Mask-Wearing and Handwashing Behaviors of Chinese Rural Residents during the Pandemic of COVID-19: A Cross-Sectional Survey

Objective: To understand mask-wearing and handwashing behaviors of Chinese rural residents during the COVID-19 pandemic and to analyze the associated factors. Methods: This study used a multi-stage random sampling method to conduct a cross-sectional questionnaire survey during the period of July to December of 2021, in six counties located in Shandong, Shanxi, and Yunnan provinces representing the eastern, central, and western regions of China, respectively. A total of 3864 villagers were surveyed with a questionnaire, and 3832 valid questionnaires were finally analyzed. Descriptive statistics and logistic regression analysis were used for statistical analysis. Results: Around ninety-four percent (93.6%) of rural residents reported mask-wearing during the COVID-19 pandemic, but only 44.5% of them could replace masks in time. Multivariate logistic regression analysis showed that those who were female, aged 15–59, had an education level of high school and above, were divorced/widowed, worked as farmers (workers), or were rural residents in Shandong Province were more likely to wear masks. Furthermore, those who were female, aged 15–59, had an education level of high school and above, were unmarried and married, were business and service workers, or were rural residents in Shandong and Shanxi Province replaced masks more timely. Around seventy percent (69.7%) of rural residents reported using soap when washing their hands, but only 38.0% of rural residents could wash their hands properly. Multivariate logistic regression analysis showed that rural residents who were aged 35–59, had an education of high school and above, or lived in Shandong Province and Shanxi Province were more likely to wash their hands with soap. Those who were aged 15–59, had an education of high school and above, worked as farmers (workers), were employees of governmental departments and retirees, were business and service workers, or were students had higher proper handwashing rates. Conclusions: During the COVID-19 pandemic, the proportion of Chinese rural residents wearing masks reached 93.6%, but only 44.5% were able to replace masks in time, gender, age, education level, marital status, occupation, and living place had an impact on mask-wearing. The proportion of Chinese rural residents who could wash hands with soap reached 69.7%, but only 38.0% could wash their hands properly. Age and education level were influencing factors for both washing-hand with soap and proper handwashing.


Background
The coronavirus 2019  pandemic is still ongoing. The main transmission routes of COVID-19 are respiratory droplet and contact transmissions [1] which led to its global rapid spread due to its highly infectious nature. As of 18 September 2022, over 609 million confirmed cases and 6.5 million deaths have been reported globally [2]. The virus of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) constantly mutates, creating what has been termed the new normal characterized by dynamic changes and repeated invasion of SARS-CoV-2 [3]. Under this new normal, China has gradually formed a "Timely Clearing Epidemics" prevention and control strategy aiming at "prevention infection transmitted from abroad and infection rebounded from domestic" [4,5].

Study Design
This study is a cross-sectional survey using a multi-stage random sampling method. Firstly, Shandong Province, Shanxi Province, and Yunnan Province were randomly selected as sample provinces to represent provinces located in the eastern, central, and western regions of China, and two counties were randomly selected as sample counties in each of the three sampled provinces. Namely, Changle County in Weifang City and Shan County in Heze City, Shandong Province; Zhongyang County and Lan County in Lvliang City, Shanxi Province; and Yao'an County in Chuxiong Yi Autonomous Prefecture and Zhenyuan Country in Pu'er City, Yunnan Province. Secondly, two townships in each sampled county were randomly selected as sample townships. Thirdly, three villages in each of the 12 sampled townships were randomly selected as sampling villages. Finally, a simple random sampling method was used to randomly select residents over 15 years of age who have resided in the village for more than 6 months.

Data Collection
The self-designed questionnaire was used by field investigators to conduct a face-toface interview with the respondents. Prior to the survey, all field investigators who are graduate students and teachers from the School of Public Health of Kunming Medical University, were strictly trained to ensure that they perform the survey. According to unified and standardized procedures. During the field survey, survey mentors checked every completed questionnaire to identify any missing item or mistake and returned the questionnaire to the investigator for correction whenever a problem was identified. Collected data included gender, age, education level, marital status, occupation, living place (province), mask-wearing, replacing behaviors covering whether to wear a mask when going out and how long for using each mask, handwashing behavior covering under what circumstances they washed hands, whether they used running water to wash hands, whether they washed hands with soap, and whether they washed hands for 20S and above. Except for the question of how long each mask is used for, all other questions had three answer options: always, sometimes, and never.
According to the "Guidelines for the Public to Proper Wear Face Mask" by the National Health Commission of the People's Republic of China [29], a single mask should be replaced after being worn for four hours. Therefore, we define the timely replacement of a mask as it being worn for less than four hours, thus defining untimely mask replacement as being a single mask worn for more than four hours.
According to the WHO guidelines on hand hygiene [33,34], proper hand washing should be performed before eating, after going to the toilet, after working, and after going to the hospital and contacting patients. In addition, it should entail the use of running water when washing hands, using soap when washing hands, and washing hands for at least 20 s. Accordingly, those questions about handwashing in the survey were combined into one indicator: whether to wash hands properly. Respondents were categorized as washing hands properly only if they answered "always" to all the above-mentioned questions about handwashing.
In total, 3864 questionnaires were obtained and 32 unqualified questionnaires were excluded from analysis. The final study sample size was 3832.

