Compliance to handwashing during the early phase of COVID-19 epidemic in Uganda: A nationwide cross-sectional survey

Richard Migisha^1,&, Bob Omoda Amodan¹, Lilian Bulage¹, Elizabeth Katana¹, Joseph Nelson Siewe Fodjo², Robert Colebunders², Alex Riolexus Ario^{1, 3}, Rhoda Kitti Wanyenze⁴

 

¹Uganda Public Health Fellowship Program, Ministry of Health, Kampala, Uganda, ²Global Health Institute, University of Antwerp, Doornstraat 331, 2610 Antwerp, Belgium, ³Ministry of Health, Kampala, Uganda, ⁴School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda

 

 

^&Corresponding author
Richard Migisha, Uganda Public Health Fellowship Program, Ministry of Health, P.O Box 7272, Kampala, Uganda. rmigisha@musph.ac.ug

 

 

 

 

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is still a major public health concern globally, and has overburdened health systems in many countries [1]. The disease was declared a global pandemic on March 11, 2020, with an estimated 118,000 confirmed cases and approximately 4300 deaths across all continents except Antarctica [2]. In Uganda, the disease outbreak was first reported on March 21, 2020 [3].As of April 12, 2020, Uganda had registered 54 confirmed cases of COVID-19 [3]. By May 6, 2020, the number of confirmed COVID-19 cases in Uganda increased to 100, with no deaths [4]. Following the confirmation of the first case in Uganda, the government imposed a ban on public transportation on March 25, 2020. Furthermore, a total nationwide lockdown was imposed beginning March 30, 2020, along with a nationwide curfew (starting 19:00 hrs to 6:30 hrs) [4]. The curfew was extended till June 2, 2020. Physical distancing, improved hand hygiene (using hand sanitizers and handwashing with soap and water), and the use of face masks were among the other COVID-19 mitigation measures that were recommended by the Ministry of Health (MoH) [4].

 

COVID-19 may be transmitted from person-to-person through respiratory droplets and contact with infected surfaces [1]. In the early stages of the pandemic, frequent, meticulous handwashing with soap and water was advised by the World Health Organization (WHO) as a major preventive strategy for COVID-19 [2]. Soap tears away the virus's outer covering. Furthermore, handwashing with soap creates a slick and mechanical action that causes the virus to rip away from the skin surface [5]. Handwashing has been viewed as an important intervention in the fight against the pandemic for a number of reasons: firstly, soap and water are cheap and readily available; secondly, handwashing is simple to practice by most individuals independently [5]. The important role of handwashing has been demonstrated previously against control of infectious disease from as early as the 19th century, when there was a significant reduction in maternal mortality from puerperal sepsis after a handwashing intervention [6, 7].

 

Frequent handwashing may be associated with dermatological reactions in some individuals [8]; some authors have also previously urged that frequent handwashing may make individuals have a false belief that they cannot acquire or transmit SARS-CoV-2 infection [8]; however, in the current context of the pandemic, proper and frequent handwashing remains a major recommendation because the benefits outweigh the risk [2]. Moreover, the complication of hand dermatitis can be easily prevented and managed by using the appropriate skin care products [8].

 

Despite the prescribed benefits of proper and frequent handwashing during the pandemic, compliance from individuals across many countries varied owing to the behavioral nature of the intervention [9]. While public education and knowledge dissemination are required for behavior change, they may not be sufficient [9]. To inform the COVID-19 control program in Uganda, we assessed the level of compliance to handwashing with soap and water, and associated factors, among Ugandan residents in the first two months of the COVID-19 outbreak.

 

 

Study design and population

 

We used data from the International Citizen Project (ICP), a cross-sectional nationwide online survey that used a self-administered questionnaire to examine adherence to preventive measures and their impact on the COVID-19 outbreak between April 16th and April 30th, 2020. The ICP survey gathered data on sociodemographic variables, the impact of COVID-19 and its restrictions on everyday life, work, and personal well-being, adherence to and satisfaction with personal and communal preventive measures, and the acceptability of these measures[10]. The questionnaire was distributed over WhatsApp, email, Facebook, and Twitter. Additionally, district health officers from across the country were sent an email with a link to the survey, which they were then asked to share with all their networks within the districts, including public servants and anyone else outside the local government. Individuals who received the questionnaire were encouraged to spread it further by sharing it with others in their networks. The ICP survey procedures and questionnaire are largely based on the citizen science Corona survey, which was initially launched by the University of Antwerp in Belgium on March 17, 2020, and has since been accepted by 21 nations around the world, including Uganda in April 2020. A total of 1,726 individuals took part in the survey. The wider nationwide cross-sectional survey's methods have been detailed elsewhere.[11, 12].

