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


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

In This Article


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.