Statistical Analysis
All data were analyzed by IBM SPSS Statistics version 25.0. Classification variables are described as numbers and proportions (%). The Chi-squared test was used to compare the regional/province differences in demographic variables, and univariate logistic regression was used to analyze the mask-wearing and handwashing behaviors of rural residents with different demographic characteristics. Variables with p-values < 0.05 in the univariate analysis were included in the final multivariate analysis to adjust for potential confounders. The results of the regression analysis are presented with odds ratios (ORs) and 95% confidence intervals (CIs) as well as coefficiencies β. A p-value < 0.05 was considered to be statistically significant.

Characteristics of Participants
A total of 3832 valid questionnaires were obtained in this study, of which female accounted for 50.5% slightly greater than the male; respondents aged 15-34, 35-59, and ≥60 years old accounted for 18.0%, 47.3%, and 34.7% of the total sample; the largest number of respondents had middle school education, accounting for 35.0%; most respondents' marital status was married accounting for 86.5%; more than half of the respondents' occupations were farmers (workers) accounting for 56.45%; the distribution of respondents in the three sampled provinces was almost even with 33.0% in Shandong Province, 33.1% in Shanxi Province, and 33.9% in Yunnan Province. The different distributions of demographic variables including age (χ 2 = 59.825, p < 0.001), education level (χ 2 = 106.336, p < 0.001), marital status (χ 2 = 10.970, p = 0.027), and occupation (χ 2 = 757.796, p < 0.001) were statistically significant among the three provinces, with Shandong province having the greatest group of people aged ≥60 who are illiterate or have little literacy. Whereas, Shanxi have the greatest group of high school and above, Yunnan have the smallest group of unmarried people, and Shanxi have the biggest group of people who are unemployed. Details about the demographic characteristics of the survey respondents are shown in Table 1.

Prevalence Rate of Mask-Wearing and Its Influencing Factors
Among all 3832 respondents, 3586 reported always wearing a mask, 101 reported sometimes wearing a mask, and 145 reported never wearing a mask during the COVID-19 pandemic. Those who reported always wearing a mask accounted for 93.6% (Table 2). The multivariate logistic regression analysis results showed that females compared with male (OR = 0.379, p < 0.001); people aged 15-34 (OR = 2.871, p = 0.001) and aged 35-59 (OR = 1.468, p = 0.018) compared with aged ≥ 60; people with aneducational level of high school and above compared with illiterate or those withlittle literacy (OR = 0.525, p = 0.013); people with a marital status of divorced/widowed compared with unmarried (OR = 0.345, p = 0.003); people with an a farming (workers) occupation (OR = 1.695, p = 0.002) compared with those who are unemployed; or people who are rural residents of Shandong province (OR = 1.569, p = 0.022) compared with Yunnan province, were more likely to wear masks (Table 3).

Prevalence Rate of Timely Mask Replacement and Its Influencing Factors
Among all 3586 survey respondents who wore masks, in total 1594 were able to replace their masks in time, accounting for 44.5%.
The multivariate logistic regression analysis results showed that females compared with males (OR = 0.814, p = 0.009); people aged 15-34 (OR = 2.199, p < 0.001) and aged 35-59 (OR = 1.660, p < 0.001) compared with those aged ≥ 60; people with an educational level of high school and above compared with middle school (OR = 0.765, p = 0.023), primary school (OR = 0.657, p = 0.002), and illiterate levels or have little literacy (OR = 0.543, p < 0.001); people with their marital status as unmarried (OR = 2.023, p = 0.007) and married (OR = 1.555, p = 0.004) compared with divorced/widowed; people with a business and service workers occupation (OR = 1.489, p = 0.003) compared with those who are unemployed; or people who are rural residents in Shandong province (OR = 3.948, p < 0.001) and Shanxi province (OR = 1.314, p = 0.003) compared with Yunnan province, were more likely to replace their masks in time (Table 4).

