Knowledge Level and Hand Hygiene Practice of Nepalese Immigrants and Their Host Country Population: A Comparative Study

Nepali people are one of the ethnic minority immigrants of Hong Kong. This epidemiological investigation aims to determine and compare the knowledge level and hand hygiene (HH) behaviour of the Nepali people and the population of their host country (i.e., native Chinese population of Hong Kong). A total of 1008 questionnaires were collected via an online platform. The overall knowledge level of the native population towards HH was considerably higher than that of the Nepali respondents. Lower levels of knowledge in young and older people were noted. Reduced HH knowledge was also observed in people with low educational level or with comorbid illness(es). Significant differences between groups were noted in the self-reported hand washing behaviours. Regarding hand drying, more Nepalese than native Chinese respondents always/sometimes dried their hands on their clothing irrespective whether after performing handwashing in public washrooms or at home. Misconceptions and suboptimal practices on HH were prevalent in the two populations. The findings of this comparative study offer valuable information for the development of culturally sensitive health educational programs to enhance HH practices for the ethnic minorities and native Chinese population.


Introduction
Handwashing is a simple and cost-effective method for preventing diarrhoea and respiratory illnesses in communities and institutions [1]. Inadequate sanitation facilities and poor knowledge about hand hygiene (HH) are associated with increased risk of contracting infectious diseases [2].
Nepal, a landlocked country in South Asia, has more than 1 million people who still practice open defecation. Approximately 15% of households in the country have no toilet facilities (21% and 11% in rural and urban areas, respectively), and 20% have no supplies of water, soap or any other available hand cleaning agents [3]. The handwashing behaviours of people residing in slums are generally suboptimal. Only 20% of mothers in Nepal wash their hands with soap after using the toilet and 14% wash their hands with soap after cleaning their babies' bottoms. Handwashing before cooking or feeding the baby is rarely performed [4]. Infectious diseases, such as influenza, malaria, pneumonia and diarrhoea, are the top leading causes of death in Nepal [5]. Numerous factors, such as poor HH, unsafe water and inadequate sanitation facilities, as well as lack of infection control experts and specialised laboratories, are associated with high prevalence of infectious diseases in Nepal [6]. Although sanitation facilities have substantially improved in recent years [7], the common standard of HH practices in the mother country (Nepal) that is deep-rooted in the Nepali population has not greatly changed and even continued to be observed by Nepali immigrants.

Knowledge Level Towards HH
The knowledge level of the Chine of the Nepali respondents (9.55 vs. 7. could not differentiate the diseases th item related to the human immunodef upper respiratory tract infection/influ concepts associated with HH amon respondents carried the misconception defence mechanism (49.4%, n = 238), ha an alcohol-based hand sanitiser contain and that lathering the hands for 10 s b 30% of the respondents believed that effect (37.8%, n = 133) ( Table 2).

Knowledge Level Towards HH
The knowledge level of the Chinese population towards HH was considerably higher than that of the Nepali respondents (9.55 vs. 7.12 out of 12). A considerable number of Nepali respondents could not differentiate the diseases that can or cannot be transmitted with poor HH, especially the item related to the human immunodeficiency virus infection (Nepalese vs. local: 47.7% vs. 2.7%), and upper respiratory tract infection/influenza-like illness (Nepalese vs. local: 56.6% vs. 85.9%). The concepts associated with HH among the Nepalese were relatively poor. Almost half of the respondents carried the misconceptions that always keeping the hands clean may decrease the body's defence mechanism (49.4%, n = 238), hands must be held under water while lathering (48.1%, n = 232), an alcohol-based hand sanitiser containing 40% alcohol was sufficient for disinfection (41.4%, n = 199) and that lathering the hands for 10 s before rinsing was enough for disinfection (58.0, n = 279). Over 30% of the respondents believed that water temperature caused a difference in the hand cleaning effect (37.8%, n = 133) ( Table 2).

Knowledge Level towards HH
The knowledge level of the Chinese population towards HH was considerably higher than that of the Nepali respondents (9.55 vs. 7.12 out of 12). A considerable number of Nepali respondents could not differentiate the diseases that can or cannot be transmitted with poor HH, especially the item related to the human immunodeficiency virus infection (Nepalese vs. local: 47.7% vs. 2.7%), and upper respiratory tract infection/influenza-like illness (Nepalese vs. local: 56.6% vs. 85.9%). The concepts associated with HH among the Nepalese were relatively poor. Almost half of the respondents carried the misconceptions that always keeping the hands clean may decrease the body's defence mechanism (49.4%, n = 238), hands must be held under water while lathering (48.1%, n = 232), an alcohol-based hand sanitiser containing 40% alcohol was sufficient for disinfection (41.4%, n = 199) and that lathering the hands for 10 s before rinsing was enough for disinfection (58.0, n = 279). Over 30% of the respondents believed that water temperature caused a difference in the hand cleaning effect (37.8%, n = 133) ( Table 2).
There are significant age-related differences, with lower levels of knowledge in young and elder people. Reduced HH knowledge was also observed in people with low educational level (primary or below) or with comorbid illness(es). Respondents with better HH knowledge generally performed HH more often during infectious disease outbreaks and took longer time to lather the hands with soap before rinsing. Females exhibited a significantly higher HH knowledge than males in the Chinese respondents (p = 0.018), but this gender difference was not observed in the Nepali respondents (Table 3).

