Hand Washing Study 1

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AdvAncement of the ScienceHand Washing Practices ina College Town Environment

Abstract Many people do not wash their hands when thebehavior in which they engage would warrant it. Most research of handwashing practices to date has taken place in high-traffic environments suchas airports and public attraction venues. These studies have established apersistent shortcoming and a gender difference in hand washing compliance.Using field observations of 3,749 people in a college town environment,the research described in this article replicates and extends earlier workwhile identifying potential environmental and demographic predictors ofhand washing compliance. Additionally, the authors research suggests thatproper hand washing practices, as recommended by the Centers for DiseaseControl and Prevention, are not being practiced. Finally, the authors research raises a question as to the accuracy of earlier measurements ofproper hand washing practices, suggesting that compliance rates areinflated. The results can help increase hand washing rates for the generalpublic and thus decrease the risk of transmitting disease.

Introduction

Many individuals take hand washing for

granted and do not consider how essentialhand washing is in the prevention of infectionsand disease. Thus they often fail towash their hands when they engage in activitythat would warrant or require hand washing.Research has established that peoplegenerally overstate the degree to which theywash their hands; that women are much morelikely to wash their hands than men; and thatwhile hand washing compliance appears tohave increased in recent years much room forgrowth still exists. According to the Centersfor Disease Control and Prevention (CDC)

(Mead et al., 1999), failing to wash or insufficientlywashing hands contributes to almost50% of all foodborne illness outbreaks. Additionally,Curtis and Cairncross (2003) performeda meta-analysis that suggests that

hand washing with soap can reduce diarrhealdisease risks by more than 40% and that handwashing interventions could save one millionlives annually. Yet we do not know why peoplefail to wash their hands at recommendedrates and in the proper fashion. Our researchattempted to establish predictors of hand

washing that can be used to induce higherrates of hand washing compliance.

Current Hand Washing Practices

Recent surveys establish that U.S. adults claimto wash their hands after using public restroomsat very high rates. In 2009, 94% (N =2,516) suggested that they consistently washtheir hands (QSR Magazine, 2009), while in


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2010, 96% (N = 1,006) stated that they alwayswash their hands after using a public restroom(Harris Interactive, 2010). Self-reports of handwashing behavior have been criticized as unre

carl P. Borchgrevink, PhdJaemin cha, PhdSeunghyun Kim, Phd

The School of Hospitality BusinessMichigan State University

liable as hand washing is a socially desirableactivity (Judah, Aunger, Schmidt, Granger, &Curtis, 2009) and observational research suggeststhese high self-report rates are inflated(Harris Interactive, 2010).

The potential discrepancy aside, it is importantto note that hand washing rates havetrended upwards in recent years. The AmericanSociety for Microbiology and the AmericanCleaning Institute have studied hand washing

practices since 1996. Most recently theyreported on hand washing in restrooms atpublic attractions in five cities across the U.S.The restroom locations included Turner Fieldin Atlanta, the Museum of Science and Industryand Shedd Aquarium in Chicago, Penn Stationand Grand Central Terminal in New York,and the Ferry Terminal Farmers Market in SanFrancisco (Harris Interactive, 2010). All locationsexperience high volumes daily, and atthe composite level, the 2010 data (N = 6,028)establishes that 85% of the observed adultswash their hands after using a public restroom.

This is an increase from 77% in 2007 (N =6,076), which was somewhat lower than the2005 rate of 83% (N = 6,336). With the exceptionof the Shedd Aquarium, which has seen a3% dip in hand washing rates since 2005, all thevenues saw a slight upward trend in observedhand washing rates (Harris Interactive, 2010).In 2003, hand washing rates were also observedacross six North American airports, averaging74% compliance (N = 4,046). The highest handwashing rates were obtained in Toronto with95% while Chicago had the lowest rate at 62%(American Society for Microbiology, 2003).

The research consistently finds a genderbias in hand washing practices. Women washtheir hands more frequently than men. In the2003 study (American Society for Microbiology)it was observed that 83% of womenwashed their hands after using the restroom,

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whereas only74% of the men did so. In a multi-year study across public attractions, womenconsistently wash more than men across allyears and venues (Harris Interactive, 2010).The average observed hand washing rates forwomen were 93% in 2010, 88% in 2007, and90% in 2005. The equivalent rates for menwere 77%, 66%, and 75%, respectively.

