Face-touching Behavior during the COVID-19 Pandemic: Self-inoculation and transmission potentials

Abstract

Purpose:

Face touching behavior has the potential for self-inoculation and transmission of the SARS-2 Coronavirus. The purpose of this research is to examine whether there is a difference in such behaviors between: (1) dental and dental hygiene students; and (2) males and females.

Methods:

Twenty minutes of archived proctoring videos of 87 dental and dental hygiene students taking final examinations were watched for incidents of face touching behavior. Data were analyzed for descriptive frequencies and independent sample t-tests were used to determine differences between dental and dental hygiene students and between males and females.

Results:

There was a significant difference between the dental hygiene and dental students. Dental hygiene students were observed 11.9 times (SD. 11.4) and dental students were observed 8.9 times (SD, 7.9) touching the T-zone (p= 0.049). Touching nose, mouth, and eyes (T-zone) failed to reach significance between the sexes.

Conclusion:

Findings suggest dental hygiene and dental students frequently touch their faces and need to be aware of this unconscious behavior. Given the significance of the COVID-19 pandemic, it is important to identify and quantify known risk factors that can be easily addressed to prevent/reduce infection transmission.

INTRODUCTION

Face-touching is an important transmission route to self-inoculate viruses and other transmissible microorganisms.¹ This is particularly important to consider during the COVID-19 pandemic. Guidelines provided by the U.S. Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) to avoid COVID-19 include: limiting close contact with others; wearing a mask; washing hands frequently; and avoiding touching one’s eyes, nose, and mouth.^2,3 The eyes, nose, and mouth are areas of the face identified as target facial membranes,⁴ or the T-zone for infection transmission. Hands touch many surfaces, some of which may be contaminated with pathogens.

Touching one’s eyes, nose, or mouth can potentially transmit (or self-inoculate) viruses through oro-naso-ocular membranes. For example, bacterial self-inoculation of Staphylococcus aureus is possible through face touching behavior. S. aureus is in the nasal mucosa of nearly one-fourth of the community and healthcare settings.^5,6 Similarly, viral self-inoculation is possible through face touching behavior. Herpes Simplex Virus Type-1 (HSV-1) self-inoculation may occur if cold sores are touched. Transmission to fingers (herpetic whitlow) and eyes (herpes opthalmicus) are possible. The extent to which face touching behavior is responsible for disease transmission in any particular disease is difficult to determine.⁵ Nevertheless, there are anecdotal reports that decreasing face touching behavior, particularly of the T-Zone, has resulted in fewer upper respiratory tract infections.^4,7

When diseases have a high transmissible rate with high morbidity, high mortality, few effective therapeutics, and no vaccines, then every consideration for safety should be in place. This is especially true for healthcare workers who may inadvertently transmit disease to themselves or others through being unaware of their face/mask/respirator touching behaviors. Some face/mask/respirator touching behavior has been attributed to an unconscious urge to relieve the irritation of the presence of mild abrasions on the face, especially if resulting from the mask/respirator.⁸ It has been reported that personal protective equipment (PPE) protocol breaches are common. Twenty-six percent of healthcare workers touched the front of their mask while doffing and nearly 50% touched the mask’s surface with ungloved hands.⁹ In a behavioral observation study in the United Kingdom, 26 medical students were observed for face-touching behavior. They had a mean of 4 mouth touches and 3 nose touches per hour.⁵

Face touching behavior also has cultural differences and may have gender differences. In a study comparing such behavior culturally between British and Japanese participants, British participants were more likely to touch the left side of the face with the left hand than Japanese participants.¹⁰ Another study indicated that men were more likely to engage in nonverbal self-touching behavior than women.¹¹ Women were reported to be more likely to self-touch during active anxiety-inducing situations.¹¹

Overall, there is limited research examining self-inoculation from face touching behavior. The specific objectives of this research were to describe face touching behavior among dental and dental hygiene students and examine whether differences exist between dental and dental hygiene students and between male and female students in unconscious face touching behavior. The rationale for conducting such a study is that, given the emergence and seriousness of the COVID-19 pandemic and the recommendations from the CDC and WHO, it is critical to document face touching incidents in dental and dental hygiene students so that targeted awareness campaigns and professional education can ensure minimal incidents.

METHODS

Ethical Statement:

This research received West Virginia University Institutional Review Board approval (protocol 2003954300).

Study design:

This study had a cross-sectional study design.

Data source:

The data used in this study were extracted from archived proctor videos for dental and dental hygiene courses which had an online final examinations after the COVID-19 pandemic shut-down of 2020. The researchers reviewed twenty minutes of video. They observed 45 dental students and 43 dental hygiene students. To be accepted into the programs, all students were required to be ages 18 years and above.

