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A scale for measuring hygiene behavior: Development, reliability and validity

Article  in  American journal of infection control · May 2009

DOI: 10.1016/j.ajic.2009.01.003 · Source: PubMed

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 A scale for measuring hygiene behavior:
Development, reliability and validity
Richard J. Stevenson, BSc (Hons), MSc, DPhil,a Trevor I. Case, BA (Hons), PhD,a Deborah Hodgson, BSc (Hons), PhD,b
Renata Porzig-Drummond, BPsych (Hons),a Javad Barouei, BSc (Hons), PhD,b and Megan J. Oaten, BPsych (Hons), PhDa
Sydney and Newcastle, Australia

Background: There is currently no general self-report measure for assessing hygiene behavior. This article details the development
and testing of such a measure.
Methods: In studies 1 to 4, a total of 855 participants were used for scale and subscale development and for reliability and validity
testing. The latter involved establishing the relationships between self-reported hygiene behavior and existing measures, hand hy-
giene behavior, illness rates, and a physiological marker of immune function. In study 5, a total of 507 participants were used to
assess the psychometric properties of the final revised version of the scale.
Results: The final 23-item scale comprised 5 subscales: general, household, food-related, handwashing technique, and personal
hygiene. Studies 1 to 4 confirmed the scale’s reliability and validity, and study 5 confirmed the scale’s 5-factor structure.
Conclusions: The scale is potentially suitable for multiple uses, in various settings, and for experimental and correlational
approaches.
Key Words: Hygiene behavior; hand washing; measurement; self-report.
Copyright ª 2009 by the Association for Professionals in Infection Control and Epidemiology, Inc.
(Am J Infect Control 2009;37:557-64.)

Poor hand and household hygiene is associated with
an increased risk of contracting infectious disease.1
Poor personal hygiene also can be a feature of certain
psychiatric conditions, notably schizophrenia and
depression, where it can adversely affect interpersonal
relationships and employment prospects.2 More cru-
cially, routine hygiene behavior is important in estab-
lishing ‘‘hygiene norms’’ in critical settings, such as
hospitals and food production.3 Given the importance
of hygiene behavior, we found it surprising that no
widely available self-report measure to assess this
behavior is available. Consequently, we aimed to
develop and test such a measure.
Hygiene behavior includes hand hygiene (a process
with 5 distinct stages), personal grooming, household
cleanliness, and food-related hygiene. The relation-
ships among these components have not been exten-
sively studied, nor have the factors accounting for
their variability. Identifying such factors is important
to provide possible clues as to how hygiene behavior
can be improved. For hand hygiene, several factors
From the Department of Psychology, Macquarie University, Sydney,
Australiaa; and Department of Psychology, University of Newcastle,
Newcastle, Australia.b
Address correspondence to Richard J. Stevenson, Department of Psy-
chology, Macquarie University, Sydney, NSW 2109, Australia. E-mail:
richard.stevenson@psy.mq.edu.au.
0196-6553/$36.00
Copyright ª 2009 by the Association for Professionals in Infection
Control and Epidemiology, Inc.
doi:10.1016/j.ajic.2009.01.003
that correlate with better practice have been identified,
namely sex,4 parental influence,3 disgust sensitivity,5
social facilitation, and facilitator status.
One major problem associated with studying
hygiene behavior is how to measure it. Direct observa-
tion may be difficult and, as with self-report, may be
affected by a participant’s need to project socially
desirable hygiene standards.6 For hand hygiene behav-
ior, measurement has relied on self-report, observa-
tion, and proxy measures (eg, illness rates, soap
usage).7 As far as self-reporting hand hygiene instru-
ments go, there are currently no validated measures,
and those that are available tend to be group-specific
(eg, to medical personnel8). More broadly (ie, outside
of hand hygiene), there appear to be no measures
focusing primarily on hygiene behavior.
As alluded to earlier, an obvious concern is that self-
report measures of hygiene behavior may be so com-
promised by impression management (ie, the desire
to present a ‘‘clean’’ and ‘‘hygienic’’ image) as to
make the measures of little practical value. We
addressed this important concern directly by testing
the criterion and construct validity of our new mea-
sure. Criterion validity was established by determining
the relationship between the new measure and several
measures that would be expected to relate to hygiene
behavior: disgust sensitivity,9 contamination sensitiv-
ity,10 sex, socioeconomic variables, and social desir-
ability (ie, the extent to which the measure covaries
with the propensity to provide socially desirable
responses). To establish construct validity, we report
several lines of data. First, we relate the new scale to
self-reported illness rates, observed hand hygiene

557
558 Stevenson et al.
behavior, and an immune marker. Second, we relate
the scale to validated self-reporting measures of
general health (ie, General Health Questionnaire
[GHQ]11), health anxiety (ie, Whiteley Index of Hypo-
chondriasis12), perceived vulnerability to disease,13
mental well being (ie, Depression, Anxiety, and Stress
Scales [DASS]14), and personality.15 Finally, we explore
the internal reliability of the new scale, its test–retest
reliability, and its factor structure, confirming the latter
in a further large sample using the revised version of
the scale.
METHODS
Participants
A total of 855 participants completed the original
version of the hygiene inventory (studies 1 to 4).
Another 507 participants completed the final version
in study 5. Study 1 comprised 219 males and 402
females (8 participants did not report sex), with an
age range of 16 to 64 years (mean, 25.3 years 6 stan-
dard deviation [SD] of 11.0 years). Study 2 comprised
42 males and 61 females, with an age range of 16 to
59 years (mean, 21.9 6 6.7 years). Study 3 served solely
to collect an older sample and comprised 23 males and
53 females, with an age range of 19 to 84 years (mean,
40.2 6 15.4 years). Study 4 comprised 47 male under-
graduate students ranging in age from 17 to 30 years
(mean, 21.0 6 3.2 years); only males were used to min-
imize error variance generated by menstrual cycle and/
or contraceptive pill usage. Study 5 comprised 129
males and 378 females, with an age range of 17 to 50
years (mean, 21.0 6 5.2 years). Participants were
recruited from undergraduate students (for course
credit), the local community, and via the Internet
(both paid and volunteer participants). All work was
approved by the university’s Human Research Ethics
Committee.
Procedure
Participants in studies 1 to 4 completed the original
50-item version of the hygiene inventory (HI50). The
items were derived from existing sources and from
identifying all other aspects of routine hygiene behav-
ior. After factor analysis, the hygiene inventory was
reduced first to 27 items (HI27) and then to a final set
of 23 items (HI23). All reported validity and reliability
data for studies 1 to 4 used only these 23 items. Study
5 used only the HI23.
Responses were coded so that higher scores reflect
greater reported hygiene behavior (Table 1; HI27).
Questions 2 to 9 and 15 to 20 had common response
options: ‘‘always’’ (scored as 4), ‘‘usually’’ (3), ‘‘occa-
sionally’’ (2), and ‘‘never’’ (1). Additional response
American Journal of Infection Control
September 2009
Table 1. Items, by subscale, included in the HI27
Subscale and questions
General hygiene
1. On an average day, approximately how many times do you wash your
hands?
2. Upon getting home, do you wash your hands?
3. After touching a pet or other animal, do you wash your hands?
4. Before eating food with your hands, do you wash your hands?
5. Before preparing food, do you wash your hands?
6. If you need to touch your face or body (eg, to scratch) while preparing
food, do you wash your hands?
7. