Written Evidence Submitted by

Dr Aaron Lawson, Research Associate, Ulster University

(C190006)

 

 

Interim Report on hand hygiene practices in Northern Ireland during the novel coronavirus (COVID-19) Pandemic

 

Mr Robert Cameron & Dr Marie Vaganay-Miller
Chief Investigators

 

Dr Aaron Lawson

Research Associate

Table of Contents

Executive Summary                                                                                                   Page 3

Introduction                                                                                                                              Page 4

Background Information                                                                                                   Pages 5-6

Findings                                                                                                                              Pages 7-12

Key Observations                                                                                                                Pages 13

Recommendations & Contacts                                                                                    Pages 14-15

 

 

 

 

 

 

 

Executive Summary

 

 

 

 

 

Introduction

  1. My name is Dr Aaron Lawson, Lecturer in Environmental Health at Ulster University, Belfast, Northern Ireland and I am submitting this interim report on behalf of the organisations I work for. Over the past five years my research has primarily focused on looking at the general population’s hand hygiene behaviour and compliance in the context of communicable disease transmission and how it can be improved through various informed intervention strategies.
  2. Ulster University in collaboration with safefood Ireland are currently conducting research into hand hygiene practices across the island of Ireland (Northern Ireland and the Republic of Ireland). This is an interim report of initial findings from observations of the general population’s handwashing behaviour and compliance when using public restrooms in Northern Ireland and the significance for the novel coronavirus (COVID-19) pandemic.
  3. While these recent observations are of handwashing behaviour and compliance in public restrooms, the interim findings can be indicative of wider hand hygiene practices in community settings.
  4. This interim report is not a detailed analysis of the overall findings but a preliminary report to highlight key observations and the potential significance of these findings to the current public health campaign and actions in relation to the COVID-19 pandemic.

 

 

 

 

 

 

 

 

 

 

 

Background Information

  1. In order to evaluate the general population’s handwashing behaviour and compliance in this study, thermal-imaging cameras were installed in one set of male and one set of female public restrooms located in Belfast city centre, Northern Ireland. Thermal-camera observation of the sink and hand dryer areas in each restroom was conducted over a 10-day period between 10 - 20 March 2020. Only those clearly identifiable as children were classified as such in the study.
  2. Public restrooms located in Belfast city centre were selected because of their availability during the ongoing novel coronavirus (COVID-19) pandemic, and also because it was theorised that urban public restrooms may provide ample opportunity for the spread of the virus during close contact between members of the general population after using the toilet.
  3. Each public restroom had only liquid soap available for washing hands, and Dyson hand dryers for drying hands. There were 3 cubicles, 5 urinals, 3 sinks and 2 hand dryers in the male restroom. In the female restroom there were 4 cubicles, 4 sinks and 2 hand dryers.
  4. An example of the images captured during the thermal-camera observation in both the ale and female public restrooms is shown in Figures 1 and 2 below.

 

A picture containing colorful, colored, child, man

Description automatically generated

Figure 1. Thermal image of male public restroom under observation in the study.

A picture containing colorful, graffiti, hydrant, room

Description automatically generated

Figure 2. Thermal image of female public restroom under observation in the study.

 

Findings:

  1. Key Finding: Hand hygiene compliance amongst the general population remains highly inadequate even considering current media campaigns around the novel coronavirus (COVID-19) pandemic.
  2. This ongoing research study involved the use of thermal-imaging cameras to observe the general population’s hand hygiene behaviour and compliance when using public restrooms. To date, a total of 498 thermal observations of members of the general population has taken place. This includes 254 males and 244 females. Of this general population, 453 were observed as being adults and 45 were observed as being children.
  3. For the purpose of this research, the hand hygiene compliance of the general population was defined into four distinct categories based upon relevant literature. The four categories and their definitions are described in the table below.
  4. *The term Inadequacy refers to the combination of non-hand hygiene, poor hand hygiene and basic hand hygiene.

HH Category

Description

Adequate HH

Washing hands for 20s using soap, water and drying for 15s using a Dyson hand dryer

Basic HH

Washing hands using soap, water and drying using a hand dryer but not for the adequate length of time.

Poor HH

Any other combination not fitting the above two.

Non HH

Did not wash or dry hands at all

 

 

 

 

 

 

 

 

 

 

 

  1. The hand hygiene compliance of the general population in this study is summarised in the tables below.
  2. Table 1 shows the overall and gender hand hygiene compliance categorisation for the sample population. Only 17.07% of the general population wash their hands adequately as defined within this study. A significant proportion show intent to wash their hands (62.65%) which is statistically significant (p = 0.02), but this is still in an inadequate fashion. Significantly, 7.23% of the overall general population do not wash or dry their hands at all, and this is more predominant amongst males and this is statistically significant (p = 0.02).

HH Compliance

Male

 

Female

 

Overall

 

 

 

n

(%)

n

(%)

n

(%)

p -value

Adequate HH

50

19.69

35

14.34

85

17.07

0.11

Basic HH

146

57.48

166

68.03

312

62.65

0.02

Poor HH

33

12.99

32

13.11

65

13.05

0.97

Non HH

25

9.84

11

4.51

36

7.23

0.02

Total

254

100.00

244

100.00

498

100.00

 

Table 1. Overall and gender hand hygiene compliance categorisation for the sample population.

 

  1. Table 2 shows the overall adult versus child hand hygiene compliance categorisation for the sample population. Significantly this table demonstrates the difference between adult and child hand hygiene. From the data gathered, children were significantly more likely to wash their hands adequately (44.44%) compared to adults (14.35%) and this is statistically significant (p = < 0.01).

HH Compliance

Adult

 

Child

 

Overall

 

 

 

n

(%)

n

(%)

n

(%)

p -value

Adequate HH

65

14.35

20

44.44

85

17.07

< 0.01

Basic HH

290

64.02

22

48.89

312

62.65

0.05

Poor HH

62

13.69

3

6.67

65

13.05

0.18

Non HH

36

7.95

0

0.00

36

7.23

0.05

Total

453

100.00

45

100.00

498

100.00

 

Table 2. Overall adult versus child hand hygiene compliance categorisation for the sample population.

  1. Table 3 shows the overall adult versus child comparison of hand hygiene adequacy versus inadequacy of the sample population. It highlights the difference in hand hygiene adequacy versus inadequacy* between adults and children.

HH Compliance

Adult

 

Child

 

Overall

 

 

n

(%)

n

(%)

n

(%)

Adequate HH

65

14.35

20

44.44

85

17.07

Inadequate HH

388

85.65

25

55.56

413

82.93

Total

453

100.00

45

100.00

498

100.00

Table 3. Overall adult versus child comparison of hand hygiene adequacy versus inadequacy of the sample population.

 

  1. Table 4 shows the overall and gender comparison of hand hygiene adequacy versus inadequacy of the sample population. It highlights the difference in hand hygiene adequacy versus inadequacy* between males and females. Overall, 80.31% of the general sample population do not wash their hands adequately despite the continued coverage in the media highlighting the importance of adequate hand hygiene in minimising the transmission of novel coronavirus (COVID-19).

HH Compliance

Male

 

Female

 

Overall

 

 

n

(%)

n

(%)

n

(%)

Adequate HH

50

19.69

35

14.34

85

17.07

Inadequate HH

204

80.31

209

85.66

413

82.93

Total

254

100.00

244

100.00

498

100.00

Table 4. Overall and gender comparison of hand hygiene adequacy versus inadequacy of the sample population.

 

 

 

 

 

 

 

 

 

  1. A breakdown of the general population’s hand hygiene behaviour is provided in the tables below.
  2. Table 5 shows the drying method used by male and female members of the general population who were observed, and Table 6 provides a breakdown of the drying method by adult and child.

Drying Method

Male

Female

Total

n

(%)

n

(%)

n

(%)

Hand dryer

198

77.95

202

82.79

400

80.32

Toilet Paper

16

6.30

15

6.15

31

6.22

Clothes

6

2.36

5

2.05

11

2.21

Not at all

34

13.39

22

9.02

56

11.24

Other

0

0.00

0

0.00

0

0.00

Total

254

100.00

244

100.00

498

100.00

Table 5. Overall frequency of drying method used by male and female members of the general population.

 

Drying Method

Adult

Child

Total

n

(%)

n

(%)

n

(%)

Hand dryer

358

79.03

42

93.33

400

80.32

Toilet Paper

30

6.62

1

2.22

31

6.22

Clothes

9

1.99

2

4.44

11

2.21

Not at all

56

12.36

0

0.00

56

11.24

Other

0

0.00

0

0.00

0

0.00

Total

453

100.00

45

100.00

498

100.00

Table 6. Overall frequency of drying method used by adult and child members of the general population.

