 
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 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.
MethodSurvey 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.
ResultsThe 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).
Hand washing1039 (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.
Use of soapA 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.
Hand drying91.2% 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%.
DiscussionThis 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: gregs@adhb.govt.nz
References:
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| | Current
issue | Search journal |
Archived issues | Classifieds
| Hotline (free ads) Subscribe | Contribute | Advertise | Contact Us | Copyright | Other Journals |
|