The impact of television on-air time on hand hygiene compliance behaviors during COVID-19 outbreak

Background There is limited data to support the impact of the COVID-19 pandemic on hand hygiene compliance among hospital visitors. Methods We monitored hand hygiene compliance among university hospital visitors in Osaka, Japan by direct observation, from December 2019 to March 2022. During this time, we measured the amount of coverage time dedicated to COVID-19 related news on the local public television channel and the number of confirmed cases and deaths. Results Over 148 days, 111,071 visitors hand hygiene compliance was monitored. The baseline compliance was 5.3% (213 of 4,026) in December 2019. From late January 2020, compliance rose significantly to almost 70% in August 2020. It remained at a level of 70%-75% until October 2021, after which, the compliance slowly declined to the mid-60% range. The number of newly confirmed cases and deaths were not related to the change in compliance, but the association between the on-air time of COVID-19-related news and compliance was statistically significant. Conclusions Hand hygiene compliance dramatically increased following the COVID-19 pandemic. The role of television in increasing hand hygiene compliance was significant.

Ignaz Semmelweis and Oliver Wendell Holmes first highlighted the importance of hand hygiene in the mid-19th century. 1,2 Later, bacteriology developed in the late 19th century, and bacteria were confirmed to reside on human skin. 3,4 Since the latter half of the 20th century, hand hygiene has been repeatedly demonstrated to reduce healthcare-associated infections, as well as community-acquired infections. [5][6][7][8][9][10] In 2009, the WHO issued comprehensive guidelines on hand hygiene. 11 Despite its recognized importance, hand hygiene is still not well practiced and has continued to be a challenge even among healthcare workers (HCWs). 12 Under these circumstances, the novel coronavirus (severe acute respiratory syndrome coronavirus 2, SARS-CoV-2) epidemic that started in China in December 2019 became a global pandemic. 13 On January 6, 2020, the Japanese Ministry of Health, Labour and Welfare issued an urgent press release regarding "pneumonia of unknown cause." 14 On January 16, 2020, a Japanese infected person with a travel history of staying in Wuhan, China, was reported for the first time in Japan. 15 On January 28, the first domestic infected case (an infected Japanese without travel history to the endemic area) was reported. 16 In addition, numerous individuals with the coronavirus disease 2019 (COVID-19) were found among the passengers and crew members of the cruise ship, Diamond Princess, which was anchored at Yokohama Port on February 3. 17 Due to the huge number of infections on board the cruise ship, information related to COVID-19 suddenly flooded through mass and social media. Across the world, hand hygiene, along with mask-wearing and social distancing, were recommended as part of comprehensive infection control. [18][19][20] Before the COVID-19 pandemic, we measured the hand hygiene compliance of visitors to a university hospital in Japan. We continued monitoring this after the pandemic began. We observed how compliance changed as the pandemic progressed. To our knowledge, there are no studies to date that measured the long-term changes in hand hygiene among non-healthcare persons, before and after the onset of the pandemic. This is the first study to quantitatively analyze the impact of the pandemic on hand hygiene behaviors in non-HCWs.

METHODS
The Osaka University Hospital implemented direct observation and monitoring of the hand hygiene behaviors of its visitors at the entrance hall of the hospital. This monitoring is a routine activity conducted by the Infection Control Team of the hospital because we believe that raising awareness about hand hygiene among the general public is important for controlling hospital infections. 21 A designated person (D.M.) monitored the number of visitors and users of alcohol-based hand rub using a manual counter at the hospital entrance for an hour a day (usually in the morning) every week. The designated observer had previously directly observed hospital visitors' adherence to hand hygiene as part of the hospital's infection control activities and had sufficient experience and training to perform the monitoring. We did not monitor the patients who exited the hospital. Compliance was calculated by dividing the number of hand-rub users by the number of visitors during the observation period. Since this project was a routine patient safety improvement initiative, it was not considered a research study. Hence, written informed consent from individual visitors was not required, in line with institutional policy. Additionally, we obtained data on the newly confirmed cases and deaths from the COVID-19 standard dataset. 22 Observation period An event to boost hand hygiene during the influenza season was held at the hospital between December 5 and 24, 2019. The observation period of this study included this event and we defined the baseline period as the period from December 10 to 26, 2019. Compliance was monitored regularly even after the outbreak of COVID-19. Thus, for our analysis, we define the period of interest as the period from January 2020 to March 2022.