 

  1. Figures 3 and 4 below shows how long members of the general population spent washing and drying hands. The mean length of time spent washing hands for all research subjects was 18.66 seconds (Std. dev: 13.91), and the mean length of time spent drying hands for all research subjects was 13.46 seconds (Std. dev: 9.49).

Figure 3. Mean length of time spent washing hands for research subjects.

Figure 4. Mean length of time spent drying hands for research subjects.

  1. For adults versus children, the mean length of time spent washing hands for adults was 17.17 seconds (SD: 12.08), and for children it was 32.51 seconds (SD: 20.75). For hand drying, the mean length of time spent by adults doing so was 12.48 seconds (SD: 8.16) and for children it was 22.26 seconds (SD: 14.85). Figure 5 below summarises this information.

Figure 5. Mean length of time spent washing and drying hands for adults and children in this study.

 

 

 

 

 

 

 

 

 

Key Observations

  1. Notwithstanding the overall aim of the study, these findings appear highly significant considering the unforeseen novel coronavirus (COVID-19) pandemic. One of the overriding messages to the general population has been on the importance of washing hands to prevent the spread of the new disease. This is emphasised in almost every news and public health announcement.
  2. The interim findings in this report indicate that despite these repeated communications and public health messages, the general population is still not practicing adequate hand hygiene compliance with 82.93% overall practicing inadequate hand hygiene compliance as per this ongoing study.
  3. Another key finding in this ongoing study would be that children have a significantly higher level of hand hygiene compliance (44.44%) compared to adults (14.35%). This may indicate that children may be valuable role models in any public health campaign on hand hygiene (It must be noted however that within the sample population there were only 45 children observed in total).
  4. Males are significantly more likely to not wash or dry their hands at all (9.84%) compared to females (4.51%) although both levels of non-hand hygiene compliance appear to be high considering current public health campaigns around minimising the transmission of novel coronavirus (COVID-19).

 

 

 

 

 

 

 

 

 

 

 

 

Recommendations

  1. This study aimed to evaluate the hand hygiene behaviour and compliance of the general population during the novel coronavirus (COVID-19) pandemic in an urban setting in the UK. This may be the only research of its kind currently being undertaken anywhere across the globe. Given the importance of this unique public health research and in light of the novel coronavirus (COVID-19) pandemic, we feel that the interim findings of this ongoing study could be highly significant in informing public health campaigns in the coming weeks and months, and potentially could be of international significance.
  2. If the indicative level of inadequate hand hygiene behaviour and compliance amongst the general population is not addressed quickly and effectively, then this will not only increase the risk of further spread, but also increase the burden of the disease on the national healthcare service and its capacity to cope.
  3. Current public health campaigns around novel coronavirus (COVID-19) do not appear, based on this study, to have the desired impact and may need to be reviewed or re-enforced in order to achieve the levels of compliance required to slow the spread of the pandemic.
  4. A major focus should be placed on improving the length of time spent washing and drying hands to at least 20 seconds or more as timing is the key factor in the adequate method of hand hygiene practice and compliance as has previously been established.
  5. Focus should also be placed on improving the behaviour of the large number in the basic hand hygiene category, displaying an intent to practice good hand hygiene, but not meeting the required 20 seconds. Improvement in behaviour among this group would make a significant difference in the levels of overall hand hygiene compliance and should be viewed as a key target group.
  6. While other initiatives to improve timing need to be investigated, a simple visual or audible timer placed in public restrooms may be a novel approach to ensure that people do spend the correct length of time washing hands in these facilities.
  7. Similarly for hand drying, most hand dryers are constricted to a pre-determined timing setting, and therefore most people who do not dry their hands adequately are potentially doing so because they trust the time limit set by the hand dryer for its operating duration, rather than using a visual or audible timer or counting themselves to make sure hands are dried adequately.
  8. Children appear to practice adequate hand hygiene compliance significantly better than adults, and they may be useful as key role models for promoting adequate hand hygiene behaviour in current and future public health campaigns around preventing the spread of COVID-19 for both children and adults. Particularly for those adults who frequently practice inadequate hand hygiene compliance.

 

 

(April 2020)

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