Changes in Hand Hygiene Behaviors and Its Related Factors Among Northern Iranian Population During the First Peak and Subsidence of COVID-19 Pandemic Period: Results From PERSIAN Guilan Cohort Study (PGCS)


 Background: Considering the importance of the hand hygiene behaviors for the prevention of COVID-19 transmission, the current study was conducted to investigate the changes in hand-washing behaviors and its related factors among the northern Iranian population during the first peak and subsidence of COVID-19 pandemic period.Methods: This cross-sectional study was conducted during two periods in Guilan (Northern provinces of Iran). First period conducted at the first peak of COVID-19 pandemic in Iran (between 03/23/2020 and 03/30/2020), and second period conducted at the first subsidence of COVID-19 pandemic in Iran (between 05/3/20 and 05/10/2020). The questionnaire was completed by 571 adult participants. Data on frequency, procedure and circumstances of hand-washing and obsessive-like behaviors were collected. Potential correlates of reduction in frequency of hand washing were analyzed by multiple logistic regression.Result: Compared to peak of COVID-19 pandemic, frequency and procedure of hand-washing and obsessive-like behaviors were significantly reduced at the subsidence of COVID-19 pandemic (all p<0.05). Females with negative family history of coronavirus disease had greater odds (Adjusted Odds Ratio = 2.19, P =0.03) of reduction in the frequency of daily hand-washing. Younger than 50 years old males and males who reduced the procedure of hand-washing had greater odds (AOR = 1.71, P =0.02 and AOR = 2.16, P =0.001, respectively) of reduction in the frequency of daily hand-washing. Conclusion: Northern Iranian populations were found to decrease their frequency and quality of hand washing and obsessive-like behaviors over time from the first peak to first subsidence of COVID-19 pandemic. Here, the factors that independently predicted reduction in frequency of hand washing in male population were younger age and reduction in procedure of hand-washing and in female population was a negative family history of coronavirus disease. Thus, special attention should be paid to maintaining the general population’s perceived susceptibility to illness, especially in younger men during the pandemic.

In Iran, the rst COVID-19 infectious case was con rmed on February 19, 2020 [4] and by the beginning of March 2020, COVID-19 cases had dramatically increased, with 148,950 cases and 7,734 con rmed deaths by the end of March 2020 [5].
The COVID-19 infection rate peaked for the rst time in late March and early April 2020, at which time approximately 3,000 new cases of COVID-19 and 140 deaths were being con rmed each day [5]. Although, one month later, in late April and early May 2020, the COVID-19 infection rate subsided with approximately 800 new cases per day [5] but, the COVID-19 infection rate peaked for the second time in early June 2020, with approximately 3,000 new cases per day [5].

Concurrent with o cial declaration of the spread of COVID-19 infection in Iran, Iranian Ministry of Health and Medical
Education made an effort to mitigate the disease transmission and attempted to educate the general population about preventive behaviors that decrease the risk of transmission, including stay at home, regular hand washing with water and soap or alcohol based hand rub, wearing a face mask in public [6]. Although these actions led to the epidemic subsided, but may increase the obsession and anxiety in society [7]. The Centers for Disease Control and Prevention (CDC) recommendation on hand-washing with proper procedure at the correct time were su cient for COVID-19 infection prevention [8] but individuals who were susceptible to obsessive-compulsive disorder were more likely to using stronger disinfectants or washing for longer in response to, worries of potential or mental contamination and anxiety [9][10][11]. On the other, decreased perceived susceptibility to illness in the community and inappropriate hand hygiene can lead to epidemic eruption [12,13].
Considering the importance of the hand hygiene behaviors for the prevention of COVID-19 transmission, the current study was conducted to investigate the changes in hand-washing behaviors and its related factors among the northern Iranian population during the rst peak and subsidence of COVID-19 pandemic period through a cross-sectional population-Based study.

Study design
In this cross sectional study, subjects were recruited by simple random sampling from PERSIAN Guilan Cohort Study (PGCS) population. The full details of the PGCS have been described elsewhere [14].In short, The PGCS was a multistage probability sample of the northern Iranian population in which 10520 individuals from 35 to 70 years of age were enrolled since 2014,, as part of the Prospective Epidemiological Research Studies in Iran (PERSIAN) [15,16].
The sample size was estimated by G*Power version 3.1.9.7 software. The sample size was estimated to be 571 participants, based on effect size (f 2 ) of 0.05 and the number of related factors (25 independent variable), with a con dence level of 95% and test power of 80%.
The inclusion criteria were participation in PGCS and willingness to complete the questionnaires. The exclusion criteria were 20% missing data in the questionnaire.

