Hand Hygiene, Face Mask Use, and Associated Factors during the COVID-19 Pandemic among the Students of Mongar Higher Secondary School, Bhutan: A Cross-Sectional Study

Non-pharmacological measures, such as hand hygiene and face mask use, continue to play an important role in the fight against the COVID-19 pandemic. However, there is a paucity of studies on the adherence to these measures among students in Bhutan. Therefore, we aimed to investigate hand hygiene and face mask-wearing behaviours, as well as their associated factors, among the students of Mongar Higher Secondary School, Bhutan. We conducted a cross-sectional study amongst the students of Mongar Higher Secondary School in Bhutan. The students self-answered the questionnaire on web-based Google Forms. Multivariable logistic regression for good hand washing and face mask use was conducted in order to identify statistically significant socio-demographic covariates. The correlation between hand hygiene and mask use was investigated using Pearson’s correlation coefficient. A total of 533 students completed the survey questionnaire, 52.9% (282) of whom were female students. Facebook (44.3%, 236) and TV (35.5%, 189) were the two most popular sources of information on COVID-19 prevention and control. Good (scores of ≥80% of total scores) hand hygiene and face mask use were reported in 33.6% (179) and 22.1% (118) of students. In multivariable logistic regression, male students presented 79% (adjusted odds ratio [AOR] = 1.79, 95% confidence interval [CI] = 1.23–2.613) odds of engaging in good hand hygiene, compared to female students. Compared to grade 9, those in grade 10 were 60% (AOR = 0.4, 95% CI 0.158–0.998) less likely to engage in good hand hygiene. Boarding students presented 68% (AOR = 1.68, 95% CI 1.001, 2.813) higher odds of wearing a face mask compared to day students. There was a significant positive correlation between good hand hygiene and face mask use (r = 0.3671, p-value < 0.001). Good hand hygiene and face mask use were reported in less than one-third of the study participants. It is recommended to continue educating students on good hand hygiene and face mask use through popular information sources.


Introduction
The COVID-19 pandemic, a disease caused by the SARS-CoV2 virus which originated in Wuhan, China, has wreaked havoc, disrupting the livelihood of billions of people across the world. The total number of cases has crossed 651.9 million, with 6.6 million deaths as of 21 December 2022 [1]. In addition to the millions of lives lost due to COVID-19, the pandemic continues to have a tremendous impact on both the mental and physical health of various individuals [2]. Despite the rolling out of vaccines, newer strains (e.g., Omicron sublineages) are emerging, resulting in new waves of COVID-19 infections [3][4][5][6][7][8][9][10][11]. In addition to vaccination, non-pharmacological measures, such as washing hands, face mask wearing, and social distancing are expected to continue to play an important role in controlling the COVID-19 pandemic [12][13][14]. Face mask use has a greater role in reducing COVID-19 due to aerosol transmission of it. However, hand hygiene can have added health benefits by reducing other infections.
Bhutan has reported 62,524 COVID-19 cases with 21 deaths, and 2 million vaccine doses administered to date [15]. In addition, the Bhutan government has continued to advocate non-pharmacological prevention measures, including hand washing, social distancing, and the use of face masks in public places [16,17]. Facilities for hand washing have been set up in schools and institutes across the country [18,19]; however, the success of preventive measures initiated by the government depends on the uptake and adherence to these preventive measures [20,21]. No studies have been undertaken in order to understand hand hygiene and face mask use in Bhutan, including among high school students. In other parts of the world, there have been varying reports of adherence to hand hygiene and face mask use in the general population [22,23] and students [24][25][26]. It is important to review and evaluate the adherence to the education program in different population groups.
As COVID-19 is a highly contagious disease primarily affecting the respiratory system, places such as schools still pose a significant risk of SARS-CoV-2 transmission [27]. However, transmission can be averted through adequate preventive measures [28,29] and adherence to these measures. Therefore, in this study, we aim to understand the current situation of hand hygiene and face mask use among Mongar Higher Secondary School students in Eastern Bhutan. The study findings will be useful to inform policymakers and healthcare professionals, regarding the development of future public health interventions, awareness raising, and health education programs.

Study Design and Setting
We conducted a cross-sectional study among the students of Mongar Higher Secondary School in classes 9 to 12, enrolled for the 2022 academic year. Mongar Higher Secondary School was selected through convenience sampling [30]. The survey was carried out between June and July 2022.