Knowledge Level Towards HH
The knowledge level of the Chinese of the Nepali respondents (9.55 vs. 7.12 could not differentiate the diseases that item related to the human immunodefici upper respiratory tract infection/influe concepts associated with HH among respondents carried the misconceptions defence mechanism (49.4%, n = 238), han an alcohol-based hand sanitiser containin and that lathering the hands for 10 s bef 30% of the respondents believed that w effect (37.8%, n = 133) ( Table 2).

Knowledge Level Towards HH
The knowledge level of the Chinese population towards HH was considerably higher than that of the Nepali respondents (9.55 vs. 7.12 out of 12). A considerable number of Nepali respondents could not differentiate the diseases that can or cannot be transmitted with poor HH, especially the item related to the human immunodeficiency virus infection (Nepalese vs. local: 47.7% vs. 2.7%), and upper respiratory tract infection/influenza-like illness (Nepalese vs. local: 56.6% vs. 85.9%). The concepts associated with HH among the Nepalese were relatively poor. Almost half of the respondents carried the misconceptions that always keeping the hands clean may decrease the body's defence mechanism (49.4%, n = 238), hands must be held under water while lathering (48.1%, n = 232), an alcohol-based hand sanitiser containing 40% alcohol was sufficient for disinfection (41.4%, n = 199) and that lathering the hands for 10 s before rinsing was enough for disinfection (58.0, n = 279). Over 30% of the respondents believed that water temperature caused a difference in the hand cleaning effect (37.8%, n = 133) ( Table 2).  Note: -Independent t-test or one-way analysis of variance as appropriate; *-Statistically significant at p < 0.05; **-Statistically significant at p < 0.01; ***-Statistically significant at p < 0.001. s-second;

Self-Reported Hand Cleaning and Hand Drying Practices
Significant differences in the self-reported hand washing behaviours were seen between groups. For example, more Nepalese than the Chinese respondents indicated that they did not perform hand washing after handling food, cooking, urinating, defalcating, caring for a sick person, showing visibly dirty hands, touching livestock or animal waste, gardening or disposing garbage bag. Over 40% of the Nepalese indicated that they only hand wash for ≤ 5 s. An increased number of local respondents would hand wash more often during infectious disease outbreaks than the Nepalese (77.0% vs. 45.9%), with the latter group inclined to ignore hand washing if they are in a hurry (p < 0.001), nobody is in the washroom (p < 0.001) or they only urinated (p < 0.001).
Regarding hand drying, more Nepalese always/sometimes dried their hands on their clothing (92.7% vs. 42.6%, p < 0.001) or used personal towel or handkerchief (83.0 vs. 35.8%, p < 0.001) than the Chinese respondents. The Chinese respondents generally preferred using paper towels supplied by the washrooms than the Nepalese (96.7% vs. 65.8%). Respondents might shake their hands to remove excess water before drying and limit the use of paper towels to two pieces. The average time for using either warm or jet hand dryers in the two groups were generally less than 20 s. For the usual hand drying practice at home, the Nepalese preferred to rub their hands on their clothes or by air evaporation, whereas the Chinese population preferred using a towel shared with family members (Table 4).

Discussion
This study is the first to examine comparatively the HH knowledge level and behaviours amo the Nepalese and the Chinese population of Hong Kong. Many Nepali respondents exhibited a ha of wearing ring(s) and artificial/acrylic nails or bracelets, whereas the local respondents w predominantly watch wearers. Long nails were associated with the presence of enteric bacte whereas ringed fingers were associated with increased bacterial load [26]. Therefore, special attent to these regions during hands washing should be made.
A considerable number of Nepali respondents indicated that they use bare hands for eati Eating using the hands is a common practice in many countries, such as Nepal, India, Africa and Middle East. Eating using the hands is not only seen as a social politeness in these countries bu believed to increase blood circulation, promote a sense of fullness and satiety and heighten sens connection with food during eating [27,28]. Therefore, the importance of performing HH bef eating must be emphasised, and the fingernails must always be kept short and clean. Approximat 27% of Nepali respondents expressed that they stopped using their hands for eating, which w probably due to acculturation after residing in Hong Kong. A very high percentage of Nep respondents did not receive influenza vaccination over the past 12 months (91.9%). In an onl survey conducted by Stedman-Smith and her team [29], it has been reported that the influe vaccine uptake was associated with protective hand hygiene behaviours. This may be due t conscious effort of the respondents to practice the two behaviours together as a more thorou approach for preventing infectious disease.
The knowledge level of the Chinese population towards HH was significantly higher than t of the Nepali respondents. A considerable number of the Nepalese could not differentiate the disea that can or cannot be transmitted with poor HH, especially in the item related to hum immunodeficiency virus infection. This finding may be due to the relatively low educational leve this minority group. Respondents with good HH knowledge in the two groups were associated w 19

Knowledge Level Towards HH
The knowledge level of the Chinese of the Nepali respondents (9.55 vs. 7.12 could not differentiate the diseases that item related to the human immunodeficie upper respiratory tract infection/influen concepts associated with HH among respondents carried the misconceptions th defence mechanism (49.4%, n = 238), hand an alcohol-based hand sanitiser containin and that lathering the hands for 10 s befo 30% of the respondents believed that w effect (37.8%, n = 133) ( Table 2).

Discussion
This study is the first to examine comparatively the HH knowledge level and behaviours amo the Nepalese and the Chinese population of Hong Kong. Many Nepali respondents exhibited a ha of wearing ring(s) and artificial/acrylic nails or bracelets, whereas the local respondents w predominantly watch wearers. Long nails were associated with the presence of enteric bacte whereas ringed fingers were associated with increased bacterial load [26]. Therefore, special attent to these regions during hands washing should be made.
A considerable number of Nepali respondents indicated that they use bare hands for eati Eating using the hands is a common practice in many countries, such as Nepal, India, Africa and Middle East. Eating using the hands is not only seen as a social politeness in these countries bu believed to increase blood circulation, promote a sense of fullness and satiety and heighten sens connection with food during eating [27,28]. Therefore, the importance of performing HH bef eating must be emphasised, and the fingernails must always be kept short and clean. Approximat 27% of Nepali respondents expressed that they stopped using their hands for eating, which w probably due to acculturation after residing in Hong Kong. A very high percentage of Nep respondents did not receive influenza vaccination over the past 12 months (91.9%). In an onl survey conducted by Stedman-Smith and her team [29], it has been reported that the influe vaccine uptake was associated with protective hand hygiene behaviours. This may be due t conscious effort of the respondents to practice the two behaviours together as a more thorou approach for preventing infectious disease.
The knowledge level of the Chinese population towards HH was significantly higher than t of the Nepali respondents. A considerable number of the Nepalese could not differentiate the disea that can or cannot be transmitted with poor HH, especially in the item related to hum immunodeficiency virus infection. This finding may be due to the relatively low educational leve this minority group. Respondents with good HH knowledge in the two groups were associated w

Knowledge Level Towards HH
The knowledge level of the Chinese of the Nepali respondents (9.55 vs. 7.12 could not differentiate the diseases that item related to the human immunodeficie upper respiratory tract infection/influen concepts associated with HH among respondents carried the misconceptions th defence mechanism (49.4%, n = 238), hand an alcohol-based hand sanitiser containin and that lathering the hands for 10 s befo 30% of the respondents believed that w effect (37.8%, n = 133) ( Table 2).

Knowledge Level Towards HH
The knowledge level of the Chinese of the Nepali respondents (9.55 vs. 7.12 could not differentiate the diseases that item related to the human immunodeficie upper respiratory tract infection/influen concepts associated with HH among respondents carried the misconceptions th defence mechanism (49.4%, n = 238), hand an alcohol-based hand sanitiser containin and that lathering the hands for 10 s befo 30% of the respondents believed that w effect (37.8%, n = 133) ( Table 2).

Knowledge Level Towards HH
The knowledge level of the Chinese of the Nepali respondents (9.55 vs. 7.12 could not differentiate the diseases that item related to the human immunodeficie upper respiratory tract infection/influen concepts associated with HH among respondents carried the misconceptions th defence mechanism (49.4%, n = 238), hand an alcohol-based hand sanitiser containin and that lathering the hands for 10 s befo 30% of the respondents believed that w effect (37.8%, n = 133) ( Table 2).

Knowledge Level Towards HH
The knowledge level of the Chinese of the Nepali respondents (9.55 vs. 7.12 could not differentiate the diseases that item related to the human immunodeficie upper respiratory tract infection/influen concepts associated with HH among respondents carried the misconceptions th defence mechanism (49.4%, n = 238), hand an alcohol-based hand sanitiser containin and that lathering the hands for 10 s befo 30% of the respondents believed that w effect (37.8%, n = 133) ( Table 2).

