Handwashing among female college students

Factors affecting hand hygiene practice during the COVID-19 pandemic in the Zimbabwean population: a qualitative study

BACKGROUND

Practicing hand hygiene is recommended as one of the key preventive measures for reducing the transmission of COVID-19 and other infectious agents. However, it is often not practiced frequently enough or correctly by the public. We aimed to identify barriers to and facilitators of hand hygiene in the Zimbabwean population during the COVID-19 pandemic.

METHODS

A qualitative study was conducted with a purposive sample of health workers, village health workers, church leaders, traditional healers, teachers, youth leaders and the general population selected from ten districts across the country from September to October 2022. Semistructured interviews were conducted with 3 key informant interviews per site. In addition, one homogenous focus group discussion was also conducted per site using a focus group discussion guide. The data were recorded on audiotapes, transcribed verbatim, and translated into English. All the analyses were performed manually using thematic analysis.

RESULTS

Two themes were identified as facilitators of hand hygiene. These include individual factors (knowledge of hand hygiene practices and how they are performed) and access-related factors (access to hand washing infrastructure, soap, and sanitizers). Among the barriers to hand hygiene, four themes were identified: individual factors (knowledge gaps in proper hand washing, lack of conviction about hand hygiene, and habitual behaviour), access-related factors (lack of access to hand washing infrastructure, soap, and sanitizers), safety concerns (concern about the side effects of sanitizers), and sociocultural and religious factors (social customs, cultural beliefs, values, and religious practices).

CONCLUSION

During public health emergencies, there is a need for people to access uninterrupted, on-premises water supplies to promote compliance with hand hygiene. The provision of clean water and hand washing facilities is critical for vulnerable communities to afford them the opportunity to improve quality of life and facilitate resilience in the event of future pandemics. Community engagement is important for identifying vulnerability factors to provide appropriate mitigatory measures.

Personal characteristics associated with handwashing behaviour among Japanese university students studying abroad: Prospective observational studies

BACKGROUND

Hand hygiene is recommended to travellers to prevent common travel-related illnesses such as diarrhoea and respiratory infection. For effective hygiene promotion interventions, we aimed to identify the personal characteristics associated with handwashing behaviour.

METHODS

Prospective observational studies consisting of pre- and post-travel surveys were conducted among Japanese university students studying abroad between 2016 and 2018 (n = 825; 6-38 travel days). Associations of age, sex, study major, and overseas travel experience with handwashing behaviour (5-point scale) were evaluated using ordinal logistic regression models, with adjustment for destination, travel duration, and psychological factors (risk perception of diarrhoea and concern about hygiene).

RESULTS

Among the participants in our analysis (n = 629), 28.0 % washed their hands before every meal while abroad. The male sex and no overseas travel experience were associated with decreased frequency of infrequent handwashing, even after adjusting for all potential confounding factors, whereas the study major was not associated. The adjusted odds ratios (95 % confidence intervals) were 0.74 (0.56-0.99) for men vs. women and 0.69 (0.52-0.93) for no overseas travel experience vs. overseas travel experience but not to the current destination.

CONCLUSIONS

The lack of overseas travel experience correlated with handwashing frequency in both men and women. In addition to the travel destination, the male sex and no overseas travel experience should be highlighted in pretravel hand hygiene interventions.

Silica nanoparticles with encapsulated DNA (SPED) to trace the spread of pathogens in healthcare

Background

To establish effective infection control protocols, understanding pathogen transmission pathways is essential. Non-infectious surrogate tracers may safely explore these pathways and challenge pre-existing assumptions. We used silica nanoparticles with encapsulated DNA (SPED) for the first time in a real-life hospital setting to investigate potential transmission routes of vancomycin-resistant enterococci in the context of a prolonged outbreak.

Methods

The two study experiments took place in the 900-bed University Hospital Zurich, Switzerland. A three-run ‘Patient experiment’ investigated pathogen transmission via toilet seats in a two-patient room with shared bathroom. First, various predetermined body and fomite sites in a two-bed patient room were probed at baseline. Then, after the first patient was contaminated with SPED at the subgluteal region, both patients sequentially performed a toilet routine. All sites were consequently swabbed again for SPED contamination. Eight hours later, further spread was tested at predefined sites in the patient room and throughout the ward. A two-run ‘Mobile device experiment’ explored the potential transmission by mobile phones and stethoscopes in a quasi-realistic setting. All SPED contamination statuses and levels were determined by real-time qPCR.

Results

Over all three runs, the ‘Patient experiment’ yielded SPED in 59 of 73 (80.8%) predefined body and environmental sites. Specifically, positivity rates were 100% on subgluteal skin, toilet seats, tap handles, and entertainment devices, the initially contaminated patients’ hands; 83.3% on patient phones and bed controls; 80% on intravenous pumps; 75% on toilet flush plates and door handles, and 0% on the initially not contaminated patients’ hands. SPED spread as far as doctor’s keyboards (66.6%), staff mobile phones (33.3%) and nurses’ keyboards (33.3%) after eight hours. The ‘Mobile device experiment’ resulted in 16 of 22 (72.7%) positive follow-up samples, and transmission to the second patient occurred in one of the two runs.

Conclusions

For the first time SPED were used to investigate potential transmission pathways in a real hospital setting. The results suggest that, in the absence of targeted cleaning, toilet seats and mobile devices may result in widespread transmission of pathogens departing from one contaminated patient skin region.

U can't touch this! Face touching behaviour whilst driving: implications for health, hygiene and human factors

Analysis of thirty-one hours of video-data documenting 36 experienced drivers highlighted the prevalence of face-touching, with 819 contacts identified (mean frequency: 26.4 face touches/hour (FT/h); mean duration: 3.9-seconds). Fewer face-touches occurred in high primary workload conditions (where additional physical/cognitive demands were placed on drivers), compared to low workload (4.4 and 26.1 FT/h, respectively). In 42.5% of touches (or 11.2 FT/h), mucous membrane contact was made, with fingertips (33.1%) and thumbs (35.6%) most commonly employed. Individual behaviours differed (ranging from 5.1 to 90.7 FT/h), but there were no significant differences identified between genders, age-groups or hand used. Results are of relevance from an epidemiological/hygiene perspective within the context of the COVID-19 pandemic (and can therefore inform the design of practical solutions and encourage behavioural change to reduce the risk of self-inoculation while driving), but they also help to elucidate how habitual human behaviours are imbricated with the routine accomplishment of tasks.

Social pressure, altruism, free-riding, and non-compliance in mask wearing by U.S. residents in response to COVID-19 pandemic

Human behavior, such as wearing a mask in public, affects the trajectory of the COVID-19 pandemic. A nationally representative survey of 1198 U.S. residents was used to study demographics, perceptions, and stated beliefs of residents who indicated they believe masks have a role in society in response to COVID-19 but self-reported not wearing masks in at least one public place studied. Individuals who believed wearing masks protected others were more likely to report voluntarily wearing them, providing possible evidence of altruism. Perceiving social pressure negatively impacted the probability of voluntary mask wearing amongst those who believed masks have a role in society, suggesting social shaming may not increase compliance among these individuals. Free-riding is one possible explanation for why an individual respondent may self-report belief that mask wearing has a role in society and simultaneously self-report not voluntarily wearing a mask in public locations. Alternatively, incomplete knowledge, confusion about the role of masks in controlling spread of COVID-19, or fatigue are all possible explanations for why adults who believe masks play a role demonstrate less than optimal compliance themselves with mask wearing. Promotion of altruism, rather than social shaming, is more likely to increase mask wearing based on this analysis. Tactics to improve public health initiative compliance and participation may change throughout the duration of the pandemic and/or may differ between segments of the population. Increased understanding of human behavior as it relates to mask wearing can inform public health communications and construction of incentive-aligned messaging to improve public health-related behaviors and associated outcomes.

