==== Front BMC Res Notes BMC Res Notes BMC Research Notes 1756-0500 BioMed Central London 5398 10.1186/s13104-020-05398-3 Research Note Handwashing and disinfection precautions taken by U.S. adults to prevent coronavirus disease 2019, Spring 2020 Brown Laura G. lrg0@cdc.gov 1 Hoover E. Rickamer xmo2@cdc.gov 2 Barrett Catherine E. ohi6@cdc.gov 1 Vanden Esschert Kayla L. oys6@cdc.gov 1 Collier Sarah A. sau9@cdc.gov 1 Garcia-Williams Amanda G. gvl8@cdc.gov 1 1 grid.416738.f0000 0001 2163 0069Centers of Disease Control and Prevention, COVID-19 Response, 1600 Clifton Road, Atlanta, GA USA 2 grid.416778.b0000 0004 0517 0244Centers for Disease Control and Prevention, National Center for Environmental Health, 4770 Buford Highway, Atlanta, GA USA 4 12 2020 4 12 2020 2020 13 55025 8 2020 24 11 2020 © The Author(s) 2020Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.Objectives The objectives of this study were to assess self-reported hygiene precautions taken by U.S. adults during spring 2020 to prevent coronavirus disease 2019 (COVID-19) and to identify demographic characteristics associated with these hygiene precautions. Results We obtained data from Porter Novelli Public Services’s national survey, Spring ConsumerStyles, conducted March 19–April 9, 2020 among a nationally representative random sample of 6463 U.S. adults aged 18 years or older. We present data from the survey question: “What, if any, precautions are you taking to prevent coronavirus?”. Respondents replied yes or no to the following precautions: washing hands often with soap and water and disinfecting surfaces at home and work often. Most respondents reported taking hygiene-related precautions to prevent COVID-19; more respondents reported handwashing (93%) than disinfecting surfaces (74%). Men, younger respondents, those with lower income and education levels, and respondents in self-rated poor health had lower reported rates of both handwashing and disinfecting surfaces. Communications about hygiene precautions for COVID-19 prevention may need to target sub-populations with the greatest gaps in hygiene-related practices. Research identifying barriers to these practices and developing effective messaging could inform and improve these communications. Keywords COVID-19CoronavirusHandwashingSurface disinfectionDemographic differencesissue-copyright-statement© The Author(s) 2020 ==== Body Introduction From January through October 2020, over 9 million cases of coronavirus disease 2019 (COVID-19), caused by the virus SARS-CoV-2, were reported in the U.S.; these included 229,978 deaths [1]. Although SARS-CoV-2 is thought to spread mainly from person to person, it is possible that people can become infected by touching something with the virus on it and then touching their own mouth, nose, or possibly eyes [2]. CDC has provided guidance to the public to help prevent the spread of COVID-19, including handwashing and cleaning and disinfection guidance [3]. These recommendations include handwashing with soap and water for at least 20 s, using hand sanitizer with at least 60% alcohol, and cleaning and disinfecting frequently touched surfaces daily, with products approved by the Environmental Protection Agency. To assess the U.S. public’s adherence to these recommendations, we analyzed national survey data on respondents’ self-reported hygiene-related precautions (handwashing and surface disinfection) taken to prevent COVID-19. We also examined associations between respondents’ demographic characteristics and their self-reported hygiene-related precautions. Main text Methods Participants and sampling Porter Novelli Public Services administers a national survey, called Spring ConsumerStyles, conducted using Ipsos’ KnowledgePanel, which is representative of the non-institutionalized U.S. population [4]. Respondents are randomly recruited by mail through probability-based, stratified sampling to participate in the