Mass media influence
An important variable, other than epidemic indicators, that we examined in relation to the general public's hand hygiene behaviors was mass media coverage. To gauge the extent of the media's influence on public awareness, we documented the on-air time devoted to NHK's coverage of COVID-19-related news, which aired in the Kansai area where the university hospital is located, between January 1, 2020, and March 31, 2022. NHK is the only public television broadcast channel in Japan. We treated the broadcast time from 9:00 a.m. the day before to 9:00 AM the day as a day unit because we monitored compliance in the morning. On-air time data were obtained from JCC Co., Ltd (Tokyo, Japan).

Statistical analysis
We employed a Bayesian structural time-series approach to estimate the relative effects of the amount of COVID-19-related television coverage on compliance. We modeled the number of hand hygiene Y t 2 f1; . . . ; n t g per day at the hospital entrance as binomially distributed, with the number of people coming in through the entrance equal to the number of visitors, n t 2 N, for a time (day) t 2 f1; . . . ; Tg where T is the total number of days of the observation period, and the corresponding probability of u t 2 R. The probability u t is modeled via the logit link to the independent variable of air time changes b t 2 fb 1 ; . . . ; b T g where b t is the change in air time from day (t À 2) (2 days before) to day (t À 1) (the day before). To consider temporal dependencies, a Gaussian random walk process m t 2 R is included in the model. The following model formulation was applied: where b 2 R is a regression coefficient representing how the air time change b t affects the probability of hand hygiene, on average. We used a prior function with a half-Cauchy distribution prior to s, a normal prior to m.

Hand hygiene compliance
During the baseline period, our 5-day observation recorded 4,026 visitors and 213 cases that demonstrated hand hygiene behaviors (5.3%). During the period of interest, we observed 107,045 visitors on 143 observation days. The compliance on January 28 was 7.6% (54 hand hygiene cases among 711 visitors). This was significantly higher than that in the baseline period (P = .014). From late January 2020, compliance continued to rise to almost 70% in August 2020. It remained at a level of 70% to 75% until October 2021, after which, compliance slowly declined to the mid-60% range (Fig 1). No seasonal effects were observed. Figure 2 shows the number of newly confirmed cases and deaths in the Osaka Prefecture. Clearly, these indicators of infection prevalence do not explain trends in hand hygiene compliance. Although hand hygiene compliance increased significantly from January to August 2020, the number of newly confirmed cases and deaths in Japan during this period was relatively small. Figure 3 shows the cumulative number of confirmed cases and deaths in the Osaka Prefecture. Again, these indicators do not explain the observed trends. Even after January 2022, when the cumulative number of confirmed cases and deaths in Japan increased dramatically, no increase in hand hygiene compliance was observed.
The role of the media Thus, changes in compliance cannot be explained simply by epidemic indicators. It is necessary to consider the possibility that psychological and social factors may intervene. Hence, we focused on television coverage time as an indicator of psychological impact and public concern. This is because, in consideration of the gatekeeping theory, 23 the kind of news covered by mass media selects and how frequently they are reported, determine public concern. We considered television coverage time to be the most representative and accessible indicator of mass media. Figure 4 shows the hours of COVID-19-related news broadcast on NHK during each 24-hours period, and Figure 5 shows its distribution. At maximum, 7.7 hours in a day (May 20, 2020) was devoted to the news coverage (Fig 5). After this peak, the on-air time gradually decreased and fluctuated according to the infection trend.

Bayesian posterior estimates
We estimated the values of the parameters based on our model. We conducted Markov chain Monte Carlo (MCMC) simulations with

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4 independent chains and a total of 4,000 iterations per chain, and the first 2,000 were discarded as burn-in steps. The convergence of the MCMC simulations was checked using the Gelman-Rubin statistic 23 and was less than 1.10 for all parameters indicating that the MCMC simulations converged. We also checked the effective sample size of the parameters, that is, the number of independent MCMC samples related to autocorrelation (the total number of MCMC samples was 8,000).    In addition, we defined the compliance difference as the change in compliance relative to the increase in the unit on-air time and the link function as a logistic function (that is, when the compliance is 50%, the compliance response to the change in coverage time is the maximum). This value was estimated (Fig 6). The results showed that a 1-hour increase in coverage time boosts hand hygiene rates by up to 0.96% (95% confidence interval [CI] = [0.32%, 1.60%]).