The dynamic theory of reasoned action: evidence for a reverse causal process in the context of WHO handwashing guidelines

OBJECTIVE

This study provided a first empirical test of the Reverse Dynamic Theory of Reasoned Action (RDTRA) developed by Boster et al.

DESIGN

In a longitudinal experiment, 169 participants were exposed to a WHO handwashing-guidelines behavioural induction, followed by an immediate posttest and a follow-up one week later.

MAIN OUTCOME MEASURES

The study measured attitudes and norms about WHO handwashing guidelines, as well as self-reported handwashing behaviour.

RESULTS

The experimental induction produced variance in self-reported handwashing behaviour, allowing a test of the RDTRA using path analysis and structural equation modelling (SEM). Results were consistent with the RDTRA, with a positive effect of behaviour on both the attitude and norm coupled with excellent model fit. Results were inconsistent with behaviour as an outcome of attitudes and norms in this context.

CONCLUSION

For health behaviours, such as the WHO handwashing technique, initial behavioural adoption may promote subsequent shaping of attitudes and perceived norms. Boundary conditions for this effect may include the degree of spontaneity and consent involved in behaviour adoption.

Implementation of a Service-Learning Project Focused on Handwashing and Vaccinations Within an Undergraduate Microbiology Laboratory Course

Two relevant topics in keeping populations healthy are handwashing and vaccinations. Thus, the service-learning project titled "We Are Healthy" campaign was introduced within a microbiology laboratory course with two objectives; our biologists would better understand the importance of these actions by designing activities that engage the student community and to obtain an understanding of the campus community's behaviors and beliefs concerning these topics. Students designed the campaign to include handwashing stations, pictures of bacterial cultures from swabbing common surfaces, and trivia questions testing their peers' knowledge of various vaccines, as well as handwashing and vaccination surveys. To assess the impact of the campaign on microbiology students (n = 34), they were provided 10 questions that were scored on a scale from 1 to 5 (1 = strongly disagree; 5 = strongly agree). Student gains (score > 3) were reported for depth in knowledge, development of better public speaking skills, and greater respect for volunteers suggesting that the campaign was beneficial. This study subsequently led to the receiving of grants that allowed the continuation of the campaign within the course, the securing of funding for handwashing and hand sanitizing stations and the initiation of new undergraduate research projects.

Explaining Handwashing Behavior in a Sample of College Students during COVID-19 Pandemic Using the Multi-Theory Model (MTM) of Health Behavior Change: A Single Institutional Cross-Sectional Survey

Amidst the COVID-19 pandemic, handwashing offers a simple and effective hygienic measure for disease prevention. Reportedly, a significant proportion of college students did not follow handwashing recommendations provided by the Centers for Disease Control and Prevention (CDC) in the pre-COVID era. The purpose of this cross-sectional study was to explore and explain the handwashing behavior among college students during the COVID-19 pandemic using a contemporary fourth-generation multi-theory model (MTM) of health behavior change. Data were collected from 713 college students at a large public university in the Southern U.S. in October 2020 using a validated 36-item survey. Statistical analyses included independent samples t-tests, Pearson correlation, and hierarchical regression modeling. Among students not following handwashing recommendations, the constructs of participatory dialogue (β = 0.152; p < 0.05) and behavioral confidence (β = 0.474; p < 0.0001) were statistically significant and accounted for 27.2% of the variance in the likelihood of initiation of the behavior. Additionally, the constructs of emotional transformation (β = 0.330; p < 0.0001), practice for change (β = 0.296; p < 0.0001), and changes in the social environment (β = 0.180; p < 0.05) were statistically significant and accounted for 45.1% of the variance in the likelihood of sustaining handwashing behavior. This study highlights the applicability and usability of the MTM in designing and testing behavior change interventions and media messaging in campaigns targeting college students.

Antiviral efficacy of personal care formulations against Severe Acute Respiratory Syndrome Coronavirus 2

Background

Non-therapeutic interventions such as practicing good hand hygiene continue to be the mainstay of protection from SARS-CoV-2 and other emerging respiratory viruses.

Methods

We have evaluated a range of commercially available personal care products including soaps, handwash liquids and alcohol-based hand sanitizers for antiviral efficacy against a clinical isolate of SARS-CoV-2 using internationally accepted standardized protocols at user-relevant contact time-points and product dilutions.

Results

All the tested products resulted in 3 to 4 log reduction of SARS-CoV-2 titer.

Conclusion

Our data re-affirms recommendations by global public health authorities that proper hand hygiene can reduce SARS-CoV-2 viral load significantly which should likely limit spread of the contagion.

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Personal care formulations from Unilever showed efficacy against SARS-CoV-2.

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All tests were conducted at user relevant contact duration and product dilution.

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Soap bars with varying TFM content resulted in ≥ 3 log reduction.

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Liquid cleansers with varying surfactant levels resulted in ≥ 3 log reduction.

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Sanitizers with variable % of alcohol resulted in ≥ 3 to 4 log reduction.

Improving the impact of non-pharmaceutical interventions during COVID-19: examining the factors that influence engagement and the impact on individuals

BACKGROUND

During an evolving outbreak or pandemic, non-pharmaceutical interventions (NPIs) including physical distancing, isolation, and mask use may flatten the peak in communities. However, these strategies rely on community understanding and motivation to engage to ensure appropriate compliance and impact. To support current activities for COVID-19, the objectives of this narrative review was to identify the key determinants impacting on engagement.

METHODS

An integrative narrative literature review focused on NPIs. We aimed to identify published peer-reviewed articles that focused on the general community (excluding healthcare workers), NPIs (including school closure, quarantine, isolation, physical distancing and hygiene behaviours), and factors/characteristics (including social, physical, psychological, capacity, motivation, economic and demographic) that impact on engagement.

RESULTS

The results revealed that there are a range of demographic, social and psychological factors underpinning engagement with quarantine, school closures, and personal protective behaviours. Aside from the factors impacting on acceptance and compliance, there are several key community concerns about their use that need to be addressed including the potential for economic consequences.

CONCLUSION

It is important that we acknowledge that these strategies will have an impact on an individual and the community. By understanding the barriers, we can identify what strategies need to be adopted to motivate individuals and improve community compliance. Using a behavioural framework to plan interventions based on these key barriers, will also ensure countries implement appropriate and targeted responses.

