Background
In public health perspectives, hygiene measures are most effective to control the outbreak of novel infectious diseases [
1,
2], as well as to reduce the incidence of common respiratory, diarrheal and gastrointestinal illnesses [
3]. Personal hygiene measures are applied to control transmission of bacterial and viral infections in the community [
2].
Regarding use of public toilets, common hygiene measures include hand washing, drying hands, disinfecting or covering the toilet seat surface before use, and flushing the toilet with the lid closed [
4‐
6]. Studies have shown that skin, gut and vaginal micro-organisms are prevalent on public toilet surfaces [
7]. Infection risks of microorganisms in public toilets are mainly related to infective doses of pathogens. Probability of transmission is high for certain enteric pathogens such as norovirus and enterohemorrhagic
E. coli (EHEC) in which < 100 cells are sufficient for infection [
8]. It has been shown that disinfection of seats with wipes resulted in a 50-fold reduction in mean bacterial counts [
9,
10]. Potentially infectious aerosols may be produced in large quantities during flushing [
11,
12]. Toilet plume is a contributor to the transmission of enteric diseases [
5]. Despite the above studies, there has been limited research on various inappropriate behaviors such as spitting into the urinal or toilet bowls and stepping on the toilet seat. Spitting in the urinal is an interesting phenomenon and of special concern as it may increase risk of transferring respiratory diseases when the urine splashes back into the air [
13].
Various factors can affect actual hygiene practices. Studies have shown that individual knowledge and attitudes can influence their practices [
2,
14,
15]. Demographic factors are also associated with the public’s practices of hygiene measures. Females were found to be more likely than males to wash their hands after using the toilet [
16‐
19]. Besides, other influencing factors included family influence, education, peer influence and work experiences [
20].
Previous qualitative studies explored the attitudes of the public towards hygiene behaviors. Western studies have found some of the public dismissed the hygiene behaviors as they considered them bothersome and inconvenient. Some also thought that infection was difficult to be controlled and one had to “accept fate”. And yet, some had a belief that the infection would happen to others instead of themselves [
21,
22]. Some psychological studies also found that some people might spit after seeing dirty toilet stuff [
23,
24]. However, little is known about hygiene behaviors in public toilets among Chinese.
Our study aimed to explore toilet hygiene behaviors of the Hong Kong Chinese by using a mixed-methods approach, including qualitative interviews and a questionnaire survey. The findings can enhance the understanding of professionals in fields of infection control, health education and health policy on the toilet hygiene practice.
Material and methods
Qualitative approach
Focus groups and individual interviews were conducted from June 2016 to January 2017 to explore in-depth views of the general public on the study topic. Focus group interviews can establish quickly a range of perspectives on a topic as the group dynamics and interactions facilitate generating rich information, while in individual interviews, participants can freely share information without any concerns that may arise in front a group. We purposively recruited adult participants (aged 18 or over) with a wide range of demographic characteristics (e.g. age, sex and income) and experience in the sample. We sent invitation letters with reply slips to social services centers in different districts of Hong Kong asking for their help to recruit participants. Potential participants who agreed to participate in the interviews were contacted by telephone. Four focus group interviews were held, of which two groups were for males and two for females. Three additional individual interviews were conducted to supplement the focus groups to see if more detailed experiences could help us to generate new themes. Two men and a woman from young and middle age groups were recruited and interviewed individually. The recruitment process ceased at the point of data saturation at which repetitive findings were seen. HKD100 (US$12.8) was offered to each interview subjects as an incentive for participation.
Each focus group interview lasted over 1 hour, while individual interviews lasted about 45 min. We used the same topic guide which was developed by the research team for both focus group discussions and individual interviews (Supplementary file 1). The interview questions focused on participants’ views and hygiene practices in public toilets, enablers and barriers to complying with recommended measures. The interviews were conducted in Cantonese (the local dialect) and audio-recorded, which were then transcribed verbatim. The accuracy of the transcripts was checked against the audio recordings. Using the content analysis approach described by Hsieh and Shannon [
25], coding categories were inductively derived from the text data and a codebook was generated. Then we used the codebook to guide the analysis of the rest of the interviews and the data were coded independently by two investigators. The coding consistency between the two sets was checked and the majority of the codes were consistent. Inconsistencies were resolved by discussion between the two investigators to reach an agreement for a common theme. The key themes identified from the qualitative findings were incorporated in the design of a questionnaire for the quantitative survey.
Quantitative approach
A questionnaire was developed based on published evidence [
26,
27] as well as the themes identified from the focus group and individual interviews. The questionnaire asked about knowledge, attitudes, practices, enablers, barriers, expectations on toilet hygiene policies, and demographic information (Supplementary file 2). The questionnaire was pilot-tested for its face- and content-validity with 10 laymen. All subjects rated most of the items as comprehensible and relevant. Minor modifications were made based on the feedback.
A cross-sectional survey was conducted among the general public between July 2017 and April 2018. The target population were Chinese aged 18 or above residing in Hong Kong. We sent invitation letters to 45 community centers that served young adults / family / elderly in all 18 districts in HK, and 10 community centers accepted the invitation. Social workers at the community centers helped us recruit participants. Around 20 to 40 questionnaires were distributed at each center to participants who were visiting the center on the surveying days. Most participants completed the questionnaire by themselves. For some elderly respondents who had difficulties reading, our research assistants were on site to support and assist their reading and understanding of the questionnaire. An incentive of HKD 20 (US$2.6) was provided as a token of gratitude. Subjects who had intellectual disability or were not able to communicate in Chinese were excluded.