Procedures:

Two professors (RCW and AKTS) viewed 20 minutes of archived proctoring videos of dental and dental hygiene students taking their online final examinations after the COVID-19 pandemic shut-down of 2020. Prior to the final examinations, all dental and dental hygiene students had access to the School of Dentistry’s COVID-19 task Force clinical training documents and resources. These resources, based upon CDC, American Dental Association, and Occupational Safety and Health Administration guidance recommended strict infection control policies which included avoiding touching the T-zone of the face. All dental and dental hygiene students, as well as the school’s faculty members, were required to complete and be tested upon infection control educational modules specifically addressing COVID-19.

In watching the archived proctoring videos, the researchers recorded incidents of touching face, eyes, glasses, nose, mouth, hair, and ears per student. Data were analyzed with Statistical Product and Service Solutions (SPSS) version 26 (IBM, New York) for descriptive statistics and differences between the face touching behavior of dental and dental hygiene students as well as the differences between male and female students.

RESULTS

Descriptive data:

Three videos of 87 dental and dental hygiene students were viewed. The researchers observed 24 males (27.9%) and 62 females (72.1%) in the videos. Approximately half of the students were dental hygiene students (42 students, 48.8%). The dental hygiene students were third- and fourth-year student (n = 21, and n = 22, respectively). The dental students were second year students (n = 45). The overall percentage of students who touched the mucosal membrane T-zone (mouth, nose, and eyes) during the twenty minutes of viewing was 95.4% (83 students). The mean number of T-zone touches was 10.3 (SD, 9.8; minimum 0, maximum 41). Although not the main focus of this study, The mean number of any face touching (mouth, nose, eyes, hair, ear, and/or glasses) was 15.5 (SD, 11.1; minimum 2, maximum 51). (Table 1)

Table 1.

Dental and Dental Hygiene Student T-Zone Touching Behaviors in 20 Minutes of Observations

T-Zone Touching Frequency	Overall (n=87)	Dental Hygiene Students (n=42)	Dental Students (n=45)
	N (%) or Mean (SD)	N (%) or Mean (SD)	N (%) or Mean (SD)	p-value
Eyes
0	30 (34.5%)	1cell size suppressed	24 (53.3%)
≥1	57 (65.5%)	35 (83.3%)	21 (46.7%)
Mean (SD)	1.8 (2.5)	2.3 (2.7)	1.4 (2.2)	.964
Nose
0	21 (24.1%)	Cell size suppressed	12 (26.7%)
≥1	66 (75.9%)	34 (81.0%)	32 (71.1%)
Mean (SD)	2.5 (3.2)	2.3 (3.0)	2.8 (3.4)	.208
Lips
0	27 (27.8%)	11 (26.2%)	16 (35.6%)
≥1	60 (69.0%)	31 (73.8%)	29 (64.4%)
Mean (SD)	4.4 (5.4)	5.4 (6.9)	3.4 (3.4)	<.005

¹due to limited cell sizes and potential for participant identification, all cell sizes were suppressed when cell was <10.

p-values based on independent sample t-tests

Outcome data:

Dental hygiene students were more likely to touch their lips, nose, ears, T-zone, bite their nails, or touch any T-zone, hair, ears, and/or glasses than dental students. Details are presented in Table 1. In analysis by sex, males were more likely to touch their noses (p = 0.012) and females were more likely to touch their lips (p=0.011). The difference in touching the T-zone or touching any T-zone, hair, ears, and/or glasses failed to reach significance between the sexes. Details are presented in Table 2.

Table 2.

Male and Female Dental and Dental Hygiene Student T-Zone Touching Behaviors in 20 Minutes of Observation

T-Zone Touching Frequency	Male students (n=24)	Female Students (n=62)
	N (%) or Mean (SD)	N (%) or Mean (SD)	p-value
Eyes
0	11 (45.8%)	19 (30.6%)
≥1	13 (54.2%)	43 (69.4%)
Mean (SD)	1.7 (2.5)	1.8 (2.5)	.498
Nose
0	1cell size suppressed	16 (25.8%)
≥1	20 (83.3%)	46 (74.2%)
Mean (SD)	3.7 (3.9)	2.1 (2.8)	.012
Lips
0	1 cell size suppressed	21 (33.9%)
≥1	18 (75.0%)	41 (66.1%)
Mean (SD)	3.2 (3.3)	4.9 (6.1)	.011

¹due to limited cell sizes and potential for participant identification, all cell sizes were suppressed when cell was <10.

One participant did not report sex.

p-values based on independent sample t-tests

DISCUSSION

In this study, we showed that over 95% of dental and dental hygiene students unconsciously touched their mucosal membrane T-zone (mouth, nose, and/or eyes) during the first twenty minutes of taking their tests. We also found that both male and female students frequently touched their faces while taking tests.

In a recent systematic review on the frequency of T-zone touching, published recently amidst the COVID-19 pandemic, the authors found no significant difference in face touching behavior between sexes in 9 of the 10 reviewed studies.¹ The systematic review was conducted with studies from different settings and regions of the world. The authors concluded that the participants touched their eyes, nose, mouth, and chin approximately 69 times per hour.¹ Extrapolating our results to an hourly rate, there would be an estimated 30.9/hour rate of touching the T-zone and 46.5/hour rate of touching the any T-zone, hair, ears, and/or glasses. The results of this study are lower than those provided in the systematic review.

