The trajectory of COVID-19 pandemic and handwashing adherence: findings from 14 countries

Zofia Szczuka, Charles Abraham, Adriana Baban, Sydney Brooks, Sabrina Cipolletta, Ebrima Danso, Stephan U. Dombrowski, Yiqun Gan, Tania Gaspar, Margarida Gaspar de Matos, Konstadina Griva, Michelle Jongenelis, Jan Keller, Nina Knoll, Jinjin Ma, Mohammad Abdul Awal Miah, Karen Morgan, William Peraud, Bruno Quintard, Vishna ShahKonstantin Schenkel, Urte Scholz, Ralf Schwarzer, Maria Siwa, Kamil Szymanski, Diana Taut, Silvia C.M. Tomaino, Noa Vilchinsky, Hodaya Wolf, Aleksandra Luszczynska

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17 Scopus citations


Background: The COVID-19 pandemic has affected people’s engagement in health behaviors, especially those that protect individuals from SARS-CoV-2 transmission, such as handwashing/sanitizing. This study investigated whether adherence to the World Health Organization’s (WHO) handwashing guidelines (the outcome variable) was associated with the trajectory of the COVID-19 pandemic, as measured by the following 6 indicators: (i) the number of new cases of COVID-19 morbidity/mortality (a country-level mean calculated for the 14 days prior to data collection), (ii) total cases of COVID-19 morbidity/mortality accumulated since the onset of the pandemic, and (iii) changes in recent cases of COVID-19 morbidity/mortality (a difference between country-level COVID-19 morbidity/mortality in the previous 14 days compared to cases recorded 14–28 days earlier). Methods: The observational study (#NCT04367337) enrolled 6064 adults residing in Australia, Canada, China, France, Gambia, Germany, Israel, Italy, Malaysia, Poland, Portugal, Romania, Singapore, and Switzerland. Data on handwashing adherence across 8 situations (indicated in the WHO guidelines) were collected via an online survey (March–July 2020). Individual-level handwashing data were matched with the date- and country-specific values of the 6 indices of the trajectory of COVID-19 pandemic, obtained from the WHO daily reports. Results: Multilevel regression models indicated a negative association between both accumulation of the total cases of COVID-19 morbidity (B = −.041, SE =.013, p =.013) and mortality (B = −.036, SE =.014 p =.002) and handwashing. Higher levels of total COVID-related morbidity and mortality were related to lower handwashing adherence. However, increases in recent cases of COVID-19 morbidity (B =.014, SE =.007, p =.035) and mortality (B =.022, SE =.009, p =.015) were associated with higher levels of handwashing adherence. Analyses controlled for participants’ COVID-19-related situation (their exposure to information about handwashing, being a healthcare professional), sociodemographic characteristics (gender, age, marital status), and country-level variables (strictness of containment and health policies, human development index). The models explained 14–20% of the variance in handwashing adherence. Conclusions: To better explain levels of protective behaviors such as handwashing, future research should account for indicators of the trajectory of the COVID-19 pandemic. Trial registration: Clinical Trials.Gov, #NCT04367337.

Original languageEnglish
Article number1791
JournalBMC Public Health
Issue number1
StatePublished - 5 Oct 2021

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© 2021, The Author(s).


  • COVID-19
  • Cross-country
  • Hand hygiene
  • Morbidity
  • Mortality
  • Pandemic


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