Ethical consideration
The ethical approval was obtained from the ethics committee of Guilan University of Medical Sciences, Rasht, Iran (IR.GUMS.REC.1399.004).

Measurements
In the rst period of study, general characteristics of participants were collected, including age, education, gender, occupation, residency, marital status, underling disease (Includes cardiovascular disease, uncontrolled high blood pressure, uncontrolled diabetes, respiratory diseases and BMI > 40), immune de ciency condition ( corticosteroid use, chemotherapy, malignancies, organ transplants and HIV), pregnancy and past history of COVID-19 infection in participants or their families.
Information about hand-washing behavior and believes were collected twice, in the rst period of study (peak of COVID-19 pandemic) and second period of study (subsidence of COVID-19 pandemic).
A data gathering questionnaire was designed to assess the hand-washing behavior and believes, based on recommendations on appropriate hand-washing by WHO [18] and CDC [19] and Obsessive-Compulsive Disorder criteria in the DSM 5 [20]. Content validity of the questionnaire was con rmed by 20 experts with CVI = 0.8 and CVR = 0.71. A pilot study was conducted with 40 participants prior to the study in order to con rm the face validity and reliability of the questionnaire. The results of this pilot study con rmed the face validity and reliability of the questionnaire with Cronbach's alpha of 0.86.
Information about hand-washing behavior and believes was collected in following areas: Section 1 collected data on frequency of hand-washing per day Section 2 collected data on type of detergent used for hand-washing (categories as only soap, soap + alcohol or bleach) Section 3 collected data on procedure of hand-washing by 5 yes or no questions to de ne if they include each step, as follows: 1) Wet hands with running, clean water, 2) rubbing hands together with the soap to lather them, including under the nails, between the ngers, and backs of the hands, 3) Scrub the hands for at least 20 seconds, 4) Rinse the hands well under running, clean water, 5) Dry hands by a clean towel. Each yes answer got one point and the total score was 5.
Section 4 collected data on circumstances of hand-washing by 14 yes or no questions to de ne if they include each condition, as follows: 1)Before, 2)during, 3)after preparing food, 4)before eating, 5)before, 6)after caring for someone who is sick at home, 7)before, 8)after treating a wound or cut, 9)after toilet using, 10)after or cleaning up a child who has used the toilet or changing diapers, 11)after sneezing, coughing or blowing nose, 12)after animal waste, animal feed, or touching an animal, 13)after pet treats or handling pet food, 14)after touching garbage. Each yes answer got one point and total score was 14.
Section 5 collected data on worries about hand-washing or obsessive-like behaviors by 8 yes or no questions to de ne if they experience each item, as follows: 1) worry about remaining a contamination on a properly washed hand, 2) afraid or anxious about hands are not clean enough, even after repeated rinsing, 3)wash in a special order, 4) starts washing again for fear of mistake, 5) avoid places or situations where may be exposed to germs or soil, 6)avoid touching surfaces in public places, 7) red, cracked and scaly hands due hand-washing, 8)effect of pollution concerns and efforts to reduce them in daily relationships and activities. Each yes answer got one point and total score was 8.

Statistical analysis
Change in type of detergents, procedure and circumstances of hand-washing and obsessive-like behaviors, over time (at the subsidence versus the peak of COVID-19 pandemic) were examined by McNamar tests. Change in hand washing frequency (the frequency was categorized to, 0-4 times, 5-8 times, 9-12 times, more than 13 times) over time was examined by Wilcoxon test. Change in score of obsessive-like behaviors and score of procedure and circumstances of hand-washing over time was examined by paired T test.
Independent T test and chi-square test were used to examine the differences of procedure and circumstances of handwashing score, obsessive-like behaviors score and reduction in hand hygiene behaviors between male and female.
Additionally, to identify factors related to decrease in hand-washing frequency at least one time, simple and multiple logistic regression models strati ed by gender were used. Factors with a p value < 0.05 on a univariate analysis were entered into a multivariate analysis. Unadjusted and adjusted odds ratios (ORs) with 95% con dence intervals (CIs) were calculated.
The SPSS version 17.0 software (SPSS Inc., Chicago, IL, USA) was used to for all data analysis.

