key: cord-0893482-pur7xw4s authors: Basch, Corey H.; Fera, Joseph; Pellicane, Alessia; Basch, Charles E. title: Handwashing videos on TikTok during the COVID-19 Pandemic: Potential for disease prevention and health promotion date: 2021-10-07 journal: Infect Dis Health DOI: 10.1016/j.idh.2021.09.039 sha: c21a24c122c8855d98878d818825b7a275979447 doc_id: 893482 cord_uid: pur7xw4s BACKGROUND: Handwashing has long been promoted to maintain health and in preventing disease transmission. One of the most valuable ways to convey messages related to handwashing is through visual display, such as video for educational purposes and to enhance learning. Social media is an important and popular way to disseminate messages to a wide audience. METHODS: In this cross-sectional, descriptive study, two hashtags, #WashYourHands and #SafeguardSplash were used to select the sample of 100 from available TikTok videos. In order to code each video, the same coding categories were used for both hashtags, including (1) wetting and rinsing hands (2) lathering soap (3) time used for scrubbing (4) drying hands (5) mentions COVID-19 (6) mentions using hand sanitizer instead of soap (7) mentions how germs spread (8) mentions key times to wash hands (9) and actual depiction of washing hands. Additional descriptive categories were coded as well. The observations recorded were tabulated and descriptive statistics were performed. Independent one-tailed t-tests (α=.05) were calculated to determine if a video’s hashtag had a significant association with its garnered views, likes, and/or comments. RESULTS: In total, the 100-video sample received 1,990,834,567 views, 40,355,468 likes, and 173,422 comments. Despite the fact that each hashtag made up an equal proportion (50%) of the total sample, videos with #WashYourHands accounted for 93.3% of the total views. Coverage of the important steps involved in handwashing, such as drying hands, was minimal as was relevant background information. Conclusions: The results indicate that while this opportunity is being realized to some degree, the majority of videos did not cover topics related important concepts of hand hygiene. Given the high engagement of younger audiences with TikTok, this could be a powerful mechanism for demonstrating and encouraging proper handwashing, especially in a population with low rates of handwashing. Handwashing has long been promoted to maintain health and has been referred to as "public health 101" in reference to its simplicity in preventing disease transmission [1] . In 1847, Dr. Ignaz Semmelweis proved that the simple act of handwashing could reduce rates of puerperal fever caused by bacterial infection [2] [3] . Despite the findings, recommendations by Semmelweis for mandatory handwashing were rejected [3] . In the ensuing decades, as other innovative thinkers confirmed the findings and germ theory evolved, this theory became more widely accepted [3] . Globally, many people do not have access to clean water and soap [4] [5] , but even when soap and water are accessible, handwashing is often not initiated in recommended situations or completed properly [6] [7] [8] [9] . The United States Centers for Disease Control and Prevention (CDC) highlight five steps to follow when washing hands. "1) Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap. 2) Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails. 3) Scrub your hands for at least 20 seconds. 4) Rinse your hands well under clean, running water. 5) Dry your hands using a clean towel or air dry them." Yet, proper handwashing following these steps is often not achieved [10] . Flash forward to the present day, and the necessity of handwashing could not be more relevant. Messages promoting handwashing became abundant with emergence of COVID-19 [2] . The CDC and the World Health Organization (WHO) set specific guidelines for handwashing to curb COVID-19 transmission [10, 11] . Hand hygiene has and continues to be one of the most important ways to prevent transmission of many important infectious diseases, including a variety of respiratory and gastrointestinal illnesses [12] [13] [14] . Children are especially vulnerable and face increased consequences of these illnesses [15] [16] . Hence, many intervention efforts have been designed to increase proper handwashing with children in mind [17] [18] [19] [20] [21] . Handwashing is critical in improving development in children [22] , but doing so is largely dependent on access to clean water and soap [23] and the direction of caretakers, which is often low [24] . Recent studies have found that handwashing rates are low in adolescents [25] with roughly one out of three participating in appropriate hand hygiene [26] [27] . One of the most valuable ways to convey messages and observe behaviors related to handwashing is through visual display [28] [29] [30] [31] . The value of visual learning has been well established [32] , for example using video for educational purposes and to enhance learning [33] . Social media is an important and popular way to disseminate messages to a wide audience, especially those in younger age brackets who are frequent users of social media. A highly popular video