Prevalence Rate of Handwashing with Soap and Its Influencing Factors
Among all 3832 respondents, 2672 reported always washing-hands with soap, 911 reported sometimes washing-hands with soap, and 249 reported never handwashing with soap. Those who reported always washing their hands with soap accounted for 69.7% (Table 5). The multivariate logistic regression analysis results showed that people aged 35-59 (OR = 1.408, p < 0.001) compared with those aged ≥ 60; people with an educational level of high school and above compared with primary school (OR = 0.727, p = 0.022) and illiterate levels or have little literacy (OR = 0.630, p = 0.001); or people who are rural residents in Shandong province (OR = 1.799, p < 0.001) and Shanxi province (OR = 2.331, p < 0.001) compared with Yunnan province, were more likely to wash their hands with soap (Table 6).

Prevalence Rate of Proper Handwashing and Its Influencing Factors
According to the WHO's guidelines on hand hygiene, among all 3832 respondents, 1457 could wash their hands properly, which was counted with survey respondents who answered "always" to all the seven handwashing questions, accounting for 38.0%. The details about the seven handwashing questions and the answers given by the survey respondents are shown in Table 5.
The multivariate logistic results showed that people aged 15-34 (OR = 1.284, p = 0.035) and aged 35-59 (OR = 1.356, p < 0.001) compared with those aged ≥ 60; people with an educational level of high school and above compared with illiterate levels or people have little literacy (OR = 0.554, p < 0.001) and primary school (OR = 0.635, p < 0.001); people who have a farming (workers) occupation as (OR = 1.245, p = 0.011), employees of governmental departments and retirees (OR = 2.210, p < 0.001), business and service workers (OR = 1.719, p < 0.001), or students (OR = 2.362, p = 0.004) compared with those who are unemployed, were more likely to wash their hands properly (Table 7).

Discussion
Respiratory droplet and contact are the main routes of COVID-19 transmission [35]. Under the current "new normal" of the pandemic, people need to properly wear masks and wash their hands to prevent the disease [36]. In our study, we found that the prevalence rate of mask-wearing among Chinese rural residents during the pandemic of COVID-19 was 93.6%, which is higher and similar to the results of other studies in China [37,38], and it was also higher than the result of 84.6% reported by Rader et al. through a cross-sectional survey in the United States in the second half of 2020 [39]. The results of multivariate logistic regression analysis showed that rural residents who were female, aged 15-59, or had an education level of high school and above, were more likely to wear masks, which is consistent with the results of other studies [40,41]. This may be related to the fact that these groups have better hygienic habits and awareness of self-protection in their daily lives, and they have better acceptance and compliance with the government's policy and guidelines on disease prevention. Notably, COVID-19 causes higher mortality in the elderly population [42]; however, our findings showed that the group of people aged 60 and above had a lower proportion of mask-wearing. Our findings also showed that divorced/widowed individuals compared with the unmarried were more likely to wear masks and the underlying reasons were unknown, probably due to sample bias, which needs further study in the future. Farmers (workers) were more likely to wear masks than the unemployed, which may be related to the fact that they are required to wear masks at workplaces. Rural residents in Shandong Province were more likely to wear masks, which may be related to the fact that the health literacy in the eastern region is better than that in the central and western regions [43].
Wearing a mask can effectively reduce virus infection, but wearing a single mask for a long time will not only make its protective performance greatly reduced and increase the risk of respiratory infections, but also may cause bacteria to grow in the inner layer of the mask. This is due to breathing in water vapor which makes breathing resistance increase and thus affects breathing, hence the mask should be replaced in time to achieve the best protection effect [44,45]. Our study found that only 44.5% of the rural residents could replace their masks in time. Those who were male, aged ≥ 60, or had an education of middle school and below, were less likely to replace their masks in time, which is consistent with the results of the study in Shanghai, China [46]. This may be caused by their limited knowledge about COVID-19 prevention and limited accessibility to masks; however, the underlying reasons need further study in the future. The divorced/widowed group had a higher proportion of mask-wearing than the unmarried; however, they were less likely to replace masks than the unmarried and married, the reasons for this need further study. Business and service workers were timelier in replacing their masks than the unemployed, which may be related to requirements and more-intensified COVID-19 prevention knowledge delivered at workplaces. The timelier replacement of masks by rural residents in Shandong Province and Shanxi Province may be due to the more effective publicity and education taken by the local governments and also, the better accessibility of masks in economically more developed regions. To summarize, the female, the younger, the unmarried, the more educated, and the rural residents of Shandong Province had better mask-wearing and timely-replacing behavior, which may be related to their better hygiene habits, and greater awareness of self-protection.
Handwashing is also a very important measure for the prevention of COVID-19, and studies have shown that handwashing reduces the risk of COVID-19 infection [26,47]. Earlier studies have also found that handwashing reduces the transmission of respiratory viruses by 45-55% [48]. In particular, handwashing with soap is one of the cheapest and most effective ways of preventing diseases [35,49]. In our study, we found that 69.7% of the rural residents could wash their hands with soap, which was significantly higher than the 25.1% reported by Tao et al. in a survey conducted in five Chinese provinces in 2013 prior to the COVID-19 pandemic [50]. This implies that the COVID-19 pandemic increases the prevalence rate of handwashing with soap among Chinese rural residents. Our multivariate logistic regression analysis result showed that those who were aged 35-59 years, had an with education level of high school and above, were more likely to use soap when washing their hands, which is consistent with the results reported by studies from other countries [51,52]. This may be related to the better hygiene practices of those groups. Rural residents in Shandong and Shanxi provinces were more likely to use soap when washing their hands than their counterparts in Yunnan, probably due to the better economic condition and health knowledge of rural residents in Shandong and Shanxi provinces.
Although handwashing is a relatively inexpensive and effective measure that can be widely used for personal protection, it is very difficult to maintain a high rate of proper handwashing. In our study, we found that only 38.0% of the rural residents could wash their hands properly. By further analyzing their handwashing behavior and influencing factors, we found that people aged 15-59, those with an education level of high school and above, those with a farming (workers) occupation, those who are employees of governmental departments and retirees, those who are business and service workers, and those who are students have a higher probability of proper handwashing, which may be related to the higher health literacy of those groups, which is consistent with the studies from China and Iran [41,43]. Health education and outreach interventions of COVID-19 prevention should pay more attention to targeting rural residents who are male, elderly, have a lower education level, and those who are unemployed for proper mask-wearing and handwashing behaviors to enable them to understand the importance of these behaviors for disease prevention, so as to forge a better prevention effect in the "new normal" era of COVID-19 pandemic. Better handwashing with soap and proper handwashing behavior among younger, more educated, and rural residents may be related to their higher receptivity to external information and ability to execute guidelines.