survey panel. They receive the surveys through email and complete them online. If needed, respondents were provided with a laptop or tablet and access to the Internet, to help ensure that those with technological limitations were not excluded from the survey. Respondents receive reward points they can redeem online for gift cards or prizes. The 2020 Spring ConsumerStyles survey was conducted from March 19–April 9, 2020 and was sent via email to 11,097 participants. The final sample included 6463 adults who completed the survey, yielding a response rate of 58.2%, which was similar to the 2019 Spring ConsumerStyles survey [4]. The analyses were weighted to match the U.S. Census 2019 U.S. Current Population Survey proportions by gender, age, annual household income, race/ethnicity, household size, education, census region, metropolitan status, and parental status. See the Porter Novelli website for more information on ConsumerStyles methodology [4]. Outcome variable Coronavirus was defined for respondents as ‘the 2019 novel coronavirus’ as part of the survey. To assess hygiene-related precautions taken in response to COVID-19, respondents were asked, “What, if any, precautions are you taking to prevent coronavirus?”. They then responded yes or no to a series of actions, listed randomly. We present data on the following precautions: washing hands often with soap and water and disinfecting surfaces at home/work often (hereafter, referred to as handwashing and disinfecting surfaces). Demographic variables Data on demographic characteristics of gender, age, income, education, race/ethnicity, metropolitan status (metropolitan vs. non-metropolitan), and geographic region (based on U.S. Census regions) were collected when respondents agreed to participate in the panel; data on self-rated health were collected in the survey itself. Analysis We calculated percentages for both precautions, overall and by demographic characteristics (Table 1). We calculated prevalence ratios for comparisons across demographic categories by calculating the ratio of the prevalence of behavior in one demographic category compared to another (e.g., handwashing prevalence for females vs. males). Because we were interested in all comparisons across categories within characteristics (e.g., ages 18–29 vs. 30–44 vs. 45–59), we used multiple reference levels per characteristic. Prevalence ratios, 95% confidence intervals, and p-values were obtained using Zou’s modified Poisson approach [5] (Table 2). We used this modified approach because it provides the most accurate confidence intervals and p-values. Comparisons significant at p < .05 are discussed below. Multiple comparison adjustments were not made. We weighted the data to adjust for selection and nonresponse.Table 1 Percentages of respondents who reported handwashing and disinfecting surfaces often to prevent coronavirus, by demographic characteristics – Spring ConsumerStyles 2020 Characteristic Categories Washing hands often n (weighted %) Disinfecting surfaces often n (weighted %) All respondents – 6013 (93.4%) 4768 (74.0%) Gender Female 3153 (94.5) 2624 (78.7) Male 2860 (92.1) 2145 (69.1) Age 18–29 1194 (91.4) 909 (69.6) 30–44 1546 (90.1) 1182 (73.4) 45–59 1546 (94.7) 1261 (77.2) ≥ 60 1822 (96.4) 1417 (74.9) Income < $25k 745 (86.4) 587 (68.1) $25k–$49k 1050 (92.9) 850 (75.2) $50k–$99k 1977 (93.6) 1560 (73.9) ≥ $100k 2242 (95.9) 1771 (75.8) Education < High school 550 (84.7) 463 (71.4) High school 1662 (91.7) 1324 (73.1) Some college 1713 (95.0) 1812 (76.6) ≥ Bachelor’s degree 2088 (96.0) 1599 (73.5) Race/Ethnicity Non-Hispanic White 3847 (94.0) 2982 (72.8) Non-Hispanic Black 683 (91.2) 596 (79.6) Hispanic 964 (92.0) 816 (77.9) Multiracial/other 91 (96.4) 68 (72.7) Self-rated healtha Excellent 2333 (95.4) 1874 (76.6) Very good 2237 (94.1) 1759 (74.0) Good 749 (90.0) 566 (68.0) Fair 577 (92.4) 470 (75.3) Poor 113 (75.2) 96 (63.4) Regionb Northeast 