sharing social media networking service is TikTok, which has increased in popularity in recent years, so much so that it was declared one of the most downloaded apps in 2020 [34] . TikTok has nearly 700 million users across the world and is most commonly used in those aged 10-19 years [35] . Several studies on TikTok examined factors related to COVID-19 [36] [37] [38] [39] , however there is a gap in the literature related to handwashing on TikTok, which is especially of importance as adolescents are frequent users and have been found to have low rates of handwashing [25] . Therefore, the purpose of this study was to describe content on TikTok related to handwashing. In this cross-sectional, descriptive study, two hashtags were used to select the sample from available TikTok videos. Using this social media networking service, #WashYourHands and #SafeguardSplash were found using the discover feature to identify the most viewed hashtags in regards to handwashing. The purpose of choosing these two hashtags was to account for any differences that may be apparent in a hashtag challenge such as #SafeguardSplash versus a general consumer driven hashtag, #WashYourHands. A hashtag challenge is a trending activity that is widespread on TikTok and is usually accompanied by a song and/or dance with prompts. While this hashtag challenge is promoting a brand, it is also promoting handwashing. The following are the instructions noted with the challenge, "Show us your handwashing dance moves with Safeguard Hand Soap. Invite a friend and have them watch. But wait for it. Splash them at the end (not in the eye, of course!) for a good laugh and use #SafeguardSplash to show us their reaction. Remember to wash your hands for 20 seconds to Safeguard your family and wash away germs [40] ." A total of 50 relevant videos were drawn from each hashtag. It's important to note that these were the most popular hashtags in the challenge and consumer categories at the time the study was conducted. In order to code each video, the same coding categories were used for both hashtags, including (1) wetting and rinsing hands (2) lathering soap (3) time used for scrubbing (4) drying hands (5) mentions COVID-19 (6) mentions using hand sanitizer instead of soap (7) mentions how germs spread (8) mentions key times to wash hands (9) and actual depiction of washing hands. Additional data coded included number and percent of views (how many times the video was viewed) , likes (a simply click of a button to indicate approval and/or enjoyment of a video), comments (a space where viewers can add text-based commentary), and whether or not music, dance, and humor were involved. The observations recorded were tabulated and descriptive statistics were performed. Independent one-tailed t-tests (=.05) were calculated to determine if a video's hashtag had a significant association with its garnered views, likes, and/or comments. A single reviewer (AP) coded all 100 videos and a second coder (CHB) then coded a 10% random sample to demonstrate inter-rater reliability. The two reviewers differed in only 3 out of 320 data points resulting in high agreement ( = .9593). Since human subjects were not involved in this study, it was not reviewed by the Institutional Review Board (IRB) at William Paterson University; the study was deemed exempt by the IRB at Teachers College, Columbia University. 643 (1,980.16 ), respectively. The mean number of days that videos at #WashYourHands were posted at the time the study was conducted was 374.74 and the median was 390, while the mean (and median) for #SafeguardSplash challenge was 314.22 (and 315). While videos at #washyourhands were posted for, on average, 60.52 days longer, this would be unlikely to account for the very large difference in number of cumulative views. All videos with the exception of one (posted in November of 2019) were posted after the discovery of COVID-19. Table 1 shows 16 different content characteristics. The data indicate how many of the videos sampled included the respective content overall and separated by hashtag (#WashYourHands vs. #SafeguardSplash). Table 1 also includes a breakdown of video views by content present. Relative percentages are included for comparison. Despite the fact that each hashtag made up an equal proportion (50%) of the total sample, videos with #WashYourHands accounted for 93.3% of the total views while #SafeguardSplash videos accounted for only about 6.7% of the total views. A one-tailed t-test (=.05) showed this difference to be statistically significant with p=.03; that is, a video's hashtag had a statistical association with a video's number of views. There was a similar discrepancy in the percentages of likes and comments garnered by the two different hashtags. Videos with #WashYourHands received 82.45% of the total likes and 81.45% of the total comments as compared to #SafeguardSplash videos which received only 17.55% of the total likes and 18.55% of the total comments. Independent one-tailed ttests (=.05) indicated that these findings too were statistically significant with approximate p values of 0 for each. Thus, a video's hashtag also had a statistical association with its number of likes