A study of 120 secondary school students(Guinan, McGuckin-Guinan, & Sevareid,1997) found that 58% of female students and48% of male students washed their hands afterusing the restroom, although only 28% of thefemale students and 8% of the male studentsused soap. In a university campus public restroomstudy (Johnson, Sholoscky, Gabello,Ragni, & Ogonosky, 2003), 61% of women and37% of men (N = 175) were observed washingtheir hands, while the hand washing rateclimbed to 97% for women and fell to 35% ofmen when a sign was introduced to encouragehand washing. Similarly, in a British 32-day

study of highway service station restrooms (N= 198,000) that observed entry and soap usewith electronic sensors, it was found that 65%of women and 32% of men washed their hands,but that the hand washing rate increased toas much as 71% for women and 35% for menwhen messages designed to encourage handwashing were displayed using electronic dotmatrix screens (Judah et al., 2009).

A study of the hand washing practicesof university students living in a dormitoryfound that women wash their hands after

urinating 69% of the time and after bowelmovements 84% of the time, whereas the correspondingfigures for males were 43% and78% (Thumma, Aiello, & Foxman, 2008). Ina study of restaurant food workers (Green etal., 2006), food handlers washed their handsonly 32% of the time when their behaviorsmade such hand washing required.

A review of the literature on foodbornedisease outbreaks from 1975 to 1998 identified81 foodborne disease outbreaks involving14,712 people within which 93% of the

foodborne outbreaks involved infected foodworkers transmitting pathogens to the foodwith their unwashed hands (Guzewich &Ross, 1999). An observation of 80 womenin a bar bathroom (Hayes, 2002) found thatonly 40% washed their hands; when theresearcher engaged the subject and modeledhand washing, the hand washing rateincreased to 56%, while it dropped to 27%


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when the researcher appeared to be simplytalking on her cell phone. This research alsonoted that the female subjects were less likelyto wash their hands later in the night thanearlier in the evening (r = -.44, p < .01).

It is evident from the reviewed researchthat room for improvement exists in handwashing practices. Additional research isneeded to further understand how and whyhand washing rates differ and if such ratescan be influenced by environmental factorswithin the restroom. Gender is associatedwith marked differences in hand washingrates. Are other demographic variables suchas age also associated with hand washingrates? Furthermore, evidence exists thatenvironmental variables such as signageand posters influence hand washing ratesand other health-related behaviors (Etter &Laszlo, 2005; Judah et al., 2009). Do otherenvironmental variables, such as sink conditionsand type of faucet impact hand washingrates? Does the hand washing rate on campus

differ from the rate off campus?

It is unclear from the reviewed literaturewhether the various reported rates of handwashing reflect hand washing with soapas recommended by the CDC or if the ratesincorporate practices somewhat inconsistentwith the established recommendations. Assuch, our study used three measures of handwashing, defined as 1) no washingleavingthe restroom without washing or rinsinghands, 2) attempted washingwettinghands but not applying soap, and 3) washing

hands with soap, in addition to measuring theduration of washing. This added distinctionis important because Burton and co-authors(2011) reported that washing with soap andwater is more effective at removing fecal bacteriafrom hands than washing with water alone.

Methods

Participants and Procedures

Direct observations of hand washing behaviorswere conducted by 12 research assistants

in restrooms located across a college town.Observers were instructed to be unobtrusiveand disguise their observation of handwashing behaviors. To ensure this and ensureaccurate measurement and coding consistency,each of the observers met researchersindividually for training and attended trainingmeetings as a group.

All observations were recorded according


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to a standard coding form. The coding formconsisted of the subject ID, date, subjectsage group, observation time, gender, handwashing behaviors, the type and availabilityof drying mechanisms (i.e., not available,hot air, paper towel, or both), location ofrestrooms (off campus versus on campus),type of faucet (standard faucet versus motiondetection), the cleanliness of sink conditions,and availability of hand washing signage.