1075 (95.4) 865 (76.8) Midwest 1248 (93.8) 994 (74.7) South 2264 (92.8) 1815 (74.4) West 1427 (92.5) 1094 (70.9) Metropolitan statusc Metro 5233 (93.7) 4169 (74.6) Non-metro 780 (91.3) 560 (70.2) aHealth status assessed by asking “In general, would you say your health is…” bRegion categories based on U.S. Census cMetropolitan status was defined as a core-based statistical area Table 2 Prevalence ratios, confidence intervals, and p-values for comparisons of respondents’ self-reported handwashing and surface disinfecting, by demographic characteristics–Spring ConsumerStyles 2020 Characteristic Comparisona Washing hands often Disinfecting surfaces often % vs. %a PR (95% CI) p % vs. %a 95% CI p Gender Female vs. Male 94.5 vs. 92.1 1.03 (1.01, 1.04) .004 78.7 vs. 69.1 1.14 (1.10, 1.18) .001 Age 30–44 vs. 18–29 90.1 vs. 91.4 0.98 (0.95, 1.01) .392 73.4 vs. 69.6 1.05 (0.98, 1.13) .132 45–59 vs. 18–29 94.7 vs. 91.4 1.04 (1.01, 1.07) .022 77.2 vs. 69.6 1.09 (1.00, 1.19) .048 ≥ 60 vs. 18–29 96.4 vs. 91.4 1.05 (1.02, 1.09) .001 74.9 vs. 69.6 1.08 (1.01, 1.15) .026 45–59 vs. 30–44 94.7 vs. 90.1 1.05 (1.03, 1.08) .001 77.2 vs. 73.4 1.05 (1.01, 1.10) .023 ≥ 60 vs. 30–44 96.4 vs. 90.1 1.07 (1.05, 1.10) .001 74.9 vs. 73.4 1.05 (0.99, 1.12) .121 ≥ 60 vs. 45–59 96.4 vs. 94.7 1.02 (1.00, 1.03) .037 74.9 vs. 77.2 0.97 (0.933, 1.01) .125 Income $25k–$49k vs. < $25k 92.9 vs. 86.4 1.08 (1.03, 1.12) .001 75.2 vs. 68.1 1.10 (1.02, 1.19) .010 $50k–$99k vs. < $25k 93.6 vs. 86.4 1.08 (1.04, 1.13) .001 73.9 vs. 68.1 1.12 (1.01, 1.23) .026 ≥ $100k vs. < $25k 95.9 vs. 86.4 1.11 (1.07, 1.16) .001 75.8 vs. 68.1 1.11 (1.04, 1.19) .002 $50k–$99k vs. $25k–$49k 93.6 vs. 92.9 1.01 (0.98, 1.03) .520 73.9 vs. 75.2 0.98 (0.93, 1.04) .508 ≥ $100k vs. $25k–$49k 95.9 vs. 92.9 1.03 (1.00, 1.06) .005 75.8 vs. 75.2 1.00 (0.93, 1.07) .984 ≥ $100k vs. $50k–$99k 95.9 vs. 93.6 1.02 (1.01, 1.04) .010 75.8 vs. 73.9 1.03 (0.98, 1.07) .242 Education High school vs. < High school 91.7 vs. 84.7 1.08 (1.02, 1.15) .006 73.1 vs. 71.4 1.02 (0.94, 1.12) .595 Some college vs. < High school 95.0 vs. 84.7 1.12 (1.06, 1.19) .001 76.6 vs. 71.4 1.11 (0.99, 1.24) .074 ≥ Bachelor’s degree vs. < High school 96.0 vs. 84.7 1.13 (1.07, 1.20) .001 73.5 vs. 71.4 1.03 (0.95, 1.12) .494 Some college vs. High school 95.0 vs. 91.7 1.04 (1.01, 1.06) .002 76.6 vs. 73.1 1.05 (1.00, 1.10) .054 ≥ Bachelor’s degree vs. High school 96.0 vs. 91.7 1.04 (1.02, 1.07) .001 73.5 vs. 73.1 1.02 (0.96, 1.09) .535 ≥ Bachelor’s degree vs. Some college 96.0 vs. 95.0 1.01 (0.99, 1.03) .210 73.5 vs. 76.6 0.96 (0.92, 1.00) .043 Race/Ethnicity Non-Hispanic Black vs. Non-Hispanic White 91.2 vs. 94.0 0.97 (0.94, 1.00) .080 79.6 vs. 72.8 1.09 (1.04, 1.15) .001 Hispanic vs. Non-Hispanic White  92.0 vs. 94.0 0.98 (0.95, 1.01) .141 77.9 vs. 72.8 1.07 (1.02, 1.13) .011 Multiracial/Other vs. Non-Hispanic White  94.5 vs. 94.0 1.01 (0.97, 1.04) .752 68.1 vs. 72.8 0.94 (0.86, 1.02) .120 Hispanic vs. Non-Hispanic Black  92.0 vs. 91.2 1.01 (0.97, 1.05) .679 77.9 vs. 79.6 0.98 (0.91, 1.05) .531 Multiracial/Other vs. Non-Hispanic Black  94.5 vs. 91.2 1.04 (0.99, 1.08) .117 68.1 vs. 79.6 0.85 (0.78, 0.94) .001 Multiracial/Other vs. Hispanic 94.5 vs. 92.0 1.03 (0.99, 1.07) .198 68.1 vs. 77.9 0.88 (0.80, 0.96) .005 Self-rated health Fair vs. Poor 90.0 vs. 75.2 1.20 (1.05, 1.36) .007 68.0 vs. 63.4 1.07 (0.90, 1.27) .418 Good vs. Poor 94.1 vs. 75.2 1.25 (1.10. 