Journal of the New Zealand Medical Association, 09-November-2007, Vol 120 No 1265
The public hand hygiene practices of New Zealanders: a national survey
Claire Garbutt, Greg Simmons, Daniel Patrick, Thomas Miller
Hand hygiene has been shown to prevent the spread of infectious diseases since the 19th century1 and its public health benefits have been well documented in the international literature.2
Local research has identified that the time spent on both washing (Personal Communication Tom Miller, 10 September 2007) and drying hands are key determinants of the effectiveness of hand hygiene.3 While hand hygiene practices in the New Zealand healthcare environment have been studied,4 to date, those of the public have not. We report a multi-centre survey documenting the hand hygiene habits of New Zealanders in public washrooms.
Survey facilities—The survey was conducted in the toilet facilities of a large shopping mall chain in Auckland, Hamilton, Wellington, and Christchurch between 16 October 2006 and 1 December 2006. Washrooms were selected in each mall based on a high number of patrons (usually in close proximity to the food halls), and where the washroom area permitted observation of patrons’ hand hygiene from a suitable distance and without directly viewing the toilet facilities. All sites provided liquid soap, warm running water, and an option of either paper or air towels.
Observation methods—Observers were either staff of local public health services or local authorities. Observations were made on the hand hygiene practices of 150 males and 150 females in each of the four centres. Those patrons who entered the area of the toilet facilities (cubicles or urinals) were eligible for inclusion in the study.
Observers were instructed not to initiate communication with patrons. If asked the nature of their business, observers stated that they were conducting a hygiene survey. If there was more than one person carrying out hand hygiene practices at one time, data were recorded for the person who commenced hand hygiene first.
Recordings included: gender, estimated age-group by subjective judgment of the observer (child [under 16 years], adolescent [16-20 years], adult [21 years and over])), whether hands were washed, the use of soap, how long hands were washed, whether hands were dried, and the method and duration of hand drying.
Durations were timed using a stopwatch. All observers were trained in the use of the study protocol including timing and recording observations. Observers were encouraged to collect data on a number of different days and times, and also to perform observations on the mall’s late shopping night.
Washing was defined as the instant that the hands were rubbed together creating friction—with or without the presence of water. If hands were placed under the faucet without friction this was not considered to be hand washing. Drying was defined as contact of the hands with paper towels or an operating air towel within the washroom area.
Wiping hands on trousers/dress or any other surface was not considered to be drying for the purposes of the study.
Data analysis—Data were analysed using Epi Info 2002 statistical software.5 Point estimates of proportions with 95% confidence intervals (95% CI) were calculated. For continuous variables, mean and median values were calculated.
The hand hygiene practices of a total of 1200 subjects were observed. The ages of 1198 subjects were estimated at 7.6% children (<16 years of age), 16.9% adolescents (16–20 years of age), and 75.5% adults (21 years and over).
1039 (86.7%) of the 1200 subjects washed their hands (see Table 1).
Table 1. The proportion of subjects undertaking three main components of hand hygiene
*95% Confidence Interval.
No significant differences were noted in the frequency of hand washing between the four survey cities. The median duration of hand washing overall was 8.6 seconds (Table 2). The duration of hand washing for the subjects in Hamilton (median of 9.5 seconds) was longer than for those in any of the other cities. In all four cities a higher proportion of females washed their hands than males.
Table 2. Time that people spent washing and drying their hands
For all cities, 92.4% (95% CI 89.9–94.4) of females washed their hands compared to 81.0% (95% CI 77.6–84.0) of males. Females also washed hands for longer than males with a median duration of 8.8 seconds compared to 8.0 seconds for males. Only 8.1% (95% CI 6.5–9.9%) of subjects washed their hands for at least 20 seconds.
No relationship was found between the estimated age group of subjects and the length of time for which hands were washed. However, there was a marginal increase in the frequency of hand washing with increasing age group. In all cities the facilities each had one lower sink to enable children to wash their hands. In some instances, however, these were still both too high and too deep for young children to access without the assistance of an adult.
A total of 71.6% of subjects used soap when washing their hands. Overall, males used soap 66.2% (95% CI 61.8–70.3) of the time compared to 76.5% (95% CI 72.5–79.9%) for females, hence males used soap almost 10% less frequently than females.
Females used soap with greater frequency than males in all locations except in Hamilton where females used soap 77.7% of the time (95% CI 69.9–84.3%) compared to 87.1% for males (95% CI 79.9–92.4%). Soap use varied between locations, with males and females using soap less frequently in Auckland than all other locations.