Discussion
This study is the first to examine comparatively the HH knowledge level and behaviours amo the Nepalese and the Chinese population of Hong Kong. Many Nepali respondents exhibited a ha of wearing ring(s) and artificial/acrylic nails or bracelets, whereas the local respondents w predominantly watch wearers. Long nails were associated with the presence of enteric bacte whereas ringed fingers were associated with increased bacterial load [26]. Therefore, special attent to these regions during hands washing should be made.
A considerable number of Nepali respondents indicated that they use bare hands for eati Eating using the hands is a common practice in many countries, such as Nepal, India, Africa and Middle East. Eating using the hands is not only seen as a social politeness in these countries bu believed to increase blood circulation, promote a sense of fullness and satiety and heighten sens connection with food during eating [27,28]. Therefore, the importance of performing HH bef eating must be emphasised, and the fingernails must always be kept short and clean. Approximat 27% of Nepali respondents expressed that they stopped using their hands for eating, which w probably due to acculturation after residing in Hong Kong. A very high percentage of Nep

Knowledge Level Towards HH
The knowledge level of the Chinese of the Nepali respondents (9.55 vs. 7.12 could not differentiate the diseases that item related to the human immunodeficie upper respiratory tract infection/influen concepts associated with HH among respondents carried the misconceptions th defence mechanism (49.4%, n = 238), hand an alcohol-based hand sanitiser containin and that lathering the hands for 10 s befo 30% of the respondents believed that w effect (37.8%, n = 133) ( Table 2).

Discussion
This study is the first to examine comparatively the HH knowledge level and behaviours amo the Nepalese and the Chinese population of Hong Kong. Many Nepali respondents exhibited a ha of wearing ring(s) and artificial/acrylic nails or bracelets, whereas the local respondents w predominantly watch wearers. Long nails were associated with the presence of enteric bacte whereas ringed fingers were associated with increased bacterial load [26]. Therefore, special attent to these regions during hands washing should be made.
A considerable number of Nepali respondents indicated that they use bare hands for eati 26

Knowledge Level Towards HH
The knowledge level of the Chinese of the Nepali respondents (9.55 vs. 7.12 could not differentiate the diseases that item related to the human immunodeficie upper respiratory tract infection/influen concepts associated with HH among respondents carried the misconceptions th defence mechanism (49.4%, n = 238), hand ***

Discussion
This study is the first to examine comparatively the HH knowledge level and behaviours amo the Nepalese and the Chinese population of Hong Kong. Many Nepali respondents exhibited a ha of wearing ring(s) and artificial/acrylic nails or bracelets, whereas the local respondents w predominantly watch wearers. Long nails were associated with the presence of enteric bacte whereas ringed fingers were associated with increased bacterial load [26]. Therefore, special attent to these regions during hands washing should be made.
A considerable number of Nepali respondents indicated that they use bare hands for eati Eating using the hands is a common practice in many countries, such as Nepal, India, Africa and Middle East. Eating using the hands is not only seen as a social politeness in these countries bu believed to increase blood circulation, promote a sense of fullness and satiety and heighten sens connection with food during eating [27,28]. Therefore, the importance of performing HH bef eating must be emphasised, and the fingernails must always be kept short and clean. Approximat 27% of Nepali respondents expressed that they stopped using their hands for eating, which w probably due to acculturation after residing in Hong Kong. A very high percentage of Nep respondents did not receive influenza vaccination over the past 12 months (91.9%). In an onl survey conducted by Stedman-Smith and her team [29], it has been reported that the influe vaccine uptake was associated with protective hand hygiene behaviours. This may be due t conscious effort of the respondents to practice the two behaviours together as a more thorou approach for preventing infectious disease.
The knowledge level of the Chinese population towards HH was significantly higher than t of the Nepali respondents. A considerable number of the Nepalese could not differentiate the disea that can or cannot be transmitted with poor HH, especially in the item related to hum immunodeficiency virus infection. This finding may be due to the relatively low educational leve this minority group. Respondents with good HH knowledge in the two groups were associated w 14

Knowledge Level Towards HH
The knowledge level of the Chinese of the Nepali respondents (9.55 vs. 7.12 could not differentiate the diseases that item related to the human immunodeficie upper respiratory tract infection/influen concepts associated with HH among respondents carried the misconceptions th defence mechanism (49.4%, n = 238), hand an alcohol-based hand sanitiser containin and that lathering the hands for 10 s befo 30% of the respondents believed that w effect (37.8%, n = 133) ( Table 2).

Knowledge Level Towards HH
The knowledge level of the Chinese of the Nepali respondents (9.55 vs. 7.12 could not differentiate the diseases that item related to the human immunodeficie upper respiratory tract infection/influen concepts associated with HH among respondents carried the misconceptions th defence mechanism (49.4%, n = 238), hand an alcohol-based hand sanitiser containin and that lathering the hands for 10 s befo 30% of the respondents believed that w effect (37.8%, n = 133) ( Table 2).