Washing behaviors were recorded into threecategories: no washing (leaving the restroomwithout washing or rinsing their hands),attempted hand washing (wetting handswithout using soap), and washing hands withsoap. Observers also discreetly measured thetotal length of time in terms of the numberof seconds subjects hands were placed underrunning water during washing, lathering, andrinsing. The time of observation was collectedand nominal time categories were formed forthe purpose of analyses. Due to the unobtrusivenature of our observations, the subjects

age group was estimated using the trainedobservers subjective evaluations and the subjectwas placed into one of two groups: collegeage or younger and older than college age. Thecleanliness of sink conditions had three categoriesincluding dirty, reasonable, and clean,which was also based on the subjective evaluationof observers. The presence of a handwashing sign was added to the coding formlater based on observer feedback.

Statistical Analysis

Descriptive data were compiled and furtheranalyzed using Chi-square analysis andANOVA. Specifically, Chi-square analysis wasused to identify statistically significant differencesin subjects demographic variables,environmental variables in the restrooms,and among hand washing behaviors. ANOVAwas used to establish mean differences in thelength of time hands were placed under runningwater across the above specified variables.Kappa and paired t-test statistics werecalculated, using a subsample (n = 90) toevaluate inter-rater reliability.

Results

Inter-Rater Reliability

Evaluation of inter-rater agreement is an importantstep in ensuring reliability in observa-

April 2013 Journal of Environmental Health


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AdvAncement of the Sciencetional studies, especially when studies involvemultiple observers. We selected four differentrestrooms (n = 44, located in two off-campusrestrooms; and n = 46, located in two on-campusrestrooms) to determine the inter-rater reliabilityamong observers. The observers agreed100% on the environmental variables. For thetwo dependent variables, the time spent washingtime and other washing behaviors, paired-samples t-tests (Fleiss, 1981), and CohensKappa (Cohen, 1960) were used. A Kappa statisticof more than .8, more than .6, and morethan .4 is considered to have almost perfect, substantial, and moderate agreement,respectively (Landis & Koch, 1971). Excellentinter-rater reliability was demonstrated as indicatedby nonsignificant paired t-test result inestimating washing time (p > .01) and Kappa of.89 in evaluating washing behaviors.

Characteristics of Sample andOverall Findings

Table 1 presents characteristics of the sampleand observation settings. Of the 3,749 subjectsobserved, approximately 54% of observationstook place in restrooms located off campus.Sixty-two percent of observations took placein the afternoon, followed by evening/night(23.6%) and morning (14.4%). Of all subjects,60.5% of the observed subjects were women.About 62% (61.6%) of the subjects were estimatedas college age or younger, with theremainder estimated to be older than college.Nearly all restrooms had a mechanism for drying

hands (98.7%). About 64% of the restroomsin the study contained signs encouraging handwashing. Seventy-seven percent of the restroomswere equipped with a standard faucetwhile 22.9% had motion detection faucets.

Overall, 66.9% of the subjects used soapwhen washing their hands. Of these, 1.2% didnot dry their hands, but left the restrooms withwet hands. About 23% attempted to wash theirhands, that is, they wet their hands but did notuse soap. A total of 10.3% did not wash theirhands at all after using the restroom. CDC

(2012) recommends that people should rubtheir soaped hands for 15 to 20 seconds beforerinsing thoroughly. Our measure of durationincluded the length of time placed under runningwater while subjects were washing, rubbing,and rinsing their hands. Nonetheless, asshown in Table 2, only 5% or so spent morethan 15 seconds in combined washing, rubbing,and rinsing of their hands.


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Characteristics of Sample and restroom Settings (N = 3,749)Variables n%TABLE 1Observation timeMorning 538 14.4Afternoon 2,326 62.0Evening/night 885 23.6GenderMale 1,479 39.5Female 2,270 60.5AgeCollege group and youngerthan college group2,310 61.6Older than college group 1,439 38.4DryingNot available 47 1.3Only paper 2,799 74.7Only air dryer 331 8.8Both paper and air dryer 572 15.3FaucetStandard faucet 2,889 77.1Motion detection 860 22.9

