 (80.2)	<0.001	2,208 (72.0)	<0.001
Black, non-Hispanic	587 (12.2)	427 (72.7)		385 (65.6)
Asian, non-Hispanic	230 (4.8)	198 (86.2)		182 (79.0)
Other or multiple race or races, non-Hispanic^¶	145 (3.0)	104 (71.9)		95 (65.9)
Hispanic, any race or races	787 (16.3)	590 (75.0)		537 (68.2)
2019 household income, USD
<$25,000	639 (13.3)	471 (73.6)	<0.001	400 (62.5)	<0.001
$25,000–$49,999	992 (20.6)	765 (77.1)		707 (71.3)
$50,000–$99,999	1,670 (34.7)	1,343 (80.4)		1,200 (71.9)
≥$100,000	1,515 (31.5)	1,202 (79.4)		1,100 (72.6)
U.S. Census region**
Northeast	1,073 (22.3)	862 (80.3)	0.941	747 (69.6)	0.044
Midwest	913 (19.0)	710 (77.7)		646 (70.7)
South	1,674 (34.7)	1,300 (77.7)		1,217 (72.7)
West	1,157 (24.0)	909 (78.6)		797 (68.9)
Rural/Urban residence^††
Rural	544 (11.3)	423 (77.8)	0.003	396 (72.7)	0.211
Urban	4,273 (88.7)	3,358 (78.6)	0.003	3,012 (70.5)	0.211
COVID-19 experiences and beliefs
Knew someone who had test results positive for SARS-CoV-2
Yes	970 (20.1)	837 (86.4)	<0.001	771 (79.5)	<0.001
No	3,847 (79.9)	2,944 (76.5)	<0.001	2,636 (68.5)	<0.001
Knew someone who was hospitalized for severe illness or died from COVID-19
Yes	624 (12.9)	518 (83.0)	0.002	495 (79.4)	<0.001
No	4,193 (87.1)	3,263 (77.8)	0.002	2,912 (69.4)	<0.001
Level of concern of own risk of SARS-CoV-2 infection^§§
Not at all	576 (12.0)	392 (68.0)	<0.001	311 (54.0)	<0.001
Slightly	1,093 (22.7)	810 (74.1)		727 (66.5)
Moderately	1,411 (29.3)	1,086 (77.0)		966 (68.5)
Very	783 (16.2)	639 (81.6)		610 (77.9)
Extremely	954 (19.8)	854 (89.5)		793 (83.1)

Abbreviations: COVID-19 = coronavirus disease 2019; USD = U.S. dollars.
*Frequency of hand hygiene was assessed on a 5-point 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 hands with soap and water after touching high-touch surfaces in public." For this table, answers of "Often" or "Always" were considered frequent.
^†Quota sampling and survey weighting were employed to improve representativeness of the cross-sectional June cohort of the United States population by gender, age, and race/ethnicity according to the 2010 U.S. Census.
^§Bivariate chi-squared test was used to test for differences in observed and expected frequencies among groups by characteristic for each type of hand hygiene on the full 5-item Likert scale from "Never" to "Always." Statistical significance for bivariate analyses was evaluated as p<0.05.
^¶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."

Authors and Disclosures

Mark É. Czeisler^1–3, Amanda G. Garcia-Williams, PhD⁴, Noelle-Angelique Molinari, PhD⁴, Radhika Gharpure, DVM⁴, Yiman Li, MPH⁵, Catherine E. Barrett, PhD⁴, Rebecca Robbins, PhD^3,6, Elise R. Facer-Childs, PhD¹, Laura K. Barger, PhD^3,6, Charles A. Czeisler, PhD, MD^1,3,6, Shantha M.W. Rajaratnam, PhD^1–3,6 and Mark E. Howard, MBBS, PhD^1,2,7

¹Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia; ²Austin Health, Melbourne, Australia; ³Brigham and Women's Hospital, Boston, Massachusetts; ⁴CDC COVID-19 Response Team; ⁵Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC; ⁶Harvard Medical School, Boston, Massachusetts; ⁷University of Melbourne, Melbourne, Australia.

Corresponding author
Mark É. Czeisler, mark.czeisler@fulbrightmail.org.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Mark É. Czeisler reports a grant from the Australian-American Fulbright Commission and personal fees from Vanda Pharmaceuticals. Rebecca Robbins reports personal fees from Denihan Hospitality, Rituals Cosmetics, SleepCycle, Dagmejan, and byNacht. Elise R. Facer-Childs reports a grant from the Science and Industry Endowment Fund Ross Metcalf STEM+ Business Fellowship administered by the Commonwealth Scientific and Industrial Research Organisation, Canberra, Australia. Laura K. Barger reports a grant from the National Institute for Occupational Safety and Health and personal fees from the University of Pittsburgh, CurAegis, Casis, Puget Sound Pilots, Boston Children's Hospital, and Charles A. Czeisler. Charles A. Czeisler reports an endowed professorship provided to Harvard Medical School by Cephalon, Inc.; educational and research support to Harvard Medical School and Brigham and Women's Hospital from Philips Respironics, Inc. (supported in part the survey administration and analysis) and from a gift to Brigham and Women's Hospital by Alexandra Drane, the CEO of Archangels (support for The COPE Initiative); grants from the National Institute of Occupational Safety and Health, Teva Pharmaceuticals Industries, Ltd; consulting fees and equity interest from Vanda Pharmaceuticals; lecture fees from Teva Pharma Australia; and royalties from Philips Respironics for the Actiwatch-2 and Actiwatch-Spectrum devices. Shantha M.W. Rajartnam reports grants from the Turner Institute for Brain and Mental Health, Monash University, and Teva Pharmaceuticals; a grant and personal fees from the Cooperative Research Centre for Alertness, Safety and Productivity; and consultancy fees paid to Monash University from Vanda Pharmaceuticals, BHP Billiton, and Herbert Smith Freehills. Mark E. Howard reports a grant from the Institute for Breathing and Sleep, Austin Health, Melbourne, Australia. Shantha M.W. Rajartnam, Mark E. Howard, Charles A. Czeisler, Laura K. Barger, Elise R. Facer-Childs, and Mark É. Czeisler report a contract from Whoop Inc. to Monash University, which provided partial funding for administration of the June Survey. No other potential conflicts of interest were disclosed.