Knowledge Level Towards HH
The knowledge level of the Chinese of the Nepali respondents (9.55 vs. 7.12 could not differentiate the diseases that item related to the human immunodeficie upper respiratory tract infection/influen concepts associated with HH among respondents carried the misconceptions th defence mechanism (49.4%, n = 238), hand an alcohol-based hand sanitiser containin and that lathering the hands for 10 s befo 30% of the respondents believed that w effect (37.8%, n = 133) ( Table 2). < 0.00  *** Note: ABHR-Alcohol based hand rub; -Fisher's exact test; -Chi-square test; *-Statistically significant at p < 0.05; **-Statistically significant at p < 0.01; ***-Statistically significant at p < 0.001; ※-Not applicable cases were excluded from percentage calculation and the analyses. s: seconds

Discussion
This study is the first to examine comparatively the HH knowledge level and behaviours amo the Nepalese and the Chinese population of Hong Kong. Many Nepali respondents exhibited a ha of wearing ring(s) and artificial/acrylic nails or bracelets, whereas the local respondents w predominantly watch wearers. Long nails were associated with the presence of enteric bacte whereas ringed fingers were associated with increased bacterial load [26]. Therefore, special attent to these regions during hands washing should be made.
A considerable number of Nepali respondents indicated that they use bare hands for eati Eating using the hands is a common practice in many countries, such as Nepal, India, Africa and Middle East. Eating using the hands is not only seen as a social politeness in these countries bu believed to increase blood circulation, promote a sense of fullness and satiety and heighten sens connection with food during eating [27,28]. Therefore, the importance of performing HH bef eating must be emphasised, and the fingernails must always be kept short and clean. Approximat 27% of Nepali respondents expressed that they stopped using their hands for eating, which w probably due to acculturation after residing in Hong Kong. A very high percentage of Nep respondents did not receive influenza vaccination over the past 12 months (91.9%). In an onl survey conducted by Stedman-Smith and her team [29], it has been reported that the influe vaccine uptake was associated with protective hand hygiene behaviours. This may be due t conscious effort of the respondents to practice the two behaviours together as a more thorou approach for preventing infectious disease.
The knowledge level of the Chinese population towards HH was significantly higher than t of the Nepali respondents. A considerable number of the Nepalese could not differentiate the disea that can or cannot be transmitted with poor HH, especially in the item related to hum immunodeficiency virus infection. This finding may be due to the relatively low educational leve this minority group. Respondents with good HH knowledge in the two groups were associated w  < 0.00  *** Note: ABHR-Alcohol based hand rub; -Fisher's exact test; -Chi-square test; *-Statistically significant at p < 0.05; **-Statistically significant at p < 0.01; ***-Statistically significant at p < 0.001; ※-Not applicable cases were excluded from percentage calculation and the analyses. s: seconds

Discussion
This study is the first to examine comparatively the HH knowledge level and behaviours amo the Nepalese and the Chinese population of Hong Kong. Many Nepali respondents exhibited a ha of wearing ring(s) and artificial/acrylic nails or bracelets, whereas the local respondents w predominantly watch wearers. Long nails were associated with the presence of enteric bacte whereas ringed fingers were associated with increased bacterial load [26]. Therefore, special attent to these regions during hands washing should be made.
A considerable number of Nepali respondents indicated that they use bare hands for eati Eating using the hands is a common practice in many countries, such as Nepal, India, Africa and Middle East. Eating using the hands is not only seen as a social politeness in these countries bu believed to increase blood circulation, promote a sense of fullness and satiety and heighten sens connection with food during eating [27,28]. Therefore, the importance of performing HH bef eating must be emphasised, and the fingernails must always be kept short and clean. Approximat 27% of Nepali respondents expressed that they stopped using their hands for eating, which w probably due to acculturation after residing in Hong Kong. A very high percentage of Nep respondents did not receive influenza vaccination over the past 12 months (91.9%). In an onl survey conducted by Stedman-Smith and her team [29], it has been reported that the influe vaccine uptake was associated with protective hand hygiene behaviours. This may be due t conscious effort of the respondents to practice the two behaviours together as a more thorou approach for preventing infectious disease.
The knowledge level of the Chinese population towards HH was significantly higher than t

Discussion
This study is the first to examine comparatively the HH knowledge level and behaviours amo the Nepalese and the Chinese population of Hong Kong. Many Nepali respondents exhibited a ha of wearing ring(s) and artificial/acrylic nails or bracelets, whereas the local respondents w predominantly watch wearers. Long nails were associated with the presence of enteric bacte whereas ringed fingers were associated with increased bacterial load [26]. Therefore, special attent to these regions during hands washing should be made.
A considerable number of Nepali respondents indicated that they use bare hands for eati Eating using the hands is a common practice in many countries, such as Nepal, India, Africa and 28 (7.5) 43 (11.5)

Knowledge Level Towards HH
The knowledge level of the Chinese of the Nepali respondents (9.55 vs. 7.12 could not differentiate the diseases that item related to the human immunodeficie upper respiratory tract infection/influen concepts associated with HH among respondents carried the misconceptions th defence mechanism (49.4%, n = 238), hand an alcohol-based hand sanitiser containin and that lathering the hands for 10 s befo 30% of the respondents believed that w effect (37.8%, n = 133) ( Table 2). < 0.00  *** Note: ABHR-Alcohol based hand rub; -Fisher's exact test; -Chi-square test; *-Statistically significant at p < 0.05; **-Statistically significant at p < 0.01; ***-Statistically significant at p < 0.001; ※-Not applicable cases were excluded from percentage calculation and the analyses. s: seconds