Sink conditionDirty 219 5.9Reasonable 1,779 47.5Clean 1,750 46.7LocationOn campus 1,755 46.8Off campus 1,994 53.2SignSign 1,548 63.7No sign 882 36.3

Results From Chi-Square Analysis

The Chi-square analysis revealed statisticallysignificant differences in hand washingbehaviors across time of observation, gender,age, sink condition, and hand washing signage(Table 3). For example, 12.4% observedduring evenings did not wash their handswhile the morning and afternoon rates ofleaving the restroom without attempting towash were 8.6% and 9.4%, respectively. Subjectswashed their hands significantly morewith soap during mornings (70.6%) thanduring afternoons (66.4%) and evenings(67%). The gender difference was confirmed

with women using soap and engaging inproper hand washing behavior significantly

more (77.9%) than men (50.3%). About 7%of the women and 14.6% of the men did notwash their hands at all, while 15.1% of thewomen and 35.1% of the men simply wettheir hands with water. Those estimated tobe older than college (70.3%) washed theirhands with soap significantly more than the


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college age and younger group (64.8%).

When restrooms contained hand washingsigns, subjects used soap more (68.5%) thansubjects in restrooms that had no such signs(60.5%). Sink cleanliness influenced handwashing behaviors as well. When sinks wereclean, 73.9% washed their hands using soap,while the rate for reasonably clean and dirtysinks was 61.2% and 59.4%, respectively. No

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TABLE 2

overall Hand Washing Behavior and Length of Hand Washing time(N = 3,749)

Variables n%Washing behaviorNot washing

384

10.3Wetting hands without soap856

22.8Washing hands with soap2,509

66.9Length of hand washing time0 seconds

384

10.314 second(s)824

22.058 seconds1,432

38.2914 seconds911

24.215 seconds or longer198

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Chi-Square test: Comparison of Hand Washing Behavior by SampleDemographics and restroom Settings (N = 3,749)Variables Not Washing Wetting HandsWithout SoapWashingWith Soap

.210.3%(n = 384)22.8%(n = 856)66.9%(n = 2,509)% % %Observation time 13.2*Morning 8.6 20.8 70.6


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Afternoon 9.4 24.2 66.4Evening/night 12.4 20.6 67.0Gender 311.3*Male 14.6 35.1 50.3Female 7.1 15.1 77.9Age 12.9*College group and youngerthan college group10.6 24.6 64.8Older than college group 9.7 20.0 70.3Faucet 0.8Standard faucet 9.8 22.9 67.3Motion detection 10.8 23.0 66.2Sink condition 91.2*Dirty 19.6 21.0 59.4Reasonable 10.7 28.1 61.2Clean 8.1 17.9 73.9Location 4.8On campus 10.3 24.3 65.4Off campus 9.7 21.6 68.6Sign 17.4*Sign 9.7 21.7 68.5No sign 10.7 28.8 60.5*p < .01.

TABLE 3statistically significant differences in subjects hand washing behavior were found acrossfaucet type (standard faucet versus motiondetection) or restroom location (on campusversus off campus).

Results From ANOVA

Multi-way ANOVA was conducted to evaluatethe mean differences among identifiedfactors in terms that may influence thelength of washing time (Table 4). Statistically

significant differences were foundfor gender, age group, type of faucet, sinkcondition, and hand washing signage. Theaverage washing time for men and women,although short for both, was 6.27 secondsfor men and 7.07 seconds for women. Thegender effect persists. The age group olderthan college spent significantly more timewashing their hands (mean = 6.93 seconds)than did college group and younger thancollege group (mean = 6.48 seconds). Thepresence of a sign also influenced washingtime; the mean score in the presence of a sign

was 7.08 seconds and 6.50 seconds without.Subjects spent significantly more time washingtheir hands when the sink condition wasclean (mean = 7.20 seconds), compared towhen the sink appeared reasonably clean(mean = 6.36 seconds) or dirty (mean = 6.16seconds). No significant differences in handwashing time were found across time ofobservation or restroom locations.