Limitation
This study has some limitations. Firstly, it is a cross-sectional survey, and because of the inherent nature of this research method, a causal relationship cannot be established. Secondly, this study selected Shandong, Shanxi, and Yunnan as sample provinces for the eastern, central, and western regions of China, and a selection of three provinces may be too limited to represent the whole of China given its vast area, diverse ethnic groups, and socioeconomic development levels. Future study is needed to cover more provinces in China so as to obtain a more comprehensive understanding of mask-wearing and handwashing behaviors of rural residents in China.

Conclusions
Proper mask-wearing and handwashing behaviors are important protective methods to prevent the spread of COVID-19. We used a questionnaire to investigate mask-wearing and handwashing behaviors of Chinese rural residents during the COVID-19 pandemic. Our survey showed that although the proportion of Chinese rural residents wearing masks during the COVID-19 pandemic reached 93.6%, only 44.5% of them can replace masks in time. Gender, age, education level, marital status, occupation, and living place (province) are the common influencing factors for both mask-wearing and replacement. The proportion of Chinese rural residents who used soap to wash hands during the pandemic of COVID-19 increased significantly compared with the pre-pandemic period, reaching 69.7%, but only 38.0% were able to wash hands properly, with age and education level being the common influencing factors for both washing hand with soap and proper handwashing. Health education and outreach interventions of COVID-19 prevention in rural China should pay more attention to target rural residents who are male, elderly, with a lower education level, and those who are unemployed for proper mask-wearing and handwashing behaviors, so as to have a better prevention effect in the "new normal" era of the COVID-19 pandemic.
Author Contributions: J.F. designed the study and is responsible for the whole coordination and implementation of the field survey in the three provinces. Z.Z. is responsible for the data analysis and drafted the manuscript under the supervision of J.F. and the latter intensively modified the draft. C.L., Z.L., Y.W. and B.L. participated in the field survey and data collection. All authors have contributed to the final version of this manuscript. All authors have read and agreed to the published version of the manuscript. Institutional Review Board Statement: The study was approved by the Ethics Committee from Kunming Medical University under number KMMU2022MEC084. All participants were fully informed about the nature, goal, and procedures of the study and gave their informed consent.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The datasets used and/or analyzed during the current study is available from the corresponding author on reasonable request.