 

Study definitions and variables

 

For this study, we collected data on independent variables, including socio-demographic variables such as age, sex, education, location, marital status, and living/housing conditions, during the COVID-19 lockdown. In addition, we abstracted data on participants´ awareness of COVID-19, whether they smoked cigarettes or not, whether they had underlying medical conditions (e.g., diabetes, hypertension, HIV), and their level of satisfaction with handwashing as an appropriate COVID-19 preventive measure. A 5-item Likert scale was used to assess the level of satisfaction with handwashing as an appropriate COVID-19 preventive measure (1=very dissatisfied to 5=very satisfied). Participants who scored a score of 1-3 were considered to have a low degree of satisfaction, while those who had a score of 4-5 were considered to have a high level of satisfaction[11].

 

The dependent variable was handwashing with soap and water. Handwashing frequency was examined using a closed-ended question with the frequencies indicated as a number each day of the survey. In addition, participants were asked whether they washed their hands with soap and water after contacting surfaces or being in public (‘yes’ or ‘no’). Handwashing compliance was defined as: washing hands with soap and water for a minimum of 20 seconds, after touching surfaces, or having been in a public place[2].

 

Data management and statistical analysis

 

Data were extracted and cleaned using MS Excel 2019, thereafter exported to STATA 13 (Statacorp, College Station. Texas) for analysis. Our outcome of interest was compliance to handwashing with ‘yes’ coded as ‘0’ and ‘no’ coded as ‘1’. We first described characteristics of the study participants, and compared their distribution among individuals who complied with handwashing and those who did not comply, using Chi-square or two-tailed Fischer's exact test. We then performed univariable and multivariable logistic regression to identify factors associated with non-compliance to handwashing. Factors associated with non-compliance to handwashing (P<0.05) and those that were marginally associated (P<0.1) at univariable analysis were entered into multivariable logistic regression model, through backward stepwise elimination to identify factors independently associated with non-compliance to handwashing (P<0.05). We kept age in the final model, even though age was not associated with non-compliance at univariable analysis, because of biological plausibility.

 

Availability of data and materials

 

The datasets upon which our findings are based belong to the ICP COVID-19 project. For confidentiality purposes, the datasets are not publicly available. However, the data sets can be availed upon reasonable request from the corresponding author and with permission from the ICP COVID-19 project.

 

Ethical considerations

 

The study received ethical clearance from the Ethics committee of the University Hospital Antwerp and the University of Antwerp on March 23, 2020, Protocol number 20/13/148. On April 21, 2020, the study obtained clearance from the Higher Degrees, Research and Ethics Committee (HDREC) of Makerere University's College of Health Sciences, with protocol number 809. We did not collect any information that may be used to identify study participants. Participants were given an information sheet outlining the risks and benefits of participating in the survey, as well as the method in which the data would be collected and how confidentiality would be protected. Before participating in the study, all participants gave their informed consent electronically. Data were stored in a secure, password-protected server in Belgium. Secondary analyses of all data acquired by the ICP investigation were approved under all the ethical approvals.

 

 

Characteristics of study participants

 

Overall, 1,726 participants responded with a mean age (SD) of 36 (±11) years (range: 12-76 years). Most of the participants were male (59%), married/living with partners (58%), and lived in apartments (84%). Nearly all participants had ever heard about COVID-19 (99.7%), and were Ugandans (97%) Table 1. The distribution of sex (P=0.030), nationality (P=0.011), housing conditions (P<0.001), participants who had ever heard about COVID-19 (P=0.033), smoking and level of satisfaction with handwashing as an appropriate COVID-19 preventive measure (P<0.001) was statistically significant between participants who did not comply and those who complied with handwashing Table 1.

 

Compliance to handwashing and frequency during the early phase of COVID-19 epidemic in Uganda

 

Among the 1,726 participants assessed for compliance to handwashing with soap and water, 1662 (96%) complied; the remaining 64 (3.7%; 95%CI: 2.9-4.7%) were not compliant. Of the total 1,726 participants, most washed their hands 6-10 times/day (41%), followed by 3-5 times/day (34%); Only 31 participants (1.8%) did not wash their hands at all; 30 participants (1.7%) washed their hands more than 30 times/day Figure 1.

 

Factors associated with non-compliance to handwashing during the early phase of COVID-19 epidemic in Uganda

 

In multivariable analysis, individuals who had significantly higher odds of non-compliance were those who stayed in huts/shacks or who were homeless (aOR=6.1, 95%CI: 2.0-18; P=0.002) and individuals who had not heard of COVID-19 (aOR=13, 95%CI: 2.4-72, P=0.003) Table 2. Individuals with high level of satisfaction with handwashing as an appropriate COVID-19 preventive measure were less likely to be non-compliant to handwashing (aOR=0.26, 95%CI: 0.15-0.45, P<0.001)

 

 

We assessed the level of compliance to handwashing with soap and water and associated factors in the first two months of the COVID-19 outbreak in Uganda. Nearly all (96%) of the respondents were compliant to handwashing; poor housing conditions (being homeless, or staying in huts/shacks) and not being aware of COVID-19 were associated with non-compliance. Respondents who were highly satisfied with handwashing as an appropriate COVID-19 prevention measure were less likely to be non-compliant.