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Discussion

Hand washing is the most effective thing onecan do to reduce the spread of infectious diseasesaccording to CDC (CDC, 2012; Meadet al., 1999). Our study provided detailedinformation about how long and in whatenvironments different groups engaged invarious hand washing behaviors. While earlierresearch reported that not all wash theirhands, prior studies have not identified factorsassociated with proper hand washingbehaviors. Additionally, previous studies didnot clearly distinguish between washing withand without soap. Our study recognizes theimportance of environmental factors thatpromote proper hand washing behaviors. Toour knowledge, our study was one of the firststudies to focus on hand washing behaviorsand the length of time spent washing whileincorporating environmental factors and thetime of observation.



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AdvAncement of the ScienceThe observed hand washing behaviors andthe length of time washing hands relate differentlyto different factors. Our study supportsearlier work in observing that men needmore encouragement than women to engagein proper hand washing behaviors, althoughmost men and women do wash their handsusing soap. Nonetheless, the percentages whosimply wet their hands was significantly higherfor men (35.1%) than for women (15.1%).

While our study was not specificallydesigned to test for the intervention effect of ahand washing sign, the study did find that thepresence of a sign influenced both hand washingbehaviors and the length of washing time.This is an important finding as a high percentageof people fail to wash their hands properly,and signs that include messages highlightingcorrect hand washing or reminders to use soapmay increase compliance. It appears that thiskind of explicit reminder may be particularly

useful in mens restrooms, given that morethan one-third of men simply wet their handswithout using soap.

In previous studies the automated andsequenced phases of the device/sink resultedin significant improvement in hand washingpractices (Larson, Bryan, Adler, Lee & Blane,1997; Larson, McGeer, & Quiaishi, 1991).Our study showed that the type of faucetitself (standard faucet versus motion detection)did not impact hand washing behaviors.Care must be taken in the interpretation of

washing time, as it is possible to equate washingtime with the motion-detected dispensingof water, much as our study did in terms ofmanual water flow.

More importantly, the findings of our studyshowed that it is important to maintain cleansink conditions, as clean sinks promotedproper hand washing procedures as well asincreased length of time washing hands. Whensinks are dirty, some may choose not to washtheir hands, despite knowing they should.Studying the effect of time of day on hand

washing behavior, a relatively new researchfocus, showed that hand washing generallydecreased as the evening progressed.

The most important findings of our researchrelate to the distinctions among hand washingbehaviors and the length of time handswere washed. Specifically, less than 6% of thesample approached the recommended handwashing duration. Furthermore, our study


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identified that a large proportion of subjects

Multi-Way aNoVa: Hand Washing time by Demographics andrestroom Settings (N = 3,749)Variables Hand Washing TimeMean (Seconds)F.2Observation time .92 .022Morning 6.50Afternoon 6.81Evening/night 6.77Gender 25.21* .082Male 6.27Female 7.07Age 8.14* .058College group and youngerthan college group6.48Older than college group 6.93Faucet 49.29* .114Standard faucet 6.45Motion detection 7.74Sink condition 15.76* .091Dirty 6.16

Reasonable 6.36Clean 7.20Location 2.23 .024On campus 6.63Off campus 6.86Sign 7.97* .057Sign 7.08No sign 6.50Note. Total mean = 6.75 (SD = 4.76), mean = 7.52 (SD = 4.41).*p < . 01.TABLE 4engaged in hand washing behavior that didnot involve the use of soap. It is interesting

to note that if the proportion of people whowere observed using soap when washing theirhands were combined with those who onlyused water, the hand washing rates reach thehigher levels reported in other studies. Thisraises the question of whether hand washingcompliance rates have been inflated by way ofdefinition in earlier work.

Limitations and Future Research

While the data from our study are informative,it should be noted that observations

only took place in one college town environment.Care should be therefore taken in generalizingthe findings.

As an alternative to the self-reportingmethod, direct and unobtrusive observa

tions of hand washing were used as a way toenhance reliability and validity. It should be


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recognized, however, that even an apparentunobtrusive observation may influence handwashing behaviors, as the simple presence ofothers in a restroom may lead to increasedcompliance (Bittner, Rich, Turner, & Arnold,2002; Drankiewicz & Dundes, 2003; Edwardset al., 2002; Nalbone, Lee, Suroviak, & Lannon,2005).