Using soap was associated with a longer length of time of hand washing in all locations. The median length of time spent washing for those who used soap was 10.0 seconds compared to 5.0 seconds for those who did not (p<0.0001). Those who used soap also dried their hands significantly more frequently (94.4% (95% CI 92.4–95.9%)) than those who did not use soap (83.4% (95% CI 78.6-87.5%)). There were no significant age group differences in the use of soap.
91.2% of those subjects who washed their hands also dried them. Females dried their hands more often than males. Paper towels were the hand drying method preferred by three-quarters of subjects (75.6% [95% CI 72.8–78.3%]). Among children, the preferences for drying method was split between air and paper towels, with 49.2% (95% CI 36.4–62.1%) using air towels.
While both females and males preferred to use paper towels to dry their hands, females (79.6% [95% CI 75.8-83.0%]) used them significantly more frequently than males (71.0% (95% CI 66.5–75.2%).
Only 4.6% (95% CI 3.2-6.4%) of subjects dried their hands using paper towels for the recommended 20 seconds or more.
Adults were observed to dry their hands more frequently than children or adolescents. Of the 280 subjects (29.5% [95% CI 26.7–32.6%]) who used air towels to dry their hands, the median drying time was 16.4 seconds). Only one subject (0.4%, 95% CI 0.0–2.0%) dried their hands with an air towel for 45 seconds—the period recommended for optimal dryness with this method.
The use of soap was associated with longer drying times for both air towels and paper towels. Those who washed with soap used air towels for a median of 17.8 seconds compared to 10.7 seconds for those who did not. Those who washed with soap dried their hands on paper towels for a median of 8.0 seconds compared to 6.0 seconds for those who did not.
A small proportion (4.7%, 95% CI 3.5–6.2%) used both paper and air towels. Of the 49 subjects who used both air and paper towels, 11 (22.5% [95% CI 11.8–36.6%]) washed their hands for at least 20 seconds—a much higher proportion than the general sample of 8.1%.
This survey represents the largest observational study of public hand hygiene practices conducted in New Zealand. The only major population centre not included was Dunedin as no mall with suitable space for observation was identified.
The finding that 13.3% of those observed did not practise any form of hand hygiene after going to the toilet is of concern, although this percentage is similar to overseas surveys.6–8
The finding of a lower frequency of hand hygiene in males compared to females including hand washing, soap use, hand drying, and less time spent in handwashing and drying is also consistent with the international literature on hand hygiene compliance.
Few studies have investigated hand hygiene in community settings. The most comparable survey to ours in terms of sampling frame and observational methods was conducted in Australia in 2002.8 That survey of 200 subjects, conducted in the washrooms of an Australian shopping mall food hall, found that 92% of females and 71% of males carried out some form of hand hygiene after visiting the toilet. The observation that 8% of females and 29% of males failed to wash their hands at all after going to the toilet in that study compares to 8% of females and 19% of males not practising hand hygiene in ours. Only 31% of males and 41% of females used soap in the Australian study compared to 66% and 76% in our survey.
A United States study based in the washrooms of six international airports6 observed that 17% of females and 26% of males failed to wash their hands. A further US survey conducted in the toilet facilities of six public events showed that 10% of females and 25% of males failed to wash their hands.7
The only other community-based hand hygiene survey published in New Zealand was conducted by Townsend and Simmons;9 it found that 22.9% of female and 49.1% of male pupils of an Auckland primary school (children aged 11 years and under) failed to practise hand hygiene after going to the toilet, a lower compliance with hand hygiene than those in the ‘child’ age category (<16 years) of our study—at 13.0% and 35.1% respectively.
Our study estimated the mean time spent washing hands of 8.6 seconds (8.8 seconds for females and 8.0 seconds for males) which was significantly lower than the 20 seconds recommended by the New Zealand Ministry of Health10 and the New Zealand Food Safety Authority (NZFSA).11 Only 84 subjects (7.8%) who washed their hands did so for at least 20 seconds and only 15 (1.3% of all subjects) met the recommended3 hand hygiene duration of washing for at least 20 seconds and drying using a paper towel for a further 20 seconds. Only one subject (0.2%) who washed their hands for 20 seconds, dried them for at least 45 seconds using an air towel.
Of the 49 (4.1%) subjects who used a combination of both paper and air towels to dry their hands only in 2 of these did the total drying time equal or exceed the recommended 30 seconds (10 seconds using paper towel and 20 seconds using air towel).4 Those who used soap washed on average for 5 seconds longer than those who did not.