Social Influence on Handwashing with Soap: Results from a Cluster Randomized Controlled Trial in Bangladesh

We analyzed data from a cluster-randomized controlled trial conducted among 20 schools in Rajshahi, Bangladesh, to explore the role of social influence on handwashing with soap (HWWS) in a primary school setting. Using data collected through covert video cameras outside of school latrines, we used robust Poisson regression analysis to assess the impact of social influence-defined as the presence of another person near the handwashing location-on HWWS after a toileting event. In adjusted analyses, we found a 30% increase in HWWS when someone was present, as compared with when a child was alone (Prevalence ratio 1.30; 95% confidence interval: 1.14-1.47, P < 0.001). The highest prevalence of HWWS was found when both child(ren) and adult(s) were present or when just children were present (64%). Our study supports the conclusion that the presence of another individual after a toileting event can positively impact HWWS in a primary school setting.

The Common Missed Handwashing Instances and Areas after 15 Years of Hand-Hygiene Education

The outbreak of severe acute respiratory syndrome (SARS) claimed the lives of 286 Hong Kong people in 2003. Since then, the Hong Kong government has been promoting the benefits of proper hand hygiene. There are few studies that explore the general quality of handwashing and the hand-hygiene practices of the public of Hong Kong; given this, the aim of this study is to explore this neglected topic. This study is a quantitative study that was conducted in January 2018. The results show that the majority of participants only wash their hands after using the toilet (87%) or handling vomitus or faecal matter (91%). The mean duration of handwashing was 36.54 seconds (SD = 18.57). The areas of the hand most neglected during handwashing were the fingertips (48.1%), medial area (30.5%), and back of the hand (28%). A multiple logistic regression shows that participants who have reached third-level education or higher often tend to be more hand hygienic than those who have not reached third-level education (p ≤ 0.001, B = 1.003). Thus, participants aged 30 and above tend to neglect 5 more areas of the hand than those aged below 30 (p=0.001, B = 4.933).

Serial Measurements of Soap Weights and Soap Availability to Describe Handwashing Behavior

Available measures of handwashing are prone to bias. We tested the feasibility and reliability of weighing soap at repeated visits and subtracting the measured weight from the prior weight to assess daily per capita soap consumption in a low-income community in Dhaka, Bangladesh. Fieldworkers approached 220 households twice weekly over 2 months. They interviewed participants, weighed soap, and assessed hand cleanliness and the presence of a handwashing station. Respondents used bar soap (91% [201]) and laundry detergent cakes (39% [85]) for handwashing as well as for bathing and laundry. Ninety-eight percent of households had bar soap present on at least one visit, although only 50% had bar soap at every visit during the 2-month period. Fieldworkers observed a soap fragment on the wall near the latrine in 27% (470) of visits. Households consumed a mean 1.5 g of bar soap and 3.2 g detergent cake per person per day. Daily per capita soap consumption was similar in households visited by fieldworkers after different intervals (2, 3, 4, or 5 days). Soap consumption was not associated with household wealth, education of the household head, the presence of a handwashing station, the presence of water or soap at a handwashing station, or palm inspections of the mother or child. Soap weight measurements were an objective, reliable measure of soap consumption that provided different information from other handwashing indicators. The frequent use of a soap product for purposes other than handwashing complicates using soap consumption as a handwashing measure.

Behavioral Observation and Microbiological Analysis of Older Adult Consumers' Cross-Contamination Practices in a Model Domestic Kitchen

The incidence of foodborne illness is higher in older adults because of their increased susceptibility; therefore, food safety practices are important. However, inadequate knowledge and negative attitudes toward food safety have been reported, which may increase use of unsafe food handling practices. Data on the actual food safety behaviors of older adults are lacking. In this study, food safety practices of older adults were observed and linked to microbiological analysis of kitchen surfaces to identify suspected routes of contamination. Older adults (≥60 years, n = 100) prepared a set meal in a model domestic kitchen sanitized according to a validated protocol to ensure minimal and consistent microbiological loads. Food safety behaviors were observed using ceiling-mounted cameras and recorded using a predetermined behavioral checklist. Surface microbiological contamination also was determined after food preparation. Overall, older adults frequently implemented unsafe food handling practices; 90% failed to implement adequate hand decontamination immediately after handling raw chicken. For older adults who used a larger number of adequate hand decontamination attempts, microbiological contamination levels in the kitchen following the food preparation session were significantly lower ( P < 0.001). The novel utilization of behavioral observation in conjunction with microbiological analysis facilitated identification of potentially unsafe food handling practices as suspected routes of microbiological cross-contamination in a model domestic kitchen. Findings indicate the potential impact on domestic food safety of unsafe food handling practices used by older adult consumers. This innovative approach revealed that a large proportion of older adults implement behaviors resulting in microbiological cross-contamination that may increase the risk of foodborne illness in the home.

Implications of Peer Pressure for Adolescent Nursing Research: A Concept Analysis Approach

The influence of peers is widely held as a significant factor in child and adolescent development. As health care providers seek ways to improve the health of children and adolescents, peer pressure must be examined. This article analyzes peer pressure and its relationship to the health of children and adolescents. Defining attributes of peer pressure are discussed, including incomplete identity formation, the presence of a peer influence, and a need for approval. Antecedents and consequences of peer pressure are also explored. Methods of measuring peer pressure are discussed, along with implications for health care research in the pediatric population.

An observational study of handwashing compliance in a child care facility

BACKGROUND

Handwashing (HW) compliance, although an effective means of limiting childhood illness, remains low among personnel in early childhood centers (ECCs). Our study determined HW compliance and efficacy of ECC personnel.

METHODS

Surveillance cameras were used to determine HW opportunities, compliance, occurrences, and effectiveness based on child-care oriented criteria.

RESULTS

We observed 349 HW triggering events, with 14 events per hour; a median of 2 personnel (caregivers, paraprofessional aides, or parents) were present at any given time period. Compliance was 30% (caregivers), 11% (paraprofessional aides), and 4% (parents), with an overall compliance of 22%. Between-room and between-age groups of children being cared for and compliance of caregivers and paraprofessional aides were not found to be significantly different (P < .05). For all personnel between the 10 different rooms, the median compliance was 20.2% (95% confidence interval, 8%-35%). Only 7% of personnel taking care of 2- to 3-year-old children washed their hands, the lowest compliance per age group. Of all steps in HW, paper towel usage had the highest compliance, with a 97% adherence, whereas turning off the faucet with a paper towel was the lowest at 17%.

CONCLUSIONS

Methods and strategies need to be developed to increase compliance. Current technology provides an effective means of gathering data for determining HW compliance in ECCs.

A molecular exploration of human DNA/RNA co-extracted from the palmar surface of the hands and fingers

"Touch DNA" refers to the DNA that is left behind when a person touches or comes into contact with an item. However, the source of touch DNA is still debated and the large variability in DNA yield from casework samples suggests that, besides skin, various body fluids can be transferred through contact. Another important issue concerning touch DNA is the possible occurrence of secondary transfer, but the data published in the literature in relation to the background levels of foreign DNA present on the hand surfaces of the general population are very limited. As the present study aimed at better understanding the nature and characteristics of touch DNA, samples were collected from the palmar surface of the hands and fingers ("PHF" samples) of 30 male and 30 female donors by tape-lifting/swabbing and subjected to DNA/RNA co-extraction. Multiplex mRNA profiling showed that cellular material different from skin could be observed in 15% of the PHF samples. The total amount of DNA recovered from these samples (median 5.1 ng) was significantly higher than that obtained from samples containing skin cells only (median 1.6 ng). The integrity of the DNA isolated from the donors' hands and fingers as well as the prevalence of DNA mixtures were evaluated by STR typing and compared with reference STR profiles from buccal swabs. DNA integrity appeared significantly higher in the male rather than in the female subsample, as the average percentage of the donors' alleles effectively detected in PHF profiles was 75.1% and 60.1%, respectively. The prevalence of mixtures with a foreign DNA contribution ≥20% was 19.2% (30.0% in the female PHF samples and 8.3% in the male PHF samples). The obtained results support the hypothesis that transfer of cellular material different from skin may underlie the occasional recovery of quality STR profiles from handled items. These results also suggest that gender may represent an important factor influencing the propensity of individuals to carry and transfer DNA through hand contact, possibly because of the differences in personal and hygiene habits between males and females.