While our study attempted to investigatethe role that a hand washing sign would haveon hand washing behavior, the subjects werenot asked whether they recalled seeing thesign or whether they could recall the messages.Future research should consider signcontent, design, and placement.

In our study the act of drying was measured.Approximately 2% of subjects who

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attempted to wash their hands (i.e., wettinghands without soap) or washed hands withsoap did not dry their hands at all, but wedo not know if those who attempted to drytheir hands achieved dry hands. This wouldbe good to include in future studies as studieshave demonstrated that the transfer ofmicroorganisms is more likely to occur fromwet skin than from dry skin (Mackintosh,& Hoffman, 1984; Merry, Millder, Findon,Webster, & Neff, 2001; Patrick, Miller, &Findon, 1997).

Conclusion

Our study replicated and extended earlierwork on hand washing practices. While paststudies have focused on high-traffic venuessuch as transportation hubs and stadiums,our study focused on hand washing behaviorsin a college town environment. Fieldobservations by trained observers in a varietyof restrooms provided a sample of 3,739 people

who were unobtrusively watched to notetheir hand washing behaviors.

references

The findings were consistent with earlierresearch in that a significant gender bias wasfound. Women wash their hands significantlymore often, use soap more often, and washtheir hands somewhat longer than men.Both men and women fell far short, however,of CDC-recommended hand washing

durations, averaging 6.27 and 7.07 seconds,respectively. Only 5.3% of the sample washedtheir hands for 15 seconds or more. Consideringthe definition of hand washing and thecareful training of observers, this particularfinding raises the specter of significant inflationin earlier reported hand washing compliancerates. Future studies need to measurehand washing compliance carefully.

Additionally, our study established thatrestroom environmental conditions and signageare important. Specifically, hand washing

compliance was greater when restroomsinks were clean and when signs encouraginghand washing were posted.

Hand washing compliance and practicesas reported in this and previous studies fall

short of the ideal. The public needs to becontinuously encouraged to engage in properhand washing practices. In addition, careful


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attention to restroom environmental conditionsand signage may help increase compliance.Given the established gender bias,consideration should be given to the contentof the messages targeting men and women.Perhaps men and women would respond differentlyto gender-targeted messages.

Acknowledgements: An earlier, work-in-progress,version of this manuscript was presentedat the 2011 International Council on Hotel,Restaurant, and Institutional Education AnnualConference.

Corresponding Author: Carl P. Borchgrevink,Associate Professor, The School of HospitalityBusiness, Michigan State University, 645 NorthShaw Lane, 233 Eppley Center, East Lansing,MI 48824. E-mail: [email protected].

American Society for Microbiology. (2003). Another U.S. airporttravel hazarddirty hands. Retrieved from http://www.eurekalert.org/pub_releases/2003-09/asfm-aua091103.php

Bittner, M., Rich, E., Turner, P., & Arnold, W. (2002). Limited impactof sustained simple feedback based on soap and paper towel consumptionon the frequency of hand washing in an adult intensivecare unit. Infection Control Hospital Epidemiology, 23(3), 120126.

Burton, M., Cobb, E., Donachie, P., Judah, G., Curtis, V., & Schmidt,

W. (2011). The effect of hand washing with water or soap on bacterialcontamination of hands. International Journal of EnvironmentalResearch and Public Health, 8(1), 97104.Centers for Disease Control and Prevention. (2012). Hand washing:Clean hands save lives. Retrieved from http://www.cdc.gov/

handwashing/

Cohen, J. (1960). A coefficient of agreement for nominal scales. EducationalPsychology Measurement, 20(1), 3746.

Curtis, V., & Cairncross, S. (2003). Effects of washing hands withsoap on diarrhoea risk in the community: A systematic review.The Lancet Infectious Diseases, 3(5), 275281.

Drankiewicz, D., & Dundes, L. (2003). Hand washing amongfemale college students. American Journal of Infection Control,31(2), 6771.

Edwards, D., Monk-Turner, E., Poorman, S., Rushing, M., Warren,S., & Willie, J. (2002). Predictors of hand washing behavior.Social Behavior and Personality: An International Journal, 30(8),751756.