Sample Size
The required sample size for this study was calculated as follows: where n is the sample size; Z is the value of the statistic in a normal distribution for a 95% confidence interval (this value is 1.96); P is the expected proportion (with a total proportion of one), set at 0.5; d is the precision (with a total proportion of one) set at 0.05. The sample size was 384, allowing for a 15% dropout rate; the final sample size was 441. However, all students in classes 9 to 12 were invited to the study. There were a total of 558 students for the 2022 academic year: 79 in class 9, 51 in class 10, 274 in class 11, and 154 in class 12.

Inclusion Criteria
Inclusion criteria were: (i) Students in classes 9-12; (ii) of either gender and (iii) students enrolled for the 2022 academic year.

Exclusion Criteria
Exclusion criteria were: (i) Students under class 9 and (ii) students not volunteering to fill out the questionnaire.

Data Collection Instruments
We used a web-based self-administered questionnaire, in order to minimise the transmission of COVID-19. The survey questionnaire was developed in the Google survey tool (Google Forms). The link generated from the Google Form was circulated to the students through their class teachers. The link led to the first page of the Google Form, which summarised the research background, aims, and expected outcomes. At the end of the first page, a declaration of confidentiality and informed consent to voluntarily participate in the study was provided. Only upon agreeing to participate in the study was the main questionnaire opened.
The questionnaire was adapted from an earlier study [31] and WHO guidelines [32] and consisted of four parts. Part I included sociodemographic questions (consisting of seven questions), Part II focused on knowledge of COVID-19 and relevant sources of information (four questions), Part III on hand hygiene (with 11 questions), and Part IV included questions on face mask use (16 questions). The survey was managed by the three teachers (T.W., U.W., and K.) from the school, who are part of the study team. It took around 20-30 min for students to answer the questionnaire.

Data Analysis
The responses for hand washing and face mask wearing were assessed using a 4-point Likert scale. The scoring for correct answers was 3, 2, 1, and 0 for always, often, rarely, and never, respectively. In the case of negatively quoted questions, reverse scoring was used: 0, 1, 2, and 3 for always, often, rarely, and never, respectively. Maximum scores of 33 and 45 could be scored for hand washing (Part III) and face mask wearing (Part IV), respectively. A final score of ≥26.4 and ≥38.4 was considered to classify as good hand washing and good face mask wearing (1 = good, 0 = poor), respectively. This classification was based on the modified Bloom's cut-off point [33].
Data were extracted into MS Excel 2016 (Microsoft Corporation), double-checked, and validated for accuracy. Descriptive analysis was conducted using frequencies and proportions for categorical variables. Univariate and multivariable logistic regression models for good hand hygiene and face mask use were utilised to identify statistically significant socio-demographic covariates. Any variable with a p-value < 0.2 in the univariate analysis was considered a candidate variable in the multivariable logistic model. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were used to determine the correlates of each independent variable with all potential dependent variables in the full model, with a p-value ≤ 0.05 considered statistically significant. The correlation between hand hygiene and mask use was investigated using Pearson's correlation coefficient. All explanatory variables in the multivariable model were tested for multicollinearity using a variance inflation factor (VIF), where VIF < 10 was considered a good fit for regression analysis (see Supplementary  Tables S1 and S2). Statistical analysis was conducted using the STATA version 16 software (Stata Corporation, College Station, TX, USA).