1.42) .001 74.0 vs. 63.4 1.17 (0.99, 1.37) .061 Very good vs. Poor 95.4 vs. 75.2 1.27 (1.12, 1.44) .001 76.6 vs. 63.4 1.21 (1.03, 1.42) .022 Excellent vs. Poor 92.4 vs. 75.2 1.22 (1.08, 1.40) .002 75.3 vs. 63.4 1.19 (1.00, 1.41) .046 Good vs. Fair 94.1 vs. 90.0 1.05 (1.01, 1.08) .011 74.0 vs. 68.0 1.09 (1.02, 1.16) .016 Very good vs. Fair 95.4 vs. 90.0 1.06 (1.02, 1.10) .001 76.6 vs. 68.0 1.13 (1.05, 1.20) .001 Excellent vs. Fair 92.4 vs. 90.0 1.03 (0.98, 1.07) .236 75.3 vs. 68.0 1.11 (1.02, 1.20) .018 Very good vs. Good 95.4 vs. 94.1 1.01 (1.00, 1.03) .134 76.6 vs. 74.0 1.04 (1.00, 1.08) .084 Excellent vs. Good 92.4 vs. 94.1 0.98 (0.95, 1.01) .273 75.3 vs. 74.0 1.02 (0.96, 1.09) .590 Excellent vs. Very good 92.4 vs. 95.4 0.97 (0.94, 1.00) .051 75.3 vs. 76.6 0.98 (0.92, 1.05) .596 Region Northeast vs. Midwest 95.4 vs. 93.8 1.02 (1.00, 1.04) .128 76.8 vs. 74.7 1.03 (0.98, 1.08) .301 West vs. Midwest 92.5 vs. 93.8 0.99 (0.96, 1.01) .265 70.9 vs. 74.7 0.95 (0.90, 1.00) .058 West vs. South 92.5 vs. 92.8 1.00 (0.97, 1.02) .788 70.9 vs. 74.4 0.95 (0.91, 1.00) .065 Midwest vs. South 93.8 vs. 92.8 1.01 (1.00, 1.03) .350 74.7 vs. 74.4 1.00 (0.96, 1.05) .843 Northeast vs. South 95.4 vs. 92.8 1.03 (1.01, 1.05) .013 76.8 vs. 74.4 1.03 (0.98, 1.09) .196 Northeast vs. West 95.4 vs. 92.5 1.03 (1.01, 1.06) .012 76.8 vs. 70.9 1.08 (1.02, 1.15) .005 Metropolitan status Metro vs. Non-metro 93.7 vs. 91.3 1.03 (1.00, 1.06) .082 74.6 vs. 70.2 1.06 (1.00, 1.13) .037 PR: Prevalence ratio; CI: confidence interval aThe second category or number listed is the reference level for the prevalence ratio Italics indicates significant comparisons (p < .05) Results Handwashing (Tables 1 and 2) Almost all (93.4%) respondents said they were washing their hands often with soap and water to prevent COVID-19. Women more often reported frequent handwashing than men. In general, respondents in older age categories more often reported frequent handwashing than respondents in younger age categories. Respondents 60 years of age or older more often reported frequent handwashing than respondents in all younger age categories (18–29 year-olds, 30–44 year-olds, and 45–59 year-olds). Respondents with higher incomes more often reported frequent handwashing than respondents with lower incomes, with the exception of one comparison ($50k–$99k vs. $25k–$49k). Respondents with higher educational levels more often reported frequent handwashing than respondents with lower educational levels, with the exception of one comparison (> Bachelor’s degree vs. some college). Respondents with self-rated health of fair, good, very good, and excellent more often reported frequent handwashing than those with self-rated poor health. Respondents with good and very good self-rated health more often reported frequent handwashing than those with fair self-rated health. Respondents living in the northeast region of the U.S. more often reported frequent handwashing than those living in the south and west. No differences by race/ethnicity or metropolitan status were significant. Disinfecting (Tables 1 and 2) Nearly three-fourths (74.0%) of respondents said they were disinfecting surfaces at home and work often to prevent COVID-19. Women more often than men reported frequent surface disinfection. Respondents aged 45–59 years old more often reported frequent surface disinfection than those aged 18–29 and 30–44 years old. Respondents 60 years of age and older more often reported frequent surface disinfection than those aged 18–29 years old. Respondents in the higher income categories ($25k–$49k, 50k–$99k, and ≥ $100k) more often reported frequent surface disinfection than those in the lowest category (< $25k). Respondents with some college more often reported frequent disinfection than respondents with a Bachelor’s degree or more education. Non-Hispanic Blacks and Hispanics, compared to non-Hispanic Whites and those identifying as Multiracial or other, more often reported frequent surface disinfection. Respondents with self-rated health of very good and excellent more often reported frequent surface disinfection than respondents with poor self-rated health. Those with good, very good, and excellent, compared to fair, self-rated health more often reported frequent surface disinfection. Respondents living in metropolitan, compared to non-metropolitan, areas more often reported frequent surface disinfection. Those living in the northeast more often reported disinfecting