Etter, J., & Laszlo, E. (2005). Evaluation of a poster campaignagainst passive smoking for world no-tobacco day. Patient Educationand Counseling, 57(2), 190198.

Fleiss, J. (1981). The measurement of interrater agreement. In Statistical


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methods for rates and proportions (pp. 212236). New York:John Wiley & Sons.

Green, L.R., Selman, C.A., Radke, V., Ripley, D., Mack, J.C., Reimann,D.W., Stigger, T., Motsinger, M., & Bushnell, L. (2006).Food worker hand washing practices: An observation study. Journalof Food Protection, 69(10), 24172423.

Guinan, M.E., McGuckin-Guinan, M., & Sevareid, A. (1997). Whowashes hands after using the bathroom? American Journal of InfectionControl, 25(5), 424525.

Guzewich, J., & Ross, M.P. (1999). Evaluation of risk related to microbiological contamination of ready-to-eat foods by food preparationworkers and the effectiveness of interventions to minimize those risks.Silver Spring, MD: Food and Drug Administration, Center forFood Safety and Applied Nutrition. Retrieved from http://www.fda.gov/Food/FoodSafety/RetailFoodProtection/ucm210138.htm

Harris Interactive. (2010). Survey of hand washing behavior (trended):Prepared for the American Microbiology Society and the AmericanCleaning Institute. Retrieved from http://www.microbeworld.org/images/stories/washup/2010_handwashing_behavior_survey.pdf

continued on page 24



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24 Volume 75 Number 8A dvancement of the ScienceHayes, M.C. (2002). Hand washing behavior of women in public restrooms.Missouri Western State University. Retrieved from http://clearinghouse.missouriwestern.edu/manuscripts/371.phpJohnson, H.D., Sholoscky, D., Gabello, K.L., Ragni, R.V., & Ogonosky,N.M. (2003). Gender differences in hand washing behavior associatedwith visual behavior prompts. Perceptual and Motor Skills,97(3), 805810.Judah, G., Aunger, R., Schmidt, W., Granger, S., & Curtis, V. (2009).Experimental pretesting of hand-washing interventions. AmericanJournal of Public Health, 99(S2), 405411.Landis, J., & Koch, G. (1977). The measurement of observer agreementfor categorical data. Biometrics, 33(1), 159174.Larson, E., Bryan, J., Adler, L.M., & Blane, C. (1997). A multifacetedapproach to changing hand washing behavior. American Journal ofInfection Control, 25(1), 310.Larson, E., McGeer, A., & Quiaishi, Z. (1991). Effect of an automatedsink on hand washing practices and attitudes in high-riskunits. Infection Control Hospital Epidemiology, 12(7), 422428.Mackintosh, C., & Hoffman, P. (1984). An extended model for transferof microorganisms via the hands; differences between organismsand the effect of alcohol disinfection. Journal of Hygiene,

92(3), 345355.Mead, P.S., Slutsker, L., Dietz, V., McCaig, L.F., Bresee, J.S., Shapiro,C., Griffin, P.M., & Tauxe, R.V. (1999). Food related deathand illness in the United States. Emerging Infectious Diseases, 5(5),607625.Merry, A., Millder, E., Findon, G., Webster, C., & Neff, S. (2001).Touch contamination levels during anaesthetic procedures andtheir relationship to hand hygiene procedures: A clinical audit.British Journal of Anaesthesia, 87(2), 291294.Nalbone, P., Lee, K., Suroviak, A., & Lannon, J. (2005). The effectsof social norms on male hygiene. Individual Differences Research,3(3), 171176.Patrick, D., Miller, T., & Findon, G. (1997). Residual moisture

determines the level of touch-contact associated transfer followinghand washing. Epidemiology and Infection, 119(3), 319325.QSR Magazine. (2009). Are Americans washing their hands? Retrievedfrom http://www.qsrmagazine.com/news/are-americans-washingtheir-handsThumma, J., Aiello, A.E., & Foxman, B. (2008). The associationbetween hand washing practices and illness symptoms amongcollege students living in a university dormitory. American Journalof Infection Control, 37(1), 7072.References continued from page 23Showcase Environmental Healthand All It EncompassesFor many years NEHAs Journal of Environmental

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Hand Washing Study 1

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