Poor hand hygiene by college students linked to more occurrences of infectious diseases, medical visits, and absence from classes

BACKGROUND

Proper hand hygiene has been linked to lower susceptibility to infectious diseases in many types of communities, but it has not been well established on college campuses. This study investigated the hand hygiene statuses of college students and their occurrences in relation to infectious diseases, medical visits, and absence from classes or work. It also examined the effects of education on handwashing technique to improve hand hygiene.

METHODS

College students enrolled at a university in Northwestern Ohio were recruited as study subjects. Microbial samples were collected 3 times from each of the 220 valid volunteers before washing their hands, after washing with their own procedures, and after washing with a procedure recommended by the Centers for Disease Control and Prevention (CDC). Each volunteer also answered a survey including questions on their health conditions, medical visits, and absence from classes or work.

RESULTS

Hands of 57.7% volunteers were colonized by an uncountable number of microbial colonies, which were significantly linked to more occurrences to infectious diseases (P < .05), medical visits (P < .05), and arguably more absence from classes or work (P = .09). The handwashing procedure provided by the CDC significantly improved hand hygiene.

CONCLUSION

It is critical to promote education on proper handwashing in colleges, in grade schools, and at home to improve health and learning outcomes.

Assessment of water, sanitation, and hygiene practices and associated factors in a Buruli ulcer endemic district in Benin (West Africa)

Background

Control of neglected tropical diseases (NTDs) requires multiple strategic approaches including water, sanitation and hygiene services (WASH). Buruli ulcer (BU), one of the 17 NTDs, remains a public health issue in Benin particularly in the district of Lalo. The availability of water as well as good hygiene are important for the management of Buruli ulcer particularly in the area of wound care one of the main component of the treatment of BU lesions. Given the growing importance of WASH in controlling NTDs and in order to assess the baseline for future cross-cutting interventions, we report here on the first study evaluating the level of WASH and associated factors in Lalo, one of the most BU-endemic districts in Benin.

Method

A cross-sectional study was carried to assess WASH practices and associated factors in the district of Lalo. Data were collected from 600 heads of household using structured pretested questionnaire and observations triangulated with qualitative information obtained from in-depth interviews of patients, care-givers and community members. Univariate and multivariate analysis were carried to determine the relationships between the potential associated factors and the sanitation as well as hygiene status.

Results

BU is an important conditions in the district of Lalo with 917 new cases detected from 2006 to 2012. More than 49 % of the household surveyed used unimproved water sources for their daily needs. Only 8.7 % of the investigated household had improved sanitation facilities at home and 9.7 % had improved hygiene behavior. The type of housing as an indicator of the socioeconomic status, the permanent availability of soap and improved hygiene practices were identified as the main factors positively associated with improved sanitation status.

Conclusions

In the district of Lalo in Benin, one of the most endemic for BU, the WASH indicators are very low. This study provides baseline informations for future cross-cutting interventions in this district.

Observed practices and perceived advantages of different hand cleansing agents in rural Bangladesh: ash, soil, and soap

Bangladeshi communities have historically used ash and soil as handwashing agents. A structured observation study and qualitative interviews on the use of ash/soil and soap as handwashing agents were conducted in rural Bangladesh to help develop a handwashing promotion intervention. The observations were conducted among 1,000 randomly selected households from 36 districts. Fieldworkers observed people using ash/soil to wash their hand(s) on 13% of occasions after defecation and on 10% after cleaning a child's anus. This compares with 19% of people who used soap after defecation and 27% after cleaning a child who defecated. Using ash/soil or soap was rarely (< 1%) observed at other times recommended for handwashing. The qualitative study enrolled 24 households from three observation villages, where high usage of ash/soil for handwashing was detected. Most informants reported that ash/soil was used only for handwashing after fecal contact, and that ash/soil could clean hands as effectively as soap.

A quantitative exposure model simulating human norovirus transmission during preparation of deli sandwiches

Human noroviruses (HuNoVs) are a major cause of food borne gastroenteritis worldwide. They are often transmitted via infected and shedding food handlers manipulating foods such as deli sandwiches. The presented study aimed to simulate HuNoV transmission during the preparation of deli sandwiches in a sandwich bar. A quantitative exposure model was developed by combining the GoldSim® and @Risk® software packages. Input data were collected from scientific literature and from a two week observational study performed at two sandwich bars. The model included three food handlers working during a three hour shift on a shared working surface where deli sandwiches are prepared. The model consisted of three components. The first component simulated the preparation of the deli sandwiches and contained the HuNoV reservoirs, locations within the model allowing the accumulation of NoV and the working of intervention measures. The second component covered the contamination sources being (1) the initial HuNoV contaminated lettuce used on the sandwiches and (2) HuNoV originating from a shedding food handler. The third component included four possible intervention measures to reduce HuNoV transmission: hand and surface disinfection during preparation of the sandwiches, hand gloving and hand washing after a restroom visit. A single HuNoV shedding food handler could cause mean levels of 43±18, 81±37 and 18±7 HuNoV particles present on the deli sandwiches, hands and working surfaces, respectively. Introduction of contaminated lettuce as the only source of HuNoV resulted in the presence of 6.4±0.8 and 4.3±0.4 HuNoV on the food and hand reservoirs. The inclusion of hand and surface disinfection and hand gloving as a single intervention measure was not effective in the model as only marginal reductions of HuNoV levels were noticeable in the different reservoirs. High compliance of hand washing after a restroom visit did reduce HuNoV presence substantially on all reservoirs. The model showed that good handling practices such as washing hands after a restroom visit, hand gloving, hand disinfection and surface disinfection in deli sandwich bars were an effective way to prevent HuNoV contamination of the prepared foods, but it also demonstrated that further research is needed to ensure a better assessment of the risk of HuNoV transmission during preparation of foods.

Rapid Antibacterial Activity of 2 Novel Hand Soaps: Evaluation of the Risk of Development of Bacterial Resistance to the Antibacterial Agents

Objective.

To evaluate the antimicrobial efficacy of and risk of organisms developing resistance to 2 novel hand soaps: (1) a soap containing triclosan, polyhexamethylene biguanide, and benzethonium chloride added to a soap base (TPB soap); and (2) a soap containing farnesol, polyhexamethylene biguanide, and benzethonium chloride added to a soap base (FPB soap). Tests also included soaps containing only triclosan.

Design.

The risk of emergence of resistant bacterial mutants was investigated by determining the susceptibility changes after repeated exposure of bacteria to the drugs and soaps in vitro. The effectiveness of the soaps was evaluated using an in vitro tube dilution method, a volunteer method (the ASTM standard), and 2 pig skin methods.