Discussion
This study is the first to examine comparatively the HH knowledge level and behaviours amo the Nepalese and the Chinese population of Hong Kong. Many Nepali respondents exhibited a ha of wearing ring(s) and artificial/acrylic nails or bracelets, whereas the local respondents w predominantly watch wearers. Long nails were associated with the presence of enteric bacte whereas ringed fingers were associated with increased bacterial load [26]. Therefore, special attent to these regions during hands washing should be made.
A considerable number of Nepali respondents indicated that they use bare hands for eati Eating using the hands is a common practice in many countries, such as Nepal, India, Africa and Middle East. Eating using the hands is not only seen as a social politeness in these countries bu believed to increase blood circulation, promote a sense of fullness and satiety and heighten sens connection with food during eating [27,28]. Therefore, the importance of performing HH bef eating must be emphasised, and the fingernails must always be kept short and clean. Approximat 27% of Nepali respondents expressed that they stopped using their hands for eating, which w probably due to acculturation after residing in Hong Kong. A very high percentage of Nep respondents did not receive influenza vaccination over the past 12 months (91.9%). In an onl survey conducted by Stedman-Smith and her team [29], it has been reported that the influe vaccine uptake was associated with protective hand hygiene behaviours. This may be due t conscious effort of the respondents to practice the two behaviours together as a more thorou approach for preventing infectious disease.
The knowledge level of the Chinese population towards HH was significantly higher than t of the Nepali respondents. A considerable number of the Nepalese could not differentiate the disea that can or cannot be transmitted with poor HH, especially in the item related to hum immunodeficiency virus infection. This finding may be due to the relatively low educational leve this minority group. Respondents with good HH knowledge in the two groups were associated w

Discussion
This study is the first to examine comparatively the HH knowledge level and behaviours amo the Nepalese and the Chinese population of Hong Kong. Many Nepali respondents exhibited a ha of wearing ring(s) and artificial/acrylic nails or bracelets, whereas the local respondents w predominantly watch wearers. Long nails were associated with the presence of enteric bacte whereas ringed fingers were associated with increased bacterial load [26]. Therefore, special attent to these regions during hands washing should be made.
A considerable number of Nepali respondents indicated that they use bare hands for eati Eating using the hands is a common practice in many countries, such as Nepal, India, Africa and Middle East. Eating using the hands is not only seen as a social politeness in these countries bu believed to increase blood circulation, promote a sense of fullness and satiety and heighten sens connection with food during eating [27,28]. Therefore, the importance of performing HH bef eating must be emphasised, and the fingernails must always be kept short and clean. Approximat 27% of Nepali respondents expressed that they stopped using their hands for eating, which w probably due to acculturation after residing in Hong Kong. A very high percentage of Nep respondents did not receive influenza vaccination over the past 12 months (91.9%). In an onl survey conducted by Stedman-Smith and her team [29], it has been reported that the influe vaccine uptake was associated with protective hand hygiene behaviours. This may be due t conscious effort of the respondents to practice the two behaviours together as a more thorou approach for preventing infectious disease.
The knowledge level of the Chinese population towards HH was significantly higher than t of the Nepali respondents. A considerable number of the Nepalese could not differentiate the disea that can or cannot be transmitted with poor HH, especially in the item related to hum immunodeficiency virus infection. This finding may be due to the relatively low educational leve this minority group. Respondents with good HH knowledge in the two groups were associated w

Discussion
This study is the first to examine comparatively the HH knowledge level and behaviours amo the Nepalese and the Chinese population of Hong Kong. Many Nepali respondents exhibited a ha of wearing ring(s) and artificial/acrylic nails or bracelets, whereas the local respondents w predominantly watch wearers. Long nails were associated with the presence of enteric bacte whereas ringed fingers were associated with increased bacterial load [26]. Therefore, special attent to these regions during hands washing should be made.
A considerable number of Nepali respondents indicated that they use bare hands for eati Eating using the hands is a common practice in many countries, such as Nepal, India, Africa and Middle East. Eating using the hands is not only seen as a social politeness in these countries bu believed to increase blood circulation, promote a sense of fullness and satiety and heighten sens connection with food during eating [27,28]. Therefore, the importance of performing HH bef eating must be emphasised, and the fingernails must always be kept short and clean. Approximat 27% of Nepali respondents expressed that they stopped using their hands for eating, which w probably due to acculturation after residing in Hong Kong. A very high percentage of Nep respondents did not receive influenza vaccination over the past 12 months (91.9%). In an onl survey conducted by Stedman-Smith and her team [29], it has been reported that the influe vaccine uptake was associated with protective hand hygiene behaviours. This may be due t conscious effort of the respondents to practice the two behaviours together as a more thorou approach for preventing infectious disease.
The knowledge level of the Chinese population towards HH was significantly higher than t of the Nepali respondents. A considerable number of the Nepalese could not differentiate the disea