 

A recent demographic and health survey in Uganda, prior to the COVID-19 pandemic, reported handwashing compliance of 44% among household members whose households had soap and water available[13]. The much higher level of compliance to handwashing with soap and water observed in this study emphasizes the fact that COVID-19 could have reinforced handwashing behavior[14]. This may be attributed to the extensive messaging on different media platforms, emphasizing the importance of handwashing in the pandemic[15]. Consistent with our findings, a study among Polish adolescents also reported a significant improvement in handwashing compliance with soap and water during the COVID-19 pandemic[16]. Sustaining the high level of compliance to handwashing in Uganda will require sustained health promotion efforts aimed at improving hygiene, through mass media and social media in the different phases of the epidemic and in the post-COVID-19 era.

 

Our findings demonstrated that individuals who were homeless or staying in poor housing conditions were more likely to be non-compliant to handwashing with soap and water. Poor housing conditions are a sign of low socioeconomic status, which is frequently accompanied by water scarcity; in these situations, water is prioritized for other household requirements such as cooking[17]. The water insecurity —most common in poor housing conditions— in low–income countries may undermine the COVID-19 response efforts in the developing countries, and make water-insecure areas (e.g., slums) epicenters for disease transmission[17]. We therefore recommend that designated handwashing points be availed in areas with poor housing conditions so that handwashing with soap and water is more easily accessible to all Ugandans given the wide health benefits of handwashing.

 

Our study revealed that respondents who had never heard about COVID-19 were more likely to be non-compliant to handwashing with soap and water. Persons unaware of a disease always have low knowledge levels about the disease; the low knowledge ultimately influences the perception of disease severity. According to the Health Belief Model (HBM), individuals who believe they are at risk of contracting life-threatening infections, such as COVID-19, are more inclined to practice personal preventive measures such as handwashing and wearing facemasks[18]. Moreover, evidence accruing from pandemics of respiratory infectious diseases shows that lack of appropriate knowledge about the disease may result in negative emotions among people, further complicating disease prevention measures[19, 20]. Although awareness about COVID-19 was nearly universal among our study population, the fact that respondents who were not aware about the disease were less likely to practice handwashing, calls for the need to continue sensitization and risk communication among Ugandans. Similarly, respondents who were not highly satisfied with handwashing as an appropriate COVID19 preventive measure were less likely to be compliant. This is consistent with previous findings from research about the influence of perception of social campaigns by the general public on individual preventive measures[21]. It is hypothesized that one´s attitude towards public health measures practiced in a given society may influence their willingness to embrace such interventions[21].

 

Although our study generated valuable nationwide data on handwashing frequency and adherence to handwashing with soap and water by the Ugandan population, it is important to mention the study limitations. First, we did not ascertain the handwashing behavior of the study participants, and therefore the study relied on self-report of handwashing behavior, making it susceptible to social-desirability bias. However, this was minimized by making the questionnaire self-administered. The self-report of handwashing behavior may potentially have led to overestimation of the prevalence of handwashing compliance in this study. Second, data were collected online via internet; individuals who had no access to internet connection were unable to participate in our study. Therefore, our study sample is not a good representation of the general population in Uganda, and may have overestimated the prevalence of handwashing compliance.

 

 

The level of compliance to handwashing with soap and water was much higher in the Ugandan population in the first two months of COVID-19 epidemic, compared to ‘normal times’. Poor housing conditions, low level of awareness about COVID-19, and low perceived level of satisfaction with handwashing as an effective COVID-19 preventive measure were associated with non-compliance to handwashing. We recommend continued risk communication and public education to sustain the high compliance to handwashing. There is need to avail designated handwashing points to individuals with poor housing conditions during the epidemic so as to improve epidemic control.

 

 

The authors declare no competing interests.

 

Funding

 

The ICPcovid website, which was used to organise the survey, was funded by VLIRUOS (Flemish university development aid).

 

Disclaimer

 

The authors are entirely responsible for the content of this publication, which does not necessarily reflect the official views of Makerere University School of Public Health, the Ministry of Health of Uganda, or the Global Health Institute, University of Antwerp.

 

 

RC, JNSF, and RKW contributed to conceptualization and design; RM, EK, LB, ARA, BOA contributed to data acquisition, data analysis, data interpretation, and the first draft of the manuscript; Review of the paper to ensure intellectual content and scientific integrity, LB, ARA, and RKW; Supervision, LB, ARA, and RKW. All authors read and approved the final version of the manuscript.

 

 

We are grateful to all Ugandans who took the time and effort to participate in this research. We would like to thank the Uganda Public Health Fellowship Program, the Ministry of Health Uganda, and the Makerere University School of Public Health for their support in this research.

 

 

Table 1: Characteristics of study participants by hand washing compliance status

Table 2: Univariable and multivariable logistic regression for factors associated with non-compliance to handwashing

Figure 1: Percentage prevalence of handwashing by number of times of handwashing per day among 1,726 participants assessed for handwashing compliance in the early phase of COVID-19 outbreak, April 17-13, 2020. The error bars represent 95% confidence intervals

 

 

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