surfaces than those living in the west. No differences by education were significant. Discussion These data from a nationally representative sample suggest that in the spring of 2020, most U.S. adults were taking hygiene-related precautions to prevent COVID-19. The fact that almost all adults surveyed said that they were washing their hands often with soap and water to prevent COVID-19 is encouraging, as handwashing is an important way to prevent the spread of COVID-19 and other viruses. Nearly three-quarters of adults said that they were disinfecting surfaces at home and work often to prevent COVID-19. This percentage, although high, is not as high as the percentage for handwashing. Compared to handwashing, disinfecting surfaces often may be a relatively novel behavior (i.e., people may be less familiar with the importance of frequent disinfection than they are with frequent handwashing) potentially making it harder to adopt this practice [6]. Disinfecting surfaces frequently could be more time-consuming and difficult than handwashing; this could contribute to the lower adherence to this practice. Unfamiliarity with how to disinfect surfaces [7] and, possibly, unavailability and cost of disinfectant, may also contribute to this lower adherence percentage. This study identified several demographic characteristics associated with hygiene-related practices. Men less often reported both handwashing and disinfecting; this finding is consistent with previous research showing that men engage in protective behaviors (e.g., handwashing) less often than women, even during epidemics [8, 9], and a finding consistent with work conducted during the COVID-19 pandemic [10]. Additionally, those with self-rated poor health were less likely to report handwashing and disinfecting to prevent COVID-19. As evidence indicates that COVID-19 disproportionately affects men and people with underlying health conditions, it may be particularly important for men and people in poor health to take preventive action to protect themselves from COVID-19 [11, 12]. Additional demographic characteristics were associated with a higher prevalence of hygiene-related COVID-19 prevention practices. Generally, frequent handwashing and disinfecting increased with age, although the pattern was stronger for handwashing. Compared to non-Hispanic Whites and those identifying as Multiracial or other, non-Hispanic Blacks and Hispanics reported higher disinfecting rates. Current data indicate that COVID-19 causes a disproportionate burden of severe illness and death among older people and among racial and ethnic minority groups [11–13]. It is unclear why these particular groups had higher rates of prevention practices, while other vulnerable groups (i.e., men and people in poor health) did not. More research is needed to clarify these relationships. These data, along with data showing a high rate of cloth face covering use among non-Hispanic Blacks and Hispanics [14], also suggest that individual adherence to CDC guidance is unlikely to explain the racial/ethnic disparity in rates and outcomes of COVID-19; rather, this may be due to systemic racial inequity issues. Our findings also suggest that people with lower income and education levels are less likely to take these precautions, although these patterns were, again, stronger for handwashing. People with lower income or education levels may face barriers to engaging in these behaviors. For example, they may be more likely to be classified as essential workers and work outside the home during the pandemic [15] and therefore have less time to clean. They may also have less access to water to use for handwashing; recent data indicate that lower income communities disproportionately lack access to clean water and indoor plumbing [16]. More research is needed to better understand the relationship between income, education, and these hygiene practices. Where people