Discussion
This study is the first to examine comparatively the HH knowledge level and behaviours amo the Nepalese and the Chinese population of Hong Kong. Many Nepali respondents exhibited a ha of wearing ring(s) and artificial/acrylic nails or bracelets, whereas the local respondents w predominantly watch wearers. Long nails were associated with the presence of enteric bacte whereas ringed fingers were associated with increased bacterial load [26]. Therefore, special attent to these regions during hands washing should be made.
A considerable number of Nepali respondents indicated that they use bare hands for eati Eating using the hands is a common practice in many countries, such as Nepal, India, Africa and Middle East. Eating using the hands is not only seen as a social politeness in these countries bu believed to increase blood circulation, promote a sense of fullness and satiety and heighten sens connection with food during eating [27,28]. Therefore, the importance of performing HH bef eating must be emphasised, and the fingernails must always be kept short and clean. Approximat 27% of Nepali respondents expressed that they stopped using their hands for eating, which w

Knowledge Level Towards HH
The knowledge level of the Chinese population towards HH was considerably higher t of the Nepali respondents (9.55 vs. 7.12 out of 12). A considerable number of Nepali resp -Fisher's exact test; -Chi-square test; *-Statistically significant at p < 0.05; **-Statistically significant at p < 0.01; ***-Statistically significant at p < 0.001;

Discussion
This study is the first to examine comparati the Nepalese and the Chinese population of Ho -Not applicable cases were excluded from percentage calculation and the analyses. s: seconds