Discussion
This is the first study in Bhutan to evaluate hand hygiene and mask use among students in the context of the COVID-19 pandemic. Good (scores of ≥80% in total scores) hand hygiene and face mask use was reported in only 33.6% and 22.1% of study participants, respectively. Good hand hygiene was associated with being male, while those in grade 10 were less likely to engage in good hand hygiene. Boarding students were more likely to use face masks consistently, compared to day scholar students. There was a positive correlation between good hand hygiene and face mask use.
Only one-third of participants reported good hand hygiene. This finding is contrary to what has been observed during the initial phase of the pandemic, where people showed good practices regarding COVID-19 [34]. However, similar findings of poor adherence to good hand hygiene have been reported in students in China [31] and the general population in other parts of the world [35,36]. Since the start of the pandemic, the Royal Government of Bhutan has educated the public on good hand hygiene through all available mass media, including newspapers, television, radio, and various social media platforms (e.g., Facebook).
At the start of the pandemic, people started panic-buying various items, such as face masks, sanitisers, and other essential food and grocery items [37]. As a result, hand sanitisers were distributed free-of-charge by the government. Contrary to what was observed during the initial phase of the COVID-19 pandemic, the lower percentage of students engaging in good hand hygiene could be due to a waning perception of COVID-19 risk. Other factors that could undermine good hand hygiene are the lack of adequate facilities, such as soap and water, in schools.
Male students were more likely to engage in good hand hygiene in the studied school. This finding is different from other published studies, where females typically reported higher good hand hygiene compared to males [31,38,39]. It has been postulated that females are more likely to follow hand hygiene than males, due to their nature of being less willing to engage in risky activities [40]. However, self-reporting of hand hygiene may be inflated (reporting bias), when compared to observed data, meaning that good or desirable behaviour is more frequently reported than observed [41]. Alternatively, social and cultural norms could play a role in undertaking or engaging in different health activities [42]. Therefore, studies to understand the local context are imperative in developing effective health education strategies.
In this study, 22.8% of students were identified as good face mask users; this finding was much lower than that reported in other studies [31]. Lower mask use in the study population could be due to "mask tiredness," coinciding with the relaxing of lockdowns, which might have given a false sense of reduced risk of COVID-19 infection. However, face mask use should be encouraged, due to the recent increase in COVID-19 cases in the region and the Bhutan government has reinforced mandatory use of it. Proper use of face masks has been shown to reduce the spread of COVID-19 [43][44][45][46]. The risk of spread is greater the closer a person is to a source of COVID-19 [43,47]. A study has shown a 62% reduction in the risk of predicted risk of COVID-19 among those who self-reported always using face masks [45]. A rapid systematic review of the efficacy of face masks showed that wearing them could be beneficial in the context of COVID-19 outbreaks [48].
Boarding students were more likely to use face masks consistently. Possible reasons for this include reinforcement by teachers and counsellors in the students residing on the school campus. Studies have shown that repetition and reinforcement play a key role in the sustainability of health education [49]. Therefore, reinforcing face mask use in schools where a large number of students congregate can be beneficial, especially in the event of COVID-19 cases in schools.
We observed a weak, but positive correlation between hand hygiene and face mask use. Other studies have reported a similar correlation between positive knowledge and practice [50,51], and attitude and practice [51]. This means that students engaging in one activity are likely to embrace other positive health activities. Therefore, reinforcing good hand hygiene can increase face mask use and vice versa. Such positive practices are important for breaking the transmission cycle of COVID-19 in the community. Although higher knowledge has been shown to reinforce healthier behaviours [52], according to Blooms, knowledge alone may not be enough to bring changes in habits [53]. Attitudes and learning from role-models are more predictive. Therefore, teachers and parents can play important roles. In this study, boarding students had better face mask use than day students, likely through teachers reinforcing this habit in the school.
In conclusion, the number of students engaging in good hand hygiene and face mask use in this study was quite low. These non-pharmacological preventive measures are important in preventing the spread of the COVID-19 pandemic, especially with the recent increase in COVID-19 cases in neighbouring countries. In addition, long-COVID and reminiscent disease (e.g., thromboembolic events) and chronic infections by SARS-CoV-2 play a significant role and new lineages of SARS-CoV-2 show up with new properties may show spillover effects or mutation in immunocompromised persons with the potential for mutations and newer immuno-evading viruses. Therefore, good hand hygiene and face mask use still have added roles in the COVID-19 pandemic as well as in preventing other diseases [35,54,55].
The hand hygiene results in female students require further research, as most studies have reported good hand hygiene in females, contrary to this study. To motivate good hand hygiene behaviour, health promotion messaging could focus on addressing risk perceptions of COVID-19, which might have shared benefits to promote engagement in additional COVID-19 prevention measures. Finally, increasing the visibility and accessibility of handwashing and hand sanitizing signage and materials in public settings may encourage and facilitate hand hygiene to prevent the spread of COVID-19.

Limitations of the Study
The results of this study were subject to at least five limitations. First, this was a cross-sectional study and, so, causal inferences could not be established. Second, due to the similar socio-demographic characteristics of the students, most of these factors were not associated with the outcome of interest. This could be possibly addressed by sampling schools from different parts of Bhutan, including schools from urban, semi-urban, and urban areas. Third, the responses were self-reported and, so, may be subject to recall and response bias. This bias could be addressed by objectively measuring hand hygiene and face mask use through compliance studies. Fourth, social desirability may have led to over-reporting of hand hygiene and face mask use by the students than in actual practice. Finally, the respondents were not asked about the frequency and access to soap and water or hand sanitiser, which may influence their hygiene behaviours.