Results.

The minimum inhibitory concentration and minimum bactericidal concentration of triclosan against Staphylococcus, aureus increased 8- to 62.5-fold, whereas those of TPB and FPB (both alone and in soap) were unchanged. In vitro, TPB and FPB soaps produced higher log10 reductions in colony-forming units of all tested organisms (4.95-8.58) than did soaps containing triclosan alone (0.29-4.86). In the test using the pig skin and volunteer methods, TPB soap produced a higher log10 reduction in colony-forming units (3.1-3.3) than did the soap containing triclosan alone (2.6-2.8).

Conclusion.

The results indicate that TPB and FPB soaps may provide superior rapid and broad-spectrum efficacy with a lower risk of organisms developing resistance than do soaps containing triclosan alone. Pig skin methods may be used to predict the efficacy of antibacterial soaps in the rapid disinfection of contaminated hands. Hand washing with TPB and FPB soaps by healthcare workers and the general population may reduce the transmission of pathogens, with a lower risk of promoting the emergence of resistant organisms.

Video surveillance captures student hand hygiene behavior, reactivity to observation, and peer influence in Kenyan primary schools

Background

In-person structured observation is considered the best approach for measuring hand hygiene behavior, yet is expensive, time consuming, and may alter behavior. Video surveillance could be a useful tool for objectively monitoring hand hygiene behavior if validated against current methods.

Methods

Student hand cleaning behavior was monitored with video surveillance and in-person structured observation, both simultaneously and separately, at four primary schools in urban Kenya over a study period of 8 weeks.

Findings

Video surveillance and in-person observation captured similar rates of hand cleaning (absolute difference <5%, p = 0.74). Video surveillance documented higher hand cleaning rates (71%) when at least one other person was present at the hand cleaning station, compared to when a student was alone (48%; rate ratio  = 1.14 [95% CI 1.01–1.28]). Students increased hand cleaning rates during simultaneous video and in-person monitoring as compared to single-method monitoring, suggesting reactivity to each method of monitoring. This trend was documented at schools receiving a handwashing with soap intervention, but not at schools receiving a sanitizer intervention.

Conclusion

Video surveillance of hand hygiene behavior yields results comparable to in-person observation among schools in a resource-constrained setting. Video surveillance also has certain advantages over in-person observation, including rapid data processing and the capability to capture new behavioral insights. Peer influence can significantly improve student hand cleaning behavior and, when possible, should be exploited in the design and implementation of school hand hygiene programs.

"Think the sink:" Preliminary evaluation of a handwashing promotion campaign

Owing to its utility in guiding the planning and evaluation of health promotion campaigns, the Theory of Planned Behavior was used to implement a 1-month campaign aimed at increasing handwashing among college students. Based on observations of bathroom users' handwashing behavior (n = 1,005) and an online survey (n = 188), overall handwashing did not increase as a result of the campaign; however, more students did use soap (58% vs 70%). Future campaigns designed to increase handwashing behavior in students may be advised to target messages according to gender difference-based responsiveness to handwashing norms.

A Study on Hand Contamination and Hand Washing Practices among Medical Students

Harmful microorganisms can be transferred to hands from contaminated surfaces people come into contact in daily life. Contaminated hands can transmit disease to one self as well as to others. A study was done to determine the extent to which hand hygiene practices and toilet door knobs contribute to the bacterial load of hands of toilet users in a medical school. Swabs were taken from a randomly selected sample of 60 medical students for bacterial count from both hands before and after toilet use and from door knobs of six toilets. Only 40 (66.7%) claimed they washed hands with soap. Significantly more females (83%) used soap to wash hands compared to males (50%). Bacterial load in the hands of both males and females showed an increase after toilet use. The increase was significant among male students. The dominant hand had a significantly higher bacterial load than the other. The mean bacterial load of male toilet door knobs (12 CFU/cm2) were significantly higher than of female toilet door knobs (2.5 CFU/cm2) (P<0.05). Staphylococcus aureus was isolated from the hands of 21 students. Toilets and washrooms should be designed so as to eliminate the sources of contamination of the hands.

Examining the effects of thought records and behavioral experiments in instigating belief change

OBJECTIVE

While the efficacy and effectiveness of CBT protocols are well established, much less is known about the comparative contribution of the various techniques within CBT. The present study examined the relative efficacy, in comparison to a control condition, of two central techniques in CBT: thought records (TRs) and behavioral experiments (BEs).

METHOD

A mixed within and between participants design was used to compare the efficacy of a single session TR and a single session BE intervention with a control intervention, in a non-clinical sample. Ninety one participants were randomly allocated to one of the three conditions.

RESULTS

The overall pattern of results suggests that both TR and BE had a beneficial therapeutic impact in comparison to the control condition on beliefs, anxiety, behavior and a standardized measure of symptoms. There was evidence of a small advantage of the BE over the TR intervention in that the target belief changed earlier and change generalized to beliefs about others as well as the self.

CONCLUSIONS

The findings confirm the utility of both TR and BE interventions and point to BEs as more useful in effecting belief change in that the change in the BE condition occurred sooner and generalized further.

Using child health outcomes to identify effective measures of handwashing

We assessed which practical handwashing indicators were independently associated with reduced child diarrhea or respiratory disease. Fieldworkers collected 33 indicators of handwashing at baseline in 498 households in 50 villages in rural Bangladesh. Community monitors visited households monthly and asked standard questions about diarrhea and symptoms of respiratory illness among children under 5 years of age. In multivariate analysis, three handwashing indicators were independently associated with less child diarrhea-mothers reporting usually washing hands with soap before feeding a child, mothers using soap when asked to show how they usually washed their hands after defecation, and children having visibly clean finger pads. Two indicators were independently associated with fewer respiratory infections-mothers allowing their hands to air dry after the handwashing demonstration and the presence of water where the respondents usually wash hands after defecation. These rapid handwashing indicators should be considered for inclusion in handwashing assessments.

Microbial biogeography of public restroom surfaces

We spend the majority of our lives indoors where we are constantly exposed to bacteria residing on surfaces. However, the diversity of these surface-associated communities is largely unknown. We explored the biogeographical patterns exhibited by bacteria across ten surfaces within each of twelve public restrooms. Using high-throughput barcoded pyrosequencing of the 16 S rRNA gene, we identified 19 bacterial phyla across all surfaces. Most sequences belonged to four phyla: Actinobacteria, Bacteriodetes, Firmicutes and Proteobacteria. The communities clustered into three general categories: those found on surfaces associated with toilets, those on the restroom floor, and those found on surfaces routinely touched with hands. On toilet surfaces, gut-associated taxa were more prevalent, suggesting fecal contamination of these surfaces. Floor surfaces were the most diverse of all communities and contained several taxa commonly found in soils. Skin-associated bacteria, especially the Propionibacteriaceae, dominated surfaces routinely touched with our hands. Certain taxa were more common in female than in male restrooms as vagina-associated Lactobacillaceae were widely distributed in female restrooms, likely from urine contamination. Use of the SourceTracker algorithm confirmed many of our taxonomic observations as human skin was the primary source of bacteria on restroom surfaces. Overall, these results demonstrate that restroom surfaces host relatively diverse microbial communities dominated by human-associated bacteria with clear linkages between communities on or in different body sites and those communities found on restroom surfaces. More generally, this work is relevant to the public health field as we show that human-associated microbes are commonly found on restroom surfaces suggesting that bacterial pathogens could readily be transmitted between individuals by the touching of surfaces. Furthermore, we demonstrate that we can use high-throughput analyses of bacterial communities to determine sources of bacteria on indoor surfaces, an approach which could be used to track pathogen transmission and test the efficacy of hygiene practices.

