ABSTRACT
Background: The COVID-19 pandemic has affected people’s engagement in health behaviors, especially those that protect individuals from SARS-CoV-2 transmission, such as handwashing/sanitizing. Associations between the pandemic’s trajectory and engagement in the protective behavior of handwashing are unclear. This study investigated whether adherence to the World Health Organization’s (WHO) handwashing guidelines is associated with (i) total cases of COVID-19 morbidity/mortality accumulated since the onset of the pandemic, (ii) recent cases (country-level COVID-19 morbidity/mortality in the 14 days prior to data collection), (iii) increases/acceleration in recent cases (country-level COVID-19 morbidity/mortality in the previous 14 days minus cases recorded 14-28 days earlier), and (iv) stringency of the national containment-and-health policies (in the 7 days prior to data collection).Methods: The observational study (#NCT04367337) enrolled 6,064 adults residing in Australia, Canada, China, France, Gambia, Germany, Israel, Italy, Malaysia, Poland, Portugal, Romania, Singapore, and Switzerland. Data on cross-situational handwashing adherence were collected via an online survey (March–July 2020). Individual data were matched with the WHO daily reports of COVID-19 and indices of containment-and-health policies. Country-level human development index and sociodemographic variables were controlled.Results: Multilevel regression models indicated that as the total cases of COVID-19 morbidity and mortality grew higher, handwashing adherence decreased. As increases in recent cases of COVID-19 morbidity and mortality occurred, handwashing adherence increased. Higher levels of containment-and-health policy index were associated with lower handwashing.Conclusions: Research investigating protective behaviors should account for indicators of fluctuations of COVID-19 morbidity/mortality, besides accounting for time since the beginning of the pandemic.Trial Registration: Clinical Trials.Gov, #NCT04367337, first registration date: 29/04/2020