and comments. Interestingly, all 50 of the #SafeguardSplash videos used music, showed the lathering of soap between hands, and used a song to determine handwashing length. These same content characteristics were present in only 27, 22, and 5 #WashYourHand videos, respectively. None of the #SafeguardSplash videos used sanitizer instead of soap, mentioned how germs spread, or mentioned key times to wash your hands. These same content characteristics were present in 6, 2 and 5 #WashYourHand videos, respectively. There were 6 different content characteristics present in a majority (>50%) of the total videos. These characteristics were: uses music (77%), uses humor (60%), showed lathering soap between hands (72%), uses a song to determine handwashing length (55%), shows rinsing hands under clean running water (68%), and shows actual handwashing (76%). Table 2 shows the number of likes and comments for videos exhibiting these six characteristics. The table includes the information for all 100 videos, a breakdown by hashtag, and relative percentages for comparison. The findings of this study indicate that handwashing videos are being widely viewed on TikTok, however the number of views and type of coverage differs across categorical criteria. Because the challenge hashtag is set to a specific song with specific steps to follow, handwashing techniques were exhibited to a greater extent in these videos. These techniques were absent from many videos not linked to a challenge. Further, coverage of the important steps involved in handwashing such as drying hands was minimal as was background information related to how germs spread and the key times to wash hands. This knowledge can be integral in motivating an individual to wash hands and to follow through with doing so completely. One of the most important findings from this study is that the general handwashing videos were viewed nearly 2 billion times. This widespread viewership indicates that there is a great opportunity to educate the public for disease prevention and health promotion. There is a paucity of literature which compares the two efforts, a campaign driven by a product versus one driven by consumers, with the same purpose in mind, to promote hand washing. In one respect, a campaign can be very effective if it gains popularity and the demonstration of an activity (such as handwashing) is done so in an accurate and comprehensive way. In this case, we identified key components of the handwashing process that were not or rarely included in the videos in this sample. Social media is a powerful communication medium with widespread, rapid reach that spans the globe. Unfortunately, our results show that while this opportunity is being realized to some degree, some important topics related to handwashing need more attention. The findings of this study are consistent with those from the few studies that examined consumer content on social media related to handwashing. Handwashing was a common theme present in YouTube videos related to COVID-19 specifically [41] [42] [43] [44] , however existing studies simply noted presence or absence of a number of themes rather than level of comprehensiveness. Studies of handwashing content on other social media platforms are sparse and varied. For instance, one study examined social media use and other characteristics as predictors of self-reported handwashing. The findings indicated that gender and number of children were predictors of handwashing moderated by the amount of time one spends on social media [45] . Others examined use Twitter to bolster dialogue at a professional conference [46] or to measure behaviors and sentiment related to COVID-19 [47] . This study has limitations that should be mentioned. The design was cross-sectional and the sample is small, which limits generalizability. Further, any study of social media is limited by the constant fluctuation in information. In addition, the search results attained did not adjust for algorithms, as they are not made public. TikTok is an emerging social media platform, with far fewer published studies on content than others (e.g. YouTube, Twitter, Facebook, Instagram). While the methods used in this study were based on several prior research studies [36] [37] [38] [39] , emerging research will may reveal methods that lead to greater generalizability of results. On TikTok, there is no way to account for a viewer who has not watched the complete video. Despite having several limitations, this study addresses a gap in the literature related to handwashing videos on a highly popular social media networking service. While the effort to promote an important behavior is commendable, lack of comprehensive information could negate efforts to provide information and raise awareness. In promoting health on TikTok, a challenge is to work within time constraints of short videos to provide comprehensive messaging. In an era of information abundance, an ideal scenario for public health messaging would be one whereby professionals form partnership with content creators to inform campaign efforts and overall messaging. Thus, increasing the likelihood for increased accuracy while retaining popularity. Given