Observation-based evaluation of hand hygiene practices and the effects of an intervention at a public hospital cafeteria

BACKGROUND

Hand hygiene is important before meals, especially in a hospital cafeteria where patrons may have had recent contact with infectious agents. Few interventions to improve hand hygiene have had measureable success. This study was designed to use a poster intervention to encourage hand hygiene among health care workers (HCWs) and hospital visitors (HVs) upon entry to a hospital cafeteria.

METHODS

Over a 5-week period, a poster intervention with an accessible hand sanitizer unit was deployed to improve hand hygiene in a hospital cafeteria. The dependent variable observed was hand hygiene attempts. Study phases included a baseline, intervention, and follow-up phase, with each consisting of 3 randomized days of observation for 3 hours during lunch.

RESULTS

During the 27 hours of observation, 5,551 participants were observed, and overall hand hygiene frequency was 4.79%. Hygiene attempts occurred more frequently by HCWs than HVs (P = .0008) and females than males (P = .0281). Hygiene attempts occurred more frequently after poster introduction than baseline (P = .0050), and this improvement was because of an increase in frequency of HV hand hygiene rather than HCW hand hygiene.

CONCLUSION

The poster intervention tool with easily accessible hand sanitizer can improve overall hand hygiene performance in a US hospital cafeteria.

The effect of handwashing at recommended times with water alone and with soap on child diarrhea in rural Bangladesh: an observational study

BACKGROUND

Standard public health interventions to improve hand hygiene in communities with high levels of child mortality encourage community residents to wash their hands with soap at five separate key times, a recommendation that would require mothers living in impoverished households to typically wash hands with soap more than ten times per day. We analyzed data from households that received no intervention in a large prospective project evaluation to assess the relationship between observed handwashing behavior and subsequent diarrhea.

METHODS AND FINDINGS

Fieldworkers conducted a 5-hour structured observation and a cross-sectional survey in 347 households from 50 villages across rural Bangladesh in 2007. For the subsequent 2 years, a trained community resident visited each of the enrolled households every month and collected information on the occurrence of diarrhea in the preceding 48 hours among household residents under the age of 5 years. Compared with children living in households where persons prepared food without washing their hands, children living in households where the food preparer washed at least one hand with water only (odds ratio [OR]=0.78; 95% confidence interval [CI]=0.57-1.05), washed both hands with water only (OR=0.67; 95% CI=0.51-0.89), or washed at least one hand with soap (OR=0.30; 95% CI=0.19-0.47) had less diarrhea. In households where residents washed at least one hand with soap after defecation, children had less diarrhea (OR=0.45; 95% CI=0.26-0.77). There was no significant association between handwashing with or without soap before feeding a child, before eating, or after cleaning a child's anus who defecated and subsequent child diarrhea.

CONCLUSIONS

These observations suggest that handwashing before preparing food is a particularly important opportunity to prevent childhood diarrhea, and that handwashing with water alone can significantly reduce childhood diarrhea.

Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 11. Use of antiseptics and sanitizers in community settings and issues of hand hygiene compliance in health care and food industries

Hand washing with soap is a practice that has long been recognized as a major barrier to the spread of disease in food production, preparation, and service and in health care settings, including hospitals, child care centers, and elder care facilities. Many of these settings present multiple opportunities for spread of pathogens within at-risk populations, and extra vigilance must be applied. Unfortunately, hand hygiene is not always carried out effectively, and both enteric and respiratory diseases are easily spread in these environments. Where water is limited or frequent hand hygiene is required on a daily basis, such as for many patients in hospitals and astronauts in space travel, instant sanitizers or sanitary wipes are thought to be an effective way of preventing contamination and spread of organisms among coworkers and others. Most concerns regarding compliance are associated with the health care field, but the food industry also must be considered. Specific reasons for not washing hands at appropriate times are laziness, time pressure, inadequate facilities and supplies, lack of accountability, and lack of involvement by companies, managers, and workers in supporting proper hand washing. To facilitate improvements in hand hygiene, measurement of compliant and noncompliant actions is necessary before implementing any procedural changes. Training alone is not sufficient for long-lasting improvement. Multiactivity strategies also must include modification of the organization culture to encourage safe hygienic practices, motivation of employees willing to use peer pressure on noncompliant coworkers, a reward and/or penalty system, and an operational design that facilitates regular hand hygiene.

Is structured observation a valid technique to measure handwashing behavior? Use of acceleration sensors embedded in soap to assess reactivity to structured observation

Structured observation is often used to evaluate handwashing behavior. We assessed reactivity to structured observation in rural Bangladesh by distributing soap containing acceleration sensors and performing structured observation 4 days later. Sensors recorded the number of times soap was moved. In 45 participating households, the median number of sensor soap movements during the 5-hour time block on pre-observation days was 3.7 (range 0.3-10.6). During the structured observation, the median number of sensor soap movements was 5.0 (range 0-18.0), a 35% increase, P = 0.0004. Compared with the same 5-hour time block on pre-observation days, the number of sensor soap movements increased during structured observation by ≥ 20% in 62% of households, and by ≥ 100% in 22% of households. The increase in sensor soap movements during structured observation, compared with pre-observation days, indicates substantial reactivity to the presence of the observer. These findings call into question the validity of structured observation for measurement of handwashing behavior.

A community-randomised controlled trial promoting waterless hand sanitizer and handwashing with soap, Dhaka, Bangladesh

OBJECTIVES

To pilot two intensive hand hygiene promotion interventions, one using soap and one using a waterless hand sanitizer, in low-income housing compounds in Dhaka, Bangladesh and assess subsequent changes in handwashing behaviour and hand microbiology.

METHODS

Fieldworkers randomized 30 housing compounds: 10 received handwashing promotion with free soap, 10 received handwashing promotion with free waterless hand sanitizer and 10 were non-intervention controls. Fieldworkers assessed handwashing behaviour by structured observation and collected hand rinse specimens.

RESULTS

At baseline, compound residents washed their hands with soap 26% of the time after defecation and 30% after cleaning a child's anus but <1% at other times. Compared with baseline, residents of soap intervention compounds were much more likely to wash their hands with soap after faecal contact (85-91%), before preparing food (26%) and before eating (26%). Compounds that received waterless hand sanitizer cleansed their hands more commonly than control compounds that used soap (10.4%vs. 2.3%), but less commonly than soap intervention compounds used soap (25%). Post-intervention hand rinse samples from soap and sanitizer compounds had lower concentrations of faecal indicator bacteria compared with baseline and control compounds.

CONCLUSIONS

Waterless hand sanitizer was readily adopted by this low-income community and reduced hand contamination but did not improve the frequency of handwashing compared with soap. Future deployments of waterless hand sanitizers may improve hand hygiene more effectively by targeting settings where soap and water is unavailable.

Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 9. Washing and drying of hands to reduce microbial contamination

During various daily activities at home and work, hands quickly become contaminated. Some activities increase the risk of finger contamination by pathogens more than others, such as the use of toilet paper to clean up following a diarrheal episode, changing the diaper of a sick infant, blowing a nose, or touching raw food materials. Many foodborne outbreak investigation reports have identified the hands of food workers as the source of pathogens in the implicated food. The most convenient and efficient way of removing pathogens from hands is through hand washing. Important components of hand washing are potable water for rinsing and soaps to loosen microbes from the skin. Hand washing should occur after any activity that soils hands and certainly before preparing, serving, or eating food. Antimicrobial soaps are marginally more effective than plain soaps, but constant use results in a buildup of the antimicrobial compound on the skin. The time taken to wash hands and the degree of friction generated during lathering are more important than water temperature for removing soil and microorganisms. However, excessive washing and scrubbing can cause skin damage and infections. Drying hands with a towel removes pathogens first by friction during rubbing with the drying material and then by wicking away the moisture into that material. Paper rather than cloth towels should be encouraged, although single-use cloth towels are present in the washrooms of higher class hotels and restaurants. Warm air dryers remove moisture and any surface microorganisms loosened by washing from hands by evaporation while the hands are rubbed together vigorously; however, these dryers take too long for efficient use. The newer dryers with high-speed air blades can achieve dryness in 10 to 15 s without hand rubbing.

Observed hand cleanliness and other measures of handwashing behavior in rural Bangladesh

Background

We analyzed data from the baseline assessment of a large intervention project to describe typical handwashing practices in rural Bangladesh, and compare measures of hand cleanliness with household characteristics.

Methods

We randomly selected 100 villages from 36 districts in rural Bangladesh. Field workers identified 17 eligible households per village using systematic sampling. Field workers conducted 5-hour structured observations in 1000 households, and a cross-sectional assessment in 1692 households that included spot checks, an evaluation of hand cleanliness and a request that residents demonstrate their usual handwashing practices after defecation.

Results

Although 47% of caregivers reported and 51% demonstrated washing both hands with soap after defecation, in structured observation, only 33% of caregivers and 14% of all persons observed washed both hands with soap after defecation. Less than 1% used soap and water for handwashing before eating and/or feeding a child. More commonly people washed their hands only with water, 23% after defecation and 5% before eating. Spot checks during the cross sectional survey classified 930 caregivers (55%) and 453 children (28%) as having clean appearing hands. In multivariate analysis economic status and water available at handwashing locations were significantly associated with hand cleanliness among both caregivers and children.

Conclusions

A minority of rural Bangladeshi residents washed both hands with soap at key handwashing times, though rinsing hands with only water was more common. To realize the health benefits of handwashing, efforts to improve handwashing in these communities should target adding soap to current hand rinsing practices.

Three kinds of psychological determinants for hand-washing behaviour in Kenya

Washing hands with soap at the right times - primarily after contact with faeces, but also before handling food or feeding an infant - can significantly reduce the incidence of childhood infectious disease. Here, we present empirical results which substantiate a recent claim that washing hands can be the consequence of different kinds of psychological causes. Such causes can be divided into three kinds of control over behaviour: automatic or habitual responses, motivated or goal-driven behaviour to satisfy needs, and cognitive causes which reflect conscious concerns. Empirical results are based on 3-h-long structured observations of hand-washing behaviour in 802 nationally representative Kenyan households with children under five, and structured interviews with the primary female caretaker in these households, collected in March 2007. Factor analysis of questionnaire responses identified three psychological factors which are also significant predictors of observed hand-washing behaviour: having the habit of hand-washing at particular junctures during the day, the motivated need for personal or household cleanliness, and a lack of cognitive concern about the cost of soap use. These factors each represent a different kind of psychological cause. A perceived link between clean hands and sexual attractiveness also appeared in the factor analysis, but was not a determinant of actual behaviour. We also report evidence that those who express concern about the cost of soap use are those with relatively few economic resources. We suggest that those developing hygiene promotion programmes should consider the possible existence of multiple types of strategies for increasing hand-washing behaviour.

Experimental pretesting of hand-washing interventions in a natural setting

OBJECTIVES

We pretested interventions derived from different domains of behavior change theory to determine their effectiveness at increasing hand washing with soap in a natural setting.

METHODS

We installed wireless devices in highway service station restrooms to record entry and soap use. Two text-only messages for each of 7 psychological domains were compared for their effect on soap-use rates. We collected data on nearly 200 000 restroom uses.

RESULTS

The knowledge activation domain was most effective for women, with a relative increase in soap use of 9.4% compared with the control condition (P = .001). For men, disgust was the most effective, increasing soap use by 9.8% (P = .001). Disgust was not significantly better than the control condition for women, nor was knowledge activation for men. Messages based on social norms and social status were effective for both genders.

CONCLUSIONS

Our data show that unobtrusive observation of behavior in a natural setting can help identify the most effective interventions for changing behaviors of public health importance. The gender differences we found suggest that public health interventions should target men and women differently.

Can the emotion of disgust be harnessed to promote hand hygiene? Experimental and field-based tests

Two studies carried out in Sydney, Australia explored whether inducing disgust may be a useful addition to hand-hygiene interventions. Experiment 1 employed a novel laboratory measure of hand hygiene, and tested whether a brief (3-min) video-based intervention using disgust/education, improved hand hygiene relative to education alone and a control condition. On test, a week later, the disgust intervention significantly exceeded the education and control condition combined, although the effect size was modest. Experiment 2 examined the generality of this effect in a field study. During a baseline period, soap and paper towel use in a series of washrooms were covertly monitored. This was followed by an intervention period, in which two washrooms received disgust/education-based posters and a further two, educational posters, exhorting participants to wash their hands. A follow-up period, after the posters were removed, was also monitored. The disgust-based intervention was significantly better at promoting hand hygiene. These findings suggest that even brief disgust-based interventions may be successful and that these can be tested and developed under laboratory conditions.

Biometric fingerprinting for visa application: device and procedure are risk factors for infection transmission

BACKGROUND

Biometric fingerprint identity verification is currently introduced in visa application and entry screening at border control. The system implies physical contact between the skin and the surface of the fingerprint-capturing and reading devices.

AIM

To assess the risk of infection transmission through fingerprinting.

METHODS

The medical literature was reviewed for the potential of microorganisms to be carried on the skin of hands in the community, to be transferred from hands to inanimate surfaces, to survive on surfaces, and to be transferred in doses exceeding the infectious dose. The fingerprinting procedures as currently applied were reviewed.

RESULTS

Factors that favor transfer of microorganisms are large skin-surface contact between flat fingers (2 x 20 cm(2)) and fingerprint-capturing device, nonporous contact surface, large overlap of contact surface and short turnaround time between successive applicants, high contact pressure, and difficulties to disinfect devices. Transmission risk exists for enteric viruses (rotavirus, norovirus, and hepatitis A virus), respiratory viruses (respiratory syncytial virus, rhinovirus, influenza virus, etc.), and enteropathogenic bacteria with low infectious doses (Shigella dysenteriae, Enterohemorrhagic Escherichia coli, etc.). Using Monte Carlo risk analysis on US data, transmission of human rotavirus is estimated at 191 [95% credible intervals (CI) 0-289] per million fingerprint-capturing procedures. Application of 70% isopropyl hand rub and 85% ethanol hand gel reduces the risk to 77 (95% CI 0-118) and 0.3 (95% CI 0-0.3) transmissions per million procedures, respectively.

