key: cord-0883248-21y9rdnk authors: Zhang, S. X.; Graf-Vlachy, L.; Su, R.; Li, J.; Looi, K. H. title: Who do not wash their hands during the Covid-19 pandemic? Social media use as a potential predictor date: 2020-06-03 journal: nan DOI: 10.1101/2020.06.01.20119230 sha: 4fe1f9a6f5a2ebc164a7da0753e44daa9f6289fe doc_id: 883248 cord_uid: 21y9rdnk This study predicts handwashing behavior during the Covid-19 pandemic. An analysis of 674 adults in Malaysia identifies their time spent on social media per day as a key predictor of handwashing. The association between time spent on social media and handwashing also depends on gender and the number of children in the same household. Additional predictors include age and health condition. This study helps identify specific target groups for health communication on hand hygiene via individual use of social media, which can be a key channel for health communication campaigns during a pandemic. Handwashing is one of the most basic and effective measures to prevent the spread of disease in general (Jarvis, 1994) and of upper respiratory infections in particular (WHO, 2006) . Handwashing is notably recommended during pandemics (Inglesby et al., 2006; Rewar et al., 2015) . Unfortunately, compliance remains a constant issue even among highly sophisticated populations like physicians and nurses (e.g., Gawande, 2004; Whitby et al., 2006) . Given that direct health communication, such as messaging and reminders, have positive effects on handwashing behavior (Fleischman et al., 2011; Updegraff et al., 2011) , it is advisable to identify, inform and prompt at-risk populations to regularly wash hands during a pandemic. To economize on limited resources while having optimum impact, health organizations, governments, and other parties may want to focus their health messaging on less compliant groups. This paper aims to identify predictors of handwashing behavior. We examine specifically time spent on social media, which is a key means for health communication during pandemics (Chan et al., 2020) . Social media has the advantage that the at-risk populations, once identified, can be reached for health information via the same platform. However, to our best knowledge, there has been no studies connecting social media use to hand washing in any epidemic. This study identifies social media use and several demographic variables as predictors that may be useful when deploying targeted health information campaigns on hand hygiene during the ongoing Covid-19 crisis and future pandemics. We conducted a survey of working adults in Malaysia between May 2-8, 2020, six weeks after Malaysia implemented a cordon sanitaire preventive measure to contain COVID-. CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 3, 2020. . https: //doi.org/10.1101 //doi.org/10. /2020 19. To collect more representative a sample in Malaysia, a multi-lingual and multi-ethnic country, the English version of the questionnaire was translated into Malay and Mandarin, the major languages in Malaysia. Links to the survey in Malay, Mandarin, and English were distributed via WhatsApp, Facebook Messenger, and email, via two-stage stratified sampling in terms of ethnicity, gender, age, and geographical area (Goodman, 1961) . The survey was approved by Tsinghua University (20200322), and all survey participants consented online before enrolling in the survey. The respondents could opt out at any time and were ensured confidentiality and anonymity. No personally identifying information was collected. The demographic variables of interest in this study comprise of gender, number of children living in the same household, age, educational level, and overall health condition (DeSalvo et al., 2006; Roelen et al. 2014) . The behavioral variables of interest are social media usage (measured in hours per day) and frequency of handwashing after touching things outside the home [seven-point Likert scale: 1 = never; 2 = rarely (less than 10% of the time); 3 = occasionally (about 30% of the time); 4 = sometimes (about 50% of the time); 5 = frequently (about 70% of the time); 6 = usually (about 90% of the time); 7 = every time]. We used Stata 16.1 to perform an OLS regression on the unweighted data. We obtained 674 valid responses from adults across all the Malaysian states and federal territories. 51.5% (347) respondents were female and 48.5% (327) male. Almost half of the respondents were living without children in the household (48%, 324), and progressively fewer people were living with an increasing number of children, e.g., 17.1% (115) indicated to be cohabiting with one child and only 0.6% (4) were living with more than five children. . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 3, 2020. . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 3, 2020. Table 1 shows the regression results for handwashing (F(10, 663) = 6.81, p = 0.000). Age ( Our results overall showed social media use predicts handwashing, and that this prediction exhibits distinct patterns depending on gender and number of children. More time . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 3, 2020. . https://doi.org/10.1101/2020.06.01.20119230 doi: medRxiv preprint spent on social media was positively associated with the frequency of handwashing for males with three or more children living in the same household (e.g., for those with three children: b = 0.09, 95% CI: 0.02 to 0.17, p = 0.010). However, for males with no children in the same household, more time spent on social media was negatively associated with the frequency of handwashing (e.g., for those with no children: b = -0.09, 95% CI: -0.16 to -0.02, p = 0.007). The association between time spent on social media and handwashing was not significant for males with one or two children. For females in general, the direct effect of social media use on handwashing was significant (b = 0.05, 95% CI: 0.005 to 0.09, p = 0.030). However, a margin analysis showed that more time spent on social media was significantly linked to more handwashing only for females with one child (b = 0.05, 95% CI: 0.005 to 0.09, p = 0.028) and marginally significant (p < 0.10) for females without children or with two children. The association between time spent on social media and handwashing was not significant for women with three or more children. Second, prior studies frequently identified gender as a predictor of handwashing, finding that women generally wash their hands more than men both during pandemics and in other circumstances (see Bish & Michie, 2010 for an overview; Borchgrevink et al., 2013) . While our results corroborate this direct effect of gender (b = 0.29, 95% CI: 0.08 to 0.50, p = 0.006), we also found that the gender difference depended on social media usage and the number of children. Specifically, our study revealed that there was no gender difference in handwashing between females and males who spent three hours or less on social media (p > 0.10 across all cases). The gender difference, i.e., the notion that females wash hands more than males do, was significant for those who spend more than three hours on social media and had no or one child (e.g., four hours social media and no children: b = 0.32, 95% CI: 0.05 to 0.59, p = 0.020). The gender difference was not significant for those with two or more children. Hence, . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 3, 2020. Taken together, these results suggest that research on predictors of handwashing should not rely on gender, number of children, or social media use alone but must consider all three simultaneously to yield better predictions. This finding is increasingly relevant as social media is likely a key channel of information to people, and females and males tend to have different interests and social circles on social media (Putzke et al., 2014) , and people with varying numbers of children may similarly gravitate towards different interest groups. Thus people receive social information differently depending on their gender and family situation. This study, as the first study to identify social media use as a predictor of handwashing, suggests it becomes increasingly critical to take social media usage into account in predictive models of human behavior, including handwashing during a pandemic. Finally, we add other predictors of handwashing to the literature. Extant work found mixed evidence on the association between age and protective behaviors like handwashing during virus pandemics (see Bish & Michie, 2010 for a review). Our results suggest that there is indeed a positive relationship between age and handwashing. Prior work also found that . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 3, 2020 . . https://doi.org/10.1101 /2020 more educated people tend to exhibit greater protective behavior during pandemics, but some results were inconclusive (see Bish & Michie, 2010 for a review). In our sample, there was no significant link between education and handwashing. We did, however, find a significant association between self-reported health condition and handwashing. During the pandemic, healthier people indicated greater handwashing frequency -a finding that is new to the literature. Hence, younger and less healthy people should generally be targeted. Overall, our findings can be used to develop the population at risk to enable more targeted health communication. Reminders (Morrison & Yardley, 2009 ) and signage (Updegraff et al., 2011) about handwashing, and communication regarding a pandemic in general (Fleischman et al., 2011) , are effective in increasing handwashing. Consequently, our research helps with the identification of the less compliant groups to enable more targeted delivery of such handwashing communications campaigns, especially via social media. First, the cross-sectional nature of our research precludes claims of causality, even though we are primarily interested in the predictive utility for screening less compliant groups. Second, self-reported compliance rates might be inflated due to social desirability (Borchgrevink et al., 2013) , so our estimation of the less compliant groups is conservative. Third, we tried to get a representative sample via two-stage stratified sampling in terms of ethnicity, gender, age, and geographical area, but Malaysia is a multi-facet society and the sample should not be considered as nationally representative. Fourth, social media usage was very high during the COVID-19 pandemic due to the lockdown, and future study may examine the model in lesser pandemics without heavy lockdowns. Finally, Malaysia is an upper-middle income-level country, where water for handwashing is generally accessible. Studies in countries with heterogeneous individual access to water might yield different results. . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 3, 2020. . https://doi.org/10. 1101 /2020 We identify several new predictors of handwashing during a pandemic to enable health organizations, governments, and others to create more targeted communication campaigns, particularly via social media. Such campaigns might be particularly important because of the heavy use of social media during an epidemic, yet often social media posts during a pandemic contain little practical advice (Vos & Buckner, 2016) . This study contributes by identifying less compliant groups regarding handwashing, especially via social media usage, to enable more focused health information campaigns. The authors declare that there are no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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