The use of soap use was higher for females and varied between locations, with males and females using soap less frequently in Auckland than all other locations, although the reason for this is unclear. In all locations, liquid soap dispensers were available, having been maintained regularly to ensure that soap was always available during the time subjects were observed.
Paper towels were the most popular method of hand drying in all locations. Of the 947 people in all locations who dried their hands 76% used paper towels in preference to air towels, although both methods of hand drying were equally available. The strongest preference for paper towels was noted in Wellington where 88.8% of patrons used this method.
Paper towels appear to have advantages over air towels due to the reduced time required to achieve dryness. Subjects who used air towels did so for an average of 16.4 seconds while those who used paper towels dried for an average of 7.6 seconds. For both methods this is less than half the time recommended to effectively reduce manual translocation of bacteria to other surfaces following washing.3
For small children, air towels could often only be accessed when an adult lifted and held the child, and therefore the length of time spent washing and their drying hands was determined by the adult rather than the child.
Those who used soap to wash their hands had a higher frequency (94% versus 83%) and duration of hand drying using both methods than those who did not use soap. This finding suggests that for some of the public there is a higher level of understanding of hand hygiene. Those who use soap may have an increased focus on hand hygiene and therefore recognise the need for thorough drying.
The survey suffered a number of limitations including the subjective assessment of age and the inability to assess any relationship of ethnicity on hand hygiene behaviour. All surveys are prone to biases and direct observational surveys are particularly influenced by the ‘Hawthorne effect’12 whereby the subjects’ behaviour is affected by the knowledge that they are being studied. In previous studies demonstrating a significant Hawthorne effect, the subjects were usually aware of the outcomes being measured.13
In this study the subjects were not made aware of the reason for which they were being observed, and in some cases it is likely that they did not realise that they were being observed. Subjects very rarely (less that 5%) approached the observer to ask them why they were present, however a few comments received by observers from subjects such as oh did I pass? or oops I should probably have washed for longer indicates some level of awareness. The use of more covert observation methods in future surveys such as video surveillance may reduce the Hawthorne effect.
There is still a significant gap between current hand hygiene recommendations and observed practice in our largest urban communities. It is clear from the findings of this study, and those previously carried out, that there is a significant disparity between males and females for hand hygiene compliance. These differences highlight the need for a shift in the health education strategies to specifically target males.
One proposed mechanism for increasing the length of time spent washing hands (as well as reducing the potential for faucet contamination) is to promote the use of sensor taps and to set them to run for 20 seconds, the time required to effectively wash hands. The implementation of a similar strategy with air towels may also encourage patrons to dry for the recommended duration.
This survey, despite a number of limitations, used simple reproducible methods and provides useful baseline data against which to compare future trends in hand hygiene behaviour.
While the findings show that the frequency of hand hygiene among New Zealanders is relatively high, the duration is much lower than recommended by the Ministry of Health10 and the New Zealand Food Safety Authority11 and there are significant behavioural differences between males and females.
Males were observed to have significantly poorer results in all aspects including the frequency of hand hygiene, use of soap, frequency of hand drying, and the duration of both washing and drying.
Future hand hygiene promotion needs to focus on the importance of the duration of hand washing and drying and in particular to target males.
Competing interests: None.
Author information: Claire Garbutt, Health Protection Officer, Population Protection Group, Auckland Regional Public Health Service, Auckland; Greg Simmons, Medical Officer of Health, Population Protection Group, Auckland Regional Public Health Service, Auckland; Daniel Patrick, Research Programme Manager, Social Statistics Research Group, The University of Auckland, Auckland; Tom Miller, Senior Research Fellow, Department of Medicine, The University of Auckland, Auckland
Acknowledgements: We thank the following people for their assistance with this survey:
Stephen Buetow (The University of Auckland); Hans Buik (Waikato District Health Board); John Pepper, Vanessa Coull, Paul Schuchmann, Karen Naylor, David Tu, and Dean Bentley (Hutt Valley City Council); Denise Tully, Braden Leonard, Chivala Hope, Kate McBride (Community and Public Health); John Whitmore, Shikha David, Margaret McDonald (Auckland Regional Public Health Service); and members of the New Zealand Foodsafe Partnership.
Correspondence: Dr Greg Simmons, Medical Officer of Health , Auckland Regional Public Health Service, Private Bag 92605, Symonds St, Auckland. Email: email@example.com
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