Discussion
This study is the first to examine comparatively the HH knowledge level and behaviours among the Nepalese and the Chinese population of Hong Kong. Many Nepali respondents exhibited a habit of wearing ring(s) and artificial/acrylic nails or bracelets, whereas the local respondents were predominantly watch wearers. Long nails were associated with the presence of enteric bacteria, whereas ringed fingers were associated with increased bacterial load [26]. Therefore, special attention to these regions during hands washing should be made.
A considerable number of Nepali respondents indicated that they use bare hands for eating. Eating using the hands is a common practice in many countries, such as Nepal, India, Africa and the Middle East. Eating using the hands is not only seen as a social politeness in these countries but is believed to increase blood circulation, promote a sense of fullness and satiety and heighten sensual connection with food during eating [27,28]. Therefore, the importance of performing HH before eating must be emphasised, and the fingernails must always be kept short and clean. Approximately 27% of Nepali respondents expressed that they stopped using their hands for eating, which was probably due to acculturation after residing in Hong Kong. A very high percentage of Nepoli respondents did not receive influenza vaccination over the past 12 months (91.9%). In an online survey conducted by Stedman-Smith and her team [29], it has been reported that the influenza vaccine uptake was associated with protective hand hygiene behaviours. This may be due to a conscious effort of the respondents to practice the two behaviours together as a more thorough approach for preventing infectious disease.
The knowledge level of the Chinese population towards HH was significantly higher than that of the Nepali respondents. A considerable number of the Nepalese could not differentiate the diseases that can or cannot be transmitted with poor HH, especially in the item related to human immunodeficiency virus infection. This finding may be due to the relatively low educational level of this minority group. Respondents with good HH knowledge in the two groups were associated with positive HH behaviours, such as performing HH often during infectious disease outbreak and increasing lathering time of the hands with soap before rinsing.
Another epidemiological investigation of Hong Kong conducted by the research team [25] revealed that being female, middle-aged and with tertiary education level are protective factors to improve HH knowledge. In this study, females showed significantly higher HH knowledge than males in the Chinese respondents, but this gender difference was not observed in the Nepali respondents. This finding may be because female Nepali immigrants were usually assigned a passive mother-wife role and achieved relatively lower educational level than men. Thus, a lesser dominant role than the females in Hong Kong was observed [7,10].
More Nepalese indicated that they do not wash their hands after handling food or cooking, urinating or defecating, caring for a sick person, possessing visibly dirty hands, touching livestock or animal waste, gardening or disposing of garbage bag than the Chinese respondents. Over 40% of the Nepalese indicated that they only handwash for ≤5 s. A considerable number of Nepalese respondents were inclined to ignore handwashing if they are in a hurry, if nobody is in the washroom or if they only urinated. According to Tonsing [13], immigration involves an array of changes in people's lives. Such changes can sometimes be overwhelming as individuals encounter various changes that affect them economically, culturally and psychologically and impede their immigration experiences. Huge differences in the infrastructure between Hong Kong and Nepal have been observed. The former has been classified as a high-income country, and the latter as one of the lowest income and least developed countries by the United Nations [30]. Previous handwashing behaviours, which have been developed in the mother country (Nepal) and are deeply rooted in the Nepalese, may not be easily changed even if they moved to other host countries. This practice may be especially difficult for the old generation who originated in Nepal slums who experienced defecating in public, in which no proper washing and drying facilities are available [3]. Thus, these older people may find hard adapting to another culture and practice that greatly contrasts with their practices. For example, washrooms may be housed with advanced sanitation facilities, such as hand drying devices, hands-free faucet with motion sensor and doors with automatic control, in the host country (Hong Kong).
People who spoke the primary language of the country and residence duration in a country were commonly used as indicators to determine acculturation levels [31]. HH is considered a social norm that is an effective driver to follow other's behaviour in a relevant social group [32,33]. Lengthened residency in a country implies wider exposure and interaction with the Chinese population. This situation leads to increased potential to adopt the values and beliefs of the Chinese and follow their general behavioural patterns [31] as well as tendency to practice socially acceptable behaviour.
Regarding hand drying, more Nepalese than the Chinese respondents always/sometimes dried their hands using own clothing irrespective whether after performing handwashing in public washrooms or at home. Drying hands on dirty clothes can compromise the benefits of handwashing [34]. Hands that are inadequately dried are more likely to transmit microorganisms compared with hands that have been completely dried [35].
Nepalese in Hong Kong are at a higher risk of developing various infectious diseases than the Chinese population in Hong Kong. The likelihood of transferring the infectious diseases from the Nepalese population to others residing in the same community is high as well. The incidence rate of tuberculosis infection is comparatively high among all the immigrants and minority population living in than people born in the UK [36]. Immigrants from underdeveloped countries with high endemic areas show high risk of acquiring similar infectious diseases in the immigrated areas due to poor HH compliance [12]. The incidence rate of infectious diseases is comparatively high among the immigrant workers from South Asian countries than the general Singaporean population in their host country [37]. Therefore, improving the HH practices of the Nepali population residing in Hong Kong can eventually decrease the risk of infectious diseases for the minor population and population at large.
Nepalese are one of the fastest growing ethnic minorities in Hong Kong [38], and they have considerable visibility in the society. Nepalese are organised and have established their organisations to fight for their rights [39]. Educational talks and promotional activities on HH can be effectively delivered via these bodies to reach out to these people.
Misconceptions and suboptimal practices on HH were not only prevalent among Nepalese but also among the Chinese population in Hong Kong. For example, majority of the respondents in both groups misunderstood holding the hands under water must be done while lathering, using 40% alcohol and alcohol-based hand-rub (ABHR) is sufficient for disinfection, lathering for 10 s before rinsing is enough for disinfection and water temperature may cause a difference in cleaning effects. Handwashing time and degree of friction generated during lathering are more important than water temperature in removing dirt and microorganisms, and warm water causes skin irritations and is not environmentally friendly [40,41]. The average times for using either warm or jet hand dryers in the two groups were generally less than 20 s. As a result, a considerable excess amount of water on the hands may easily re-contaminate the hands after touching the surface environment, such as door handles upon leaving washrooms. Although the majority of the Chinese respondents indicated that they clean their hands under different specific situations, they admitted that they only use water or, in rare occasions, ABHR or wet wipes for hand cleaning instead of handwashing with soap. By breaking the chain of infection and reducing the incidence of infection, hands must be washed correctly and at the right time [42]. Proper education of the public is necessary to fill these knowledge gaps.
The findings of this comparative study shed light on the understanding of the knowledge level and behaviour towards HH of the Nepalese and the Chinese population of Hong Kong. This study offers valuable information for the development of culturally-sensitive health promotional programs to enhance HH practices for the ethnic minorities and general population at large.

Limitations and Recommendations
This study exhibits a few limitations. HH is considered a socially acceptable behaviour. Thus, respondents may over-report the situation. The non-obtrusive monitoring of HH behaviour may be considered in future studies to provide an unbiased evaluation of the actual behaviour. Variables, such as duration of residency in the host country and place of birth, must be collected in the future survey to understand how these factors can influence one's acculturation level and behavioural patterns. Future studies must compare the knowledge and HH behaviours between the Nepalese in their home country and those immigrants to other countries. Furthermore, studies must investigate the change in the behavioural patterns before and after substantial improvement in the sanitation facilities at Nepal in recent years. Research must be conducted to facilitate our understanding of the environmental impact on HH behaviours. Inclusion of other common ethnic group, such as Filipinos or Indonesians, in future studies can provide valuable information for the development of culturally sensitive interventions related to HH in Hong Kong.

Conclusions
The Chinese population of Hong Kong generally exhibited better knowledge level and more favourable HH behaviour than the ethnic minorities from Nepal. Misconceptions related to the concepts associated with HH were prevalent in the two populations, indicating the need for educational enhancement. The findings of this comparative study offer valuable information for the development of culturally sensitive health educational programs to enhance HH practices for the ethnic minorities and the general population of Hong Kong.