DISCUSSION
The hand hygiene compliance of hospital visitors at the hospital entrance dramatically increased after the COVID-19 outbreak. Furthermore, compliance was significantly associated with the on-air time of COVID-19-related news broadcasts. Although the baseline period in our study was the event period to boost hand hygiene in preparation for the influenza season, the impact of COVID-19 outstripped our promotional efforts.
In terms of the media's influence, an increase in on-air time was significantly associated with higher compliance. The compliance difference at 50% was estimated to be .96% (CI = [0.32%, 1.60%]). This means that an additional hour of news coverage at 50% compliance will increase the compliance the next day by approximately 1%.
Several studies have investigated the impact of the COVID-19 pandemic on hand hygiene behaviors. Williams et al 24 reported that the hand hygiene compliance rate of HCWs in Canadian healthcare facilities increased after admitting patients with COVID-19 to their facilities. Moore et al 25 also evaluated the hand hygiene compliance during patient room entry and exit in US medical institutions in the spring of 2020. Weijers et al 26 conducted a small-scale study of the general public's hand hygiene behaviors. However, data were collected only for 3 days in May 2020, the data was not compared to pre-epidemic conditions, and hand hygiene behaviors were not monitored over time since the onset of the COVID-19 outbreak. To our knowledge, there are no studies to date that monitored hand hygiene adherence rates in the general population over 2 years or longer using the same method as before COVID-19. We assumed that most visitors to the hospital were nonmedical, and thus, representative of the general public in terms of hand hygiene behaviors. The findings of this study provide important insights into how the COVID-19 pandemic affected the hand hygiene behaviors of the general public.
There are 3 possible explanations for our findings. First, it could reflect people's anxiety and fear of the unknown. The media seemed

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to have contributed to aggravating these emotions. People may have become obsessive about cleanliness in response to the news coverage of the outbreak. The second explanation may be related to people wanting to conform to the practice fostered by media exposure. The instructive words of experts and government officials were not only to educate the general public and encourage them to act rationally, but also to create conforming pressure in relation to hand hygiene. Since late January 2020, people in Japan have been exposed to a large amount of information from "medical experts" including specialists in infectious diseases, epidemiology, and public health services. This may have encouraged greater hand hygiene compliance in the general population. Finally, people may have understood the information provided by public officials and experts from a rational perspective and behaved according to their logical and scientific thinking that hand hygiene is one of the most important precautions against the SARS-CoV-2. 27 Hand hygiene was reinforced by Japanese authorities 28 and the media repeated the same advice. 29 This study does not claim that the COVID-19 outbreak was successful in making the Japanese people comply with hand hygiene. Although compliance continued to be very high compared to the baseline study period, the trend changed soon after the outbreak started. Moreover, even in an endemic situation, people may become complacent after constantly hearing about the disease and stop paying attention to the important advice. In the future, further observations are needed to determine whether hand hygiene becomes habitual among Japanese citizens.
Our study has several limitations. First, we did not consider all information sources as factors influencing hand hygiene behaviors. People obtain information not only from conventional media but also from social media. However, we used data from the NHK news programs as a marker of media exposure to explain the outcome. The reason why we used the on-air time of COVID-19-related news on television was not because we thought that the coverage itself was a factor that directly determined people's behaviors. Rather, we assumed that the degree of social concern about COVID-19 would influence people's hand hygiene behaviors and that the amount of coverage in the media would define the degree of public concern. This is consistent with the gatekeeping theory, which states that the media are gatekeepers that filter the information conveyed to the public. 30 As a result of such gatekeeping, the public perceives pseudoreality based on the pseudo-environment created by the media, and their public concerns are determined by such perceptions.
Another limitation is the concern over generalizability. This singlecenter study was conducted at a university hospital in Osaka, Japan. The hospital has been conducting hand hygiene awareness-raising activities for visitors for a long time. 21,31 This routine activity may have influenced hospital visitors and created a bias in compliance.
In conclusion, the impact of the COVID-19 outbreak on the hand hygiene behaviors of visitors to the hospital was significant, with the media contributing to this desirable habit for at least 2 years. Further investigations are needed to determine whether high compliance with hand hygiene becomes a customary practice in daily life over time.