The data were analyzed using SPSS (Version 25). Descriptive analysis was conducted. Hygiene behavioral variables were recoded. The responses “sometimes” and “always” were grouped for further analyses due to small cell numbers of some variables. Multivariable logistic regression analyses were carried out to examine the association between age and hygiene behaviors, controlling for gender, education, marriage and birthplace. A p-value < 0.05 was considered statistically significant.
Discussion
Good personal hygiene is essential in preventing infection. Dirty public toilets are known to be a source of bacteria and viruses [
5,
7,
8,
12]. However, little is known about people’s hygiene practices in their daily use of public toilets. Our study extends the literature by exploring hygiene behaviors in public toilets among Chinese in Hong Kong. Age was a potential correlate with some public toilet hygiene behaviors.
We found that slightly more than two thirds had adequate hand hygiene habits who always washed hands with soap and dried hands with paper towels after washing. These are similar to a previous local study during the H1N1 pandemics [
19]. The compliance of 60–70% are yet suboptimal when compared to the hand hygiene study findings of other countries such as Uganda and Turkey [
4,
28]. Handwashing and hand drying have long been recognized as the most important measure in reducing transfer of bacteria to other surfaces and thus the risk of bacterial infection [
29‐
31]. Our qualitative interviews also indicated that people do not, however, properly comply with hand hygiene measures because that would take more time to execute and maintain the practice. Some steps of the practice were often neglected, and people tended to overlook the long-term impacts of poor handwashing habits on one and others’ health. While there have been public health promotions such as Dos and Don’ts illustrations and slogans in the community, more campaigns might be needed to aid the understanding of the reasons for the standard procedures in improving hand hygiene.
Our study showed many flushed toilets without having the toilet lid closed. Previous research suggested closing the toilet lid before flushing can avoid toilet plume and reduce the chance of spreading aerosols that may carry gastrointestinal pathogens such as
Clostridium difficile and norovirus [
5,
8,
32]. Our participants did not put down the toilet lid mostly because they felt public toilet lids were too dirty to touch. The refurbishment and cleanliness of the facilities appear paramount to hygiene compliance. While the Hong Kong government noticed and addressed such needs [
33,
34], other tailored measures are worth consideration. More specifically, increasing the frequency of cleaning public toilets, providing clean materials such as alcohol disinfection liquids, and innovative technology such as automatic closure may be good starting points [
34‐
36]. In an attempt to reduce the transmission of multidrug-resistant organisms such as methicillin-resistant
Staphylococcus aureus and vancomycin-resistant enterococci, all public hospitals in Hong Kong have implemented a policy to request patients to use alcohol wipes to clean the toilet seats before use [
10,
37,
38].
We noted that many spit into urinals or toilet bowls. Moreover, the elderly group were more likely to do so. Spitting is a known factor that may increase the spread of airborne infections, such as tuberculosis [
39,
40]. Besides tuberculosis, spitting and flushing without closing the toilet lids may generate droplets and aerosols containing human enteric viruses that is well known for its remarkable ability to survive in the environment [
41]. Possible explanations included that people held misconceptions about spitting into urinals/toilet bowls, such as spitting in toilets was most hygienic, and poor toilet environment might also stimulate men’s impulsion to spit. Another reason was that many found it most convenient to spit into the toilet or there was no better place to do so. Public education about how to properly dispose sputum, especially for elderly users, and cleaning the toilet environment may be worth consideration. In addition, provision of sufficient tissue paper and rubbish bin might reinforce more hygienic disposal.
Lastly, nearly half never sat on public toilet and many reported stepping on toilet seats before. Our interviews revealed the main reason for doing so was the dirtiness of public toilets. Stepping on toilet makes the toilet dirtier, and more importantly, it is also unsafe for people. There were news reports about getting hurt badly by a broken toilet as people were stepping on it [
42,
43]. Providing disposal toilet covers or disinfection wipes in public toilets may help facilitate safer toilet use practices. Given the fact that the majority did not actually sit on public toilet, building more squatting toilet in public facilities may also be a worthwhile strategy to prevent people getting injured from the practice.
The study has several limitations. First, we recruited respondents from those who were visiting social service centers. This might lead to selection bias as certain demographic subgroups may be more likely to utilize community services. Our study findings, however, provided a snapshot of how general public used public toilets, and tapped into a neglected public health issue in Hong Kong. Second, we conducted the study in a developed city in China. Our study findings may have limited representativeness of the whole Chinese population. But they may reflect to some extent the situation in developed areas in the country. Third, our study used a self-administered questionnaire in which respondents may give socially desirable responses. Non-hygienic toilet use behaviors might be underestimated.
Conclusions
While common toilet hygiene measures have long been promoted among the public in Hong Kong, our findings indicated that the local Chinese’s compliance was only suboptimal, and the hygiene measures were far from fully practiced. Some steps of these practices could be easily overlooked and neglected due to the time- and resources-consuming process. The dirtiness and poor-maintenance of the facilities in local public toilets appeared to be the predominant barrier to toilet hygiene compliance. We recommend increasing the frequency of cleaning public toilets and providing sufficient toilet paper and cleaning agents, in order to improve and reinforce the quality of toilet hygiene behaviors.
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