Although, there is limited research on studies specifically observing medical/health professionals’ or students’ face touching behavior,^5,12 in a study of face touching behavior in family medicine offices, the authors found that the clinicians and staff touched their T-zone an average of 19 times in two hours.¹² Our study results are higher than the results of the Elder et al study. Like their study, our study was limited by sample size and using a convenience sample to observe the face touching behavior. An additional limitation of our study, as compared with the Elder et al study, is that test-taking is stressful whereas the participants in the Elder et al study were clinicians and staff from seven medical offices whose stress levels were probably not impacting behavior.

There have been very few studies on the self-inoculation of respiratory viruses through the transmission route of contaminated hands coming in direct contact with mucous membranes.¹ However, some researchers did show that reducing the frequency of touching eyes, ears, and mouth also reduces the likelihood of respiratory tract infections.^7,12

Why then, do dental and dental hygiene students continue to exhibit unconscious behaviors that promote the potential to transfer pathogens to oneself and to others – i.e. face touching behavior incidents, open coughing, improper disposal of tissues? Researchers, Sax and Clark (2015), believe a difficulty for infection control or prevention lies in the fact that pathogens are invisible to the naked eye.¹³ The invisible nature of pathogens makes it more difficult to improve hand hygiene in settings where hands may not be visibly soiled, yet still need disinfection, even if it is in a home environment.¹³

The mismatch between expressed intentions and the actual behavior of these students is similar to the now widely accepted belief that certain processes that determine behavior are unconscious.¹³ The term unconsciousness or unconscious influences has recently been defined as “a lack of awareness regarding the influences or effects of a triggering stimulus.”¹⁴ However, the apparent unconscious behavior exhibited by the students, like touching behavior or removing their glasses, could be an inherent and characteristic aspect of human cognitive decision making based on the understanding of causality between the glasses and eye pain, irritation, or skin sensitivity to pressure and pain.¹⁵

Therefore, not all behaviors are necessarily unconscious. A study performed by Sax, et al., 2007, observed nurse hand hygiene within an intensive care unit after recent participation in simulation-based hand hygiene training a few days earlier.¹⁶ They found that when assessing the verbalized attitudes and beliefs against the theory of planned behavior, the nurses would certainly have scored high on intention to act. Moreover, they would also respond positively if questioned about social norms in regard to expressed positive beliefs about the outcome of the activity, yet they failed to perform proper hand hygiene and infection prevention strategies.¹⁶The behavior in question was not obstructed by any of the frequently cited barriers to hand hygiene since time pressure did not appear to be an issue, and hand-rub dispensers were abundant and conveniently located.^13,17 The same outcomes would be assumed of the dental and dental hygiene students in regards to self-inoculation from face touching behavior. Both groups of students have undergone training, as well as, both groups would have scored high on intention to act based on their verbalized attitudes and positive beliefs about the outcome of infection prevention. However, the behaviors observed of the dental and dental hygiene students regarding frequency of touching behavior the eyes, nose, and mouth were very high, which could potentially be significant risk factors for pathogen transfer and infection.

Unsafe behaviors that are committed unconsciously may be corrected with the proper mental model. Creating mental models allow individuals to make inferences about the outcome of future events based on their previous experiences with similar events.¹³ The Easy, Attractive, Social, and Timely (EASY) framework for behavioral change was suggested by Lunn, et al., 2020, to address face touching behavior.¹⁸ One operationalization of the framework is to provide tissues in a convenient location so that tissues are used rather than fingers or hands to touch the face.¹⁸ Another suggested application of the framework is to advance social acceptability of using one’s sleeve to touch the face.¹⁸ Healthcare workers can be “primed” with certain cues that automatically activate relevant mental models and elicit relevant behavior.¹⁴

For example, if healthcare workers were to ‘see’ the connection between behavior and outcome or given immediate feedback following an unsafe behavior, then unsafe behaviors that promote faulty mental models would no longer be viewed as harmless, because negative outcomes were observed.¹³ Furthermore, short-term training in and of itself may limit long term behavior. Educational principles recommend reinforcement and overlearning of behaviors.¹⁹ Most large medical/dental facilities, and credentialing and licensing agencies recognize the importance of reviewing and updating infection control knowledge and have requirements for at least bi-yearly continuing education.²⁰ Future research is needed in determining evidence-based educational methods for behavioral change. This then, could lead to positive implications in the field of infection control, as it relates to the way that healthcare workers’ mental models shape their intuitive perception of infectious risks.¹³

CONCLUSION

It is general knowledge that hands touching objects that may be contaminated and, therefore, have the potential to transfer pathogens to oneself and to others. The high frequency of dental and dental hygiene students observed touching their faces in our study shows that self-inoculation is often not considered consciously in one’s behavior. However, given the significance of the COVID-19 pandemic and public service announcements for precautions, face touching has become an important public health message and important behavior for healthcare providers to model for their patients.