live seems to be related to hygiene-related prevention practices. Those in the south and west regions of the U.S. had lower rates of handwashing compared to those living in the northeast and people living in non-metropolitan areas had lower rates of disinfecting surfaces than those living in metropolitan areas. These findings may be related to the fact that when the survey was conducted, most COVID-19 cases were in more densely populated metropolitan areas and a large COVID-19 outbreak was occurring in the northeast region of the U.S. [17]. Conclusions During March 19–April 9, 2020, most survey respondents reported frequent handwashing and surface disinfection to prevent COVID-19. These practices are important components of a layered approach to COVID-19 prevention, which also includes wearing masks and physical distancing. We also identified gaps in these self-reported practices; 7% of respondents said they were not handwashing often and 26% said they were not disinfecting surfaces often. We also found that men, younger people, people with lower incomes and lower education levels, and people in self-rated poor health generally reported lower rates of both frequent handwashing and surface disinfection. These practice gaps among sub-populations vulnerable to COVID-19 (men and people in poor health) [11, 12] are of particular concern. Practice gaps for those with low incomes are also concerning, given that underlying health conditions are more prevalent in this group [18]. Communication efforts could be informed and enhanced by research delineating why some sub-populations have lower rates of hygiene-related COVID-19 prevention practices. Additionally, more work is needed to understand how hygiene behaviors fit in with other recommended COVID-19 prevention behaviors, such as wearing masks and physical distancing. Limitations Although the data were weighted to be nationally representative and computers and internet access were provided to respondents who needed them, the results may not be fully representative of the US adult population (e.g., those uncomfortable with the internet may have had lower participation). The data might be affected by social desirability bias, resulting in an overreporting of socially desirable behaviors (e.g., handwashing). These data only measure self-reported practices, not actual practices. Many of the demographic characteristics covary, which may confound results. These data do not allow causal inferences about the reasons for differences by demographic characteristics found in self-reported practices. Abbreviations CDCCenters for Disease Control and Prevention CIConfidence interval COVID-19Coronavirus disease 2019 PRPrevalence ratio Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Acknowledgements We thank Fred Fridinger with CDC and Deanne Weber with Porter Novelli. Authors’ contributions LB assisted in data analysis and interpretation and drafted the manuscript. ERH led data analysis. KVE and SC conducted initial data analyses and replication. AGW conceived of the project, interpreted data, and reviewed and edited the manuscript. CB reviewed and edited the manuscript. All authors read and approved the final manuscript. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Funding The Centers for Disease Control and Prevention purchased the survey data license from Porter Novelli. Availability of data and materials The dataset supporting the conclusions of this article can be licensed from Porter Novelli Public Services by contacting Deanne Weber (deanne.weber@porternovelli.com). Ethics approval and consent to participate This analysis was not considered human subjects research (as defined in 45 CFR part 46) and did not require review by Centers for Disease Control and Prevention’s (CDC’s) institutional review board. CDC licensed these data from Porter Novelli Public Services. 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