Result
Demographic characteristics of 571 participants that were enrolled in this study are outlined in Table 1. The majority of the participants were male (55.3%), married (94.4%), employed (55.9%), resident in urban area (80.2%), and had diploma or less level of education (64.3%) ( Table 1). The comparison of frequency of hand-washing, type of detergents, procedure of hand-washing, circumstances of handwashing and obsessive-like behaviors at the rst peak of COVID-19 pandemic and at the rst subsidence of COVID-19 pandemic are presented in Table 2. The daily frequency of hand-washing and procedure of hand-washing score at subsidence of COVID-19 pandemic was signi cantly lower than at the peak of COVID-19 pandemic (p = 0.0001).
Additionally, 49.9% of participants reported decreasing frequency of hand-washing from peak to subsidence of COVID-19 pandemic. Use of alcohol or bleach in addition to soap at the peak of COVID-19 pandemic was signi cantly higher than at the subsidence period (p = 0.028). Total score of procedure of hand-washing at the peak of COVID-19 pandemic was signi cantly higher than at the subsidence period (p = 0.001). Also, 48.2% of participants reported decreases in at least one step of procedure of hand-washing from peak to subsidence of COVID-19 pandemic. Although, 27.5% of participants reported decreases in at least one circumstance of hand-washing, but the total score of circumstances of hand-washing was signi cantly changed over time(p = 0.342). Total score obsessive-like behaviors at the peak of COVID-19 pandemic was signi cantly higher than at the subsidence period (p = 0.001) and 65.8% of participants reported decreases in at least one obsessive-like behavior. Table 2 Comparison of frequency of hand-washing, type of detergents, procedure of hand-washing, circumstances of hand-washing and obsessive-like behaviors at the rst peak of COVID-19 pandemic and at the rst subsidence of COVID- 19  Correlations of obsessive-like behaviors with frequency, procedure and circumstances of hand-washing are shown in Table  3. There was a signi cant but weak positive correlation between obsessive-like behavior score and all frequencies, procedure and circumstances of hand-washing score (Table 3). Comparison of the reduction in hand hygiene behaviors over time from peak to subsidence of COVID-19 pandemic according to demographic characteristics of participants are shown in Table 4. Although, males were signi cantly more likely to reduce obsessive-like behaviors, there was no signi cant difference between males and females in reduction of procedure, circumstances and frequency of daily hand-washing (Table 3). Also, under 50 years old participant were signi cantly more likely to reduce frequency of daily hand-washing. There was no further association between demographic factor and reduction in hand hygiene behaviors (Table 4). Change in frequency of daily hand-washing over time from peak to subsidence of COVID-19 pandemic stratify by gender are presented in Fig. 1. Both groups reported a signi cant decrease in frequency of hand washing over time. At both times frequency of daily hand-washing was higher in female, with statistical signi cance by Chi-square analysis (p < 0.05).
Comparison of procedure of hand-washing score, circumstances of hand-washing score and obsessive-like behaviors score over time from peak to subsidence of COVID-19 pandemic stratify by gender are shown in Table 5. The score of circumstances of hand-washing at both times and the score of obsessive-like behaviors at the rst subsidence of COVID-19 pandemic were signi cantly higher in females (Table 5). Table 5 Procedure of hand-washing score, circumstances of hand-washing score, obsessive-like behaviors score and reduction in hand hygiene behaviors over time from peak to subsidence of COVID-19 pandemic stratify by gender in northern Iranian population Data are expressed as number (percentages) or mean ± standard deviation.
* Statistical signi cance based on the independent T test and chi-square test Table 6 reveals the results univariate and multivariate logistic regression to explore factors associated to reduction in the frequency of daily hand-washing over time from peak to subsidence of COVID-19 pandemic stratify by gender. In females, only negative family history of coronavirus disease was identi ed as an independent factor associated with reduction in the frequency of daily hand-washing. Females with negative family history of coronavirus disease had greater odds (Adjusted OR = 2.19, P = 0.03) of reduction in the frequency of daily hand-washing. In male, younger age and reduction in procedure of hand-washing were identi ed as independent factors associated with reduction in the frequency of daily hand-washing.
Younger than 50 years old males had greater odds (Adjusted OR = 1.71, P = 0.02) of reduction in the frequency of daily hand-washing. Also, males who reduced the procedure of hand-washing, had greater odds (Adjusted OR = 2.16, P = 0.001) of reduction in the frequency of daily hand-washing.
There was no independent association of demographic factors, underlying disease and other hand hygiene behaviors with reduction in the frequency of daily hand-washing over time from peak to subsidence of COVID-19 pandemic in both genders (Table 6).