CONCLUSIONS

The fingerprinting procedure as currently used is associated with a risk of infection transmission. Simple hygienic measures can considerably reduce this transmission risk.

Gender and ethnic differences in hand hygiene practices among college students

BACKGROUND

Poor hand hygiene on college campuses can be improved by promoting handwashing behavior. This observational study was conducted to evaluate gender and race/ethnic differences in hand hygiene practices among college students.

METHODS

Hand hygiene practices in college students were evaluated in 4 settings (soap and water; soap and water and visual prompts; soap and water and hand sanitizers; and soap and water, hand sanitizers, and visual prompts). The degree of hand hygiene (ie, adequate handwashing time, use of hand sanitizer, and hand-drying method) also was evaluated at various locations on campus.

RESULTS

Overall, 72.9% of students washed their hands, 58.3% practiced hand hygiene (using either soap or hand sanitizer), and 26.1% washed their hands adequately. Hand sanitizer use was low when students were given the option, and paper towel was the most common hand-drying method. In general, hand hygiene practices were better in academic buildings than in the student recreation center. Visual prompts improved handwashing behavior only among students in the "other" ethnic category, but not by gender.

CONCLUSIONS

Handwashing is the most effective way of preventing the spread of infectious diseases, and our findings have implications for the design of effective hand hygiene education programs in college students.

[A nationwide survey on the hand washing behavior and awareness]

OBJECTIVES

This study was conducted to evaluate the public's awareness of the importance of hand washing and to compare perceptions on the habit of hand washing with actual hand washing behavior.

METHODS

Data were collected by observing 2,800 participants washing their hands after using public restrooms in seven cities nationwide and by surveying 1,000 respondents (age>14 years) through telephone interviews using a structured questionnaire.

RESULTS

Although 94% of the survey respondents claimed to mostly or always wash their hands after using public restrooms, only 63.4% of the observed participants did wash their hands after using public restrooms. Significant factors related to increased adherence to hand washing were female gender, approximate ages of 20 to 39 years by their appearance, and the presence of other people from the observation. About 79% of the survey respondents always washed their hands after using bathrooms at home, 73% washed their hands before handling food, and 67% washed their hands upon returning to their home. However, 93.2% and 86.3% of the survey respondents did not wash their hands after coughing or sneezing and after handling money, respectively. Although most of the survey respondents (77.6%) were aware that hand washing is helpful in preventing communicable diseases, 39.6% of the survey respondents did not do so because they were 'not accustomed' to washing their hands and 30.2% thought that washing their hands is 'annoying'.

CONCLUSIONS

This is the first comprehensive report on hand washing behavior and awareness of the general population in Korea. The result of this study in terms of individual behavior and awareness of hand washing are comparable with similar studies conducted in other countries. However adherence to hand washing is still low and needs to be increased. The results of this study can be used as a baseline in setting up strategies and activities to promote adherence to hand washing.

Considering user attitude in early Development of environmentally friendly technology: a case study of NoMix toilets

Urine source separation (NoMix technology) has been proposed as a sustainable alternative to centralized wastewater treatment systems. Radical changes necessitate an early inclusion of sociological expertise, thus offering a real chance fortransdisciplinary collaboration. The practical aim of our survey is to find out how users accept and use existing NoMixtoilets and how this could be encouraged. We collected 1249 questionnaires from 2002 to 2004 in one Swiss school and one Swiss research institute. The technological immaturity of NoMix toilets was noted by many. Nevertheless, acceptance was high: 72% liked the idea and 86% would move into apartments with NoMix toilets. Moreover, most users found that NoMix toilets equal conventional toilets with respect to design (78%), hygiene (84%), and smell (78%). Like many other innovations, the NoMix technology only functions properly if it is used adequately, which we demonstrate for water saving and sitting to urinate. Many users adopted this behavior, e.g., 72% sat. Because perception and use of NoMix toilets is subjective, it can be influenced with certain measures such as good information and cleaning, or discussions with peers. We discuss the importance of social psychology for understanding the factors that influence the acceptance of environmentally friendly innovations.

An examination of covert observation and solution audit as tools to measure the success of hand hygiene interventions

BACKGROUND

Many studies have examined hand hygiene (HH) frequency and adherence in response to various interventions. This study used 2 methods to determine HH frequency and adherence to see how well the outcomes correlated.

METHODS

HH frequency was measured over 4, 1-month periods (phases 1-4), using 2 methods: an audit of HH solution used during each phase adjusted for patient-days and covert observation of HH adherence. The number of x-ray technician contacts with patients (a known quantity) across the study period was retrospectively compared with the number of observations made of x-ray technicians' HH behavior to see what proportion of contacts were observed.

RESULTS

HH solution use doubled in phase 2 and was 65% and 55% higher than the baseline level in phases 3 and 4, respectively. Observed HH adherence fell from 51% to 37% in phase 2 and then rose to 58% in phases 3 and 4. Three percent of x-ray technicians' patient contacts were observed across the 4 phases.

CONCLUSION

Observation of HH may not adequately sample patient contacts to provide an accurate measure of HH adherence. Further studies are needed to confirm this finding.

Hand-washing and methicillin-resistant Staphylococcus aureus

Effective hand-washing, including drying to decrease skin surface microbial counts, is recognized as a critical factor in infection control policies. It is also recognized that hand-washing is not always undertaken as it should be. Spending large amounts of time with the hands in water is not enough to control infection as the technique of washing hands is more important than merely the length of time under water. Therefore, ways of promoting hand hygiene must be found, as well as finding ways of ensuring that healthcare workers follow hygiene guidelines.

Hand washing compliance among retail food establishment workers in Minnesota

Inadequate hand washing by food workers is an important contributing factor to foodborne disease outbreaks in retail food establishments (RFEs). We conducted a survey of RFEs to investigate the effect of hand washing training, availability of hand washing facilities, and the ability of the person in charge (PIC) to describe hand washing according to the Minnesota Food Code (food code) on workers' ability to demonstrate food code-compliant hand washing. Only 52% of the PICs could describe the hand washing procedure outlined in the food code, and only 48% of workers could demonstrate code-compliant hand washing. The most common problems observed were failure to wash for 20 s and failure to use a fingernail brush. There was a strong positive association between the PIC being a certified food manager and being able to describe the food code hand washing procedure (odds ratio [OR], 5.5; 95% confidence interval [CI], 2.2 to 13.7), and there was an even stronger association between the PIC being able to describe hand washing and workers being able to demonstrate code-compliant hand washing (OR, 15; 95% CI, 6 to 37). Significant associations were detected among correct hand washing demonstration, physical infrastructure for hand washing, and the hand washing training methods used by the establishment. However, the principal determinant of successful hand washing demonstration was the PIC's ability to describe proper hand washing procedure. These results suggest that improving hand washing practices among food workers will require interventions that address PIC knowledge of hand washing requirement and procedure and the development and implementation of effective hand washing training methods.