Table 2.

Themes related to hand hygiene practices, barriers, facilitators, and health promotion among in-depth interview respondents

Hand Hygiene Practices
Theme	Examples	Quotes
Hand hygiene behaviors	• Washing hands with soap and water • Hand sanitizer use • Wearing gloves	• “Washing the hands, uh, and wearing gloves and uh you know, when, wh- when, folks see that, a lot of times you see people follow, follow in step with that.”
Key moments hand hygiene occurs	• Before handling food • Walking into or out of the facility • Before and after eating • After using the restroom	• “We, we washing our hands at all times, everybody is. You touch something, you know, you know you gotta wash your hands. We don't let the clients use the same utensils. Like when you're being served, we serve them. So we're really the only ones who use that particular utensil.” • “More. Everybody is more, you know… Anybody. We, we wash our hands, you know, like before we eat, after we use the bathroom. We know everybody's more conscious. You wash your hands constantly. If you cough, you're washing your hands. If you touch your face, you're washing your hands. If you touch the counter, you know to hit the hand sanitizer. You know, everybody's doing that more than we would normally have done it due to COVID-19.”
Changes to hand hygiene	• Changes to HH • Increase of washing hands and using hand sanitizer • Less hand shakings, hugs, or high five	• “Well, I see, uh, I see us washing our hands more frequently as well. And then, uh, then using gloves.” • “… and just no interaction in regards to handling hands, uh, like handshakes and stuff like that. No hugs.”
Hand Hygiene Promotion
Theme	Examples	Quotes
Format	• Posters • Flyers • Videos • In-person trainings • Meetings	• “We have posters up, like, at, at the sinks in the bathroom.” • “Well, I mean, we, we do, you know, you put up the posters and you have the training, and you know, we have the little video snippets that we have.”
Hand sanitizer dispenser locations	• Entrance/exit of the facility • Outside the restrooms • Offices • Dining room entrance • Common areas	• “Yes. Okay. So we have sanitizers at the front door, the backdoor, the dining hall, outside the restroom, inside the rest, uh, restrooms. Um, and then we also have gloves.” • “Yeah, no, we have added, um, more, um, dispensers for hand sanitizer… um, in the building. Um, and, like, we've added them in the, like, in new places that we think would be more helpful. Like, when you come off an elevator, when you go on the elevator, when you right come in the door, whatever door you come in. Um, and more on each floor. So, we add- added access to that.”
Hand Hygiene Barriers
Theme	Examples	Quotes
Multiple barriers	• Barriers include: • Remembering to practice hand hygiene • Limited time • Limited access to hand hygiene products • Location of bathrooms • Limited handwashing facilities • Unable to leave hand sanitizer with clients due to high alcohol percentage	• “Just getting up and just accessibility to the bathrooms. I mean it's not [inaudible] per area. It uh, it could be a long walk for some, more so than others. Uh, we have, this was a, this was designed to be an all male facility, but we've, course we've had uh female staff here over the last four or five years. So those combinations had to be created so. It's not easy for everyone just to walk across the hallway, or take a couple of feet here or there to wash their hands. So I guess, again, it's accessibility and just that reminder that something needs to be done more often than usual.” • “Um, just lack of, so like one of the main places that we hang out in the administrative office, there's no sink anywhere close by.”
Hand Hygiene Facilitators
Theme	Examples	Quotes
Access	• Access to products	• “Well, I mean, the biggest thing you can do for staff is provide the tools to do the job… and so if I want them to use hand sanitizer, I have to make sure they have abundant amount of hand sanitizer.”
Motivation	• Positively motivating each other	• “And then we just really, we t- We just kind of make fun of, uh, you know… Make jokes, like, hey did you wash your hands? Don't talk to me, don't touch me until you wash your hands. Stuff like that.” • “But when you, you look at it as, ‘Hey, let's join together to keep us safe and keep your family safe,’ and spin it from a positive perspective, then I notice that most people were compliant, not because you said you had to do it. More because, ‘Hey, I need to, I need to protect myself and my family. You know, I need to take care of myself, you know’."
Hand sanitizer locations	• Placing hand sanitizer dispensers throughout facility	• “So, we've posted that. Um, and then we just talk about it. We have sanitizer posted e- everywhere so they can always, um, you know, do the sanitizer, uh, pump thing. Um, our, our, uh, CDC director has given us bottles of sanitizer. So, we promote that as well.”