the high engagement of younger audiences with TikTok, an opportunity exists for demonstrating and encouraging proper handwashing in a population with low rates of handwashing. Back to the basics: Handwashing is public health 101 and it works to slow down the spread of viruses On washing hands Ignaz Semmelweis and the birth of infection control Global Access to Handwashing: Implications for COVID-19 Control in Low-Income Countries [published correction appears in Environ Health Perspect Water shutoffs in older American cities: Causes, extent and remedies Many Americans Don't Always Wash Their Hands Covid-19 exposes the gaps in infection prevention and control Hand hygiene during patient care: pursuing the Semmelweis legacy Characteristics Associated with Adults Remembering to Wash Hands in Multiple Situations Before and During the COVID-19 MMWR Morb Mortal Wkly Rep United States Centers for Disease Control and Prevention. When and How to Wash Your Hands The World Health Organization. Interim recommendations on obligatory hand hygiene against transmission of COVID-19 Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis Effect of washing hands with soap on diarrhoea risk in the community: a systematic review Handwashing and risk of respiratory infections: a quantitative systematic review Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory tract infections in 195 countries: a systematic analysis for the Global Burden of Disease Study Estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: a systematic analysis for the Global Burden of Disease Study Impact of a teacher-led school handwashing program on children's handwashing with soap at school and home in Bihar, India. PLoS One Effect of several interventions on the frequency of handwashing among elementary public school children Effect of water quality, sanitation, hand washing, and nutritional interventions on child development in rural Bangladesh (WASH Benefits Bangladesh): a cluster-randomised controlled trial Impact of water, sanitation, and hygiene interventions on improving health outcomes among school children Water and sanitation in schools: a systematic review of the health and educational outcomes Association between intensive handwashing promotion and child development in Karachi, Pakistan: a cluster randomized controlled trial Handwashing with soap, critical in the fight against coronavirus, is 'out of reach' for billions -UNICEF An observational study of handwashing compliance in a child care facility Hand-Washing Practices among Adolescents Aged 12-15 Years from 80 Countries Global Variation in Hand Hygiene Practices Among Adolescents: The Role of Family and School-Level Factors Hand washing among school children in Bogotá, Colombia Improving knowledge, attitudes and practice to prevent COVID-19 transmission in healthcare workers and the public in Thailand Evaluating healthcare workers' hand hygiene performance using first-person view video observation in a standardized patient-care scenario To play or not to play: leveraging video in medical education Video-assisted patient education to modify behavior: a systematic review Structured observations of hygiene behaviours in Burkina Faso: validity, variability, and utility TikTok was the most downloaded app of 2020 TikTok Revenue and Usage Statistics (2021) Promoting Mask Use on TikTok: Descriptive, Cross-sectional Study. JMIR Public Health Surveill COVID-19 on TikTok: harnessing an emerging social media platform to convey important public health messages A content analysis of direct-to-consumer DNA testing on TikTok A global pandemic in the time of viral memes: COVID-19 vaccine misinformation and disinformation on TikTok #SafeguardSplash Videos on TikTok Available from Effective educational videos The Role of YouTube and the Entertainment Industry in Saving Lives by Educating and Mobilizing the Public to Adopt Behaviors for Community Mitigation of COVID-19: Successive Sampling Design Study. JMIR Public Health Surveill Preventive Behaviors Conveyed on YouTube to Mitigate Transmission of COVID-19: Cross-Sectional Study. JMIR Public Health Surveill Evaluation of educational content of YouTube videos focused on hand hygiene: the need for professional communication Social media use as a predictor of handwashing during a pandemic: evidence from COVID-19 in Malaysia Enhancing engagement beyond the conference walls: analysis of Twitter use at #ICPIC2019 infection prevention and control conference Tracking COVID-19 Discourse on Twitter in North America: Infodemiology Study Using Topic Modeling and Aspect-Based Sentiment Analysis J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f  Social media, which is very popular way of communicating, may influence perceptions of handwashing.  Despite increased popularity, handwashing is understudied on TikTok.  This study demonstrates that portrayal of handwashing content is prevalent on TikTok.  While videos associated with a challenge were more comprehensive, they were lacking in viewership. Author Contributions: CH Basch and CE Basch conceptualized the study. AP collected the data, JF conducted the data analysis. All authors contributed to the manuscript production.