Discussion
Our study demonstrates that, over time from the rst peak to rst subsidence of COVID-19 pandemic in Iran, frequency and procedure of hand-washing were regressed and obsessive-like behaviors were reduced. The effect of appropriate hand hygiene behaviors in preventing COVID-19 is re ected in a worldwide interest in this issue, and has been shown as an indicator for policies to population health literacy and reduce transmission [21]. It is claimed that a proper hand washing behavior could break the transmission cycle of respiratory infection disease and decrease the risk by 6 to 44% [22]. Therefore, the second peak of COVID-19 pandemic in Iran could be due to reduced hand hygiene in rst subsidence of COVID-19 pandemic. The second peak of COVID-19 in Iran was occurred 1 months after the rst subsidence [5]. Although hand-washing is recommended as a low-cost and affordable protective behavior for prevention of some viral respiratory infections epidemic [23] and studies reported increasing frequency of hand washing, during the peak pandemic periods of COVID-19 and H1N1 in uenza [24,25], it is very hard to maintain high hand-washing compliance [26].
We found a positive correlation between obsessive-like behaviors and hand hygiene behaviors. These ndings are compatible with some previous studies that revealed a positive dose-response gradient between levels of anxiety and personal protective behaviors [27][28][29][30]. Thus, a reduction in obsessive-like behaviors may indicate a decrease in perceived susceptibility to illness in the community, which may lead to poor hand hygiene and an epidemic outbreak. Our ndings have shown that males were more likely to reduce obsessive-like behaviors, therefore, special attention should be paid to maintaining the men's perceived susceptibility in epidemics.
Our ndings revealed that during both peak and subsidence of COVID-19 pandemic, males reported less frequently handwashing than females. Similar ndings were also reported in previous studies [31,32]. However, the reduction in frequency of hand-washing was not different between males and female.
The results of regression analyses in current study demonstrate, in male participants, the younger age and reduction in procedure of hand-washing were independent predictors for reduction in frequency of hand washing. Younger than 50 years old males and males with reduced procedure of hand-washing were more likely to reduce the frequency of daily hand-washing. Some previous studies have also determined that, older adults, are more likely to follow recommended behaviors, including hand washing to prevent the infectious diseases transmission [31].
In female participants the negative family history of coronavirus disease was the only independent predictor for reduction in frequency of hand washing. Close experience of risk in family member can maintain perceived susceptibility to illness high [33].
According to obtained ndings, the necessity of constant hand hygiene education and advice was recommended to policy makers, especially in terms of the COVID-19 worldwide pandemic. Also, in order to maintain perceived susceptibility to illness in population mass media and information channels should be engaged.
The strengths of this study were population-based data and the large sample size. However, social-desirability bias due to over-reporting to 'look good' and recall bias of past experiences are limitations of all self-reporting surveys. Also, a possibility of non-contact bias due to hard-to-reach people who are not at home most of the time is the limitation of household telephone surveys.

Conclusions
The results of this study indicated that northern Iranian population were found to decrease their frequency and quality of hand washing and obsessive-like behaviors over time from the rst peak to rst subsidence of COVID-19 pandemic. Here, the factors that independently predicted reduction in frequency of hand washing in male population were younger age and reduction in procedure of hand-washing and in female population was a negative family history of coronavirus disease. Thus, special attention should be paid to maintaining the general population's perceived susceptibility to illness, especially in younger men during the pandemic.

Declarations Funding
The present study was supported by Guilan University of Medical Sciences (Grant code: 1399.004).

Availability of data and materials
The datasets generated and/or analyzed during the current study are not publicly available due to joint research and development with the company, but are available from the corresponding author.

Ethics approval and consent to participate
This article is a part of the research plan approved by the committee of Guilan University of Medical Sciences (Ethics Code: IR.GUMS.REC.1399.004). Before answering the questionnaires, each participant was provided with necessary information by the purpose of the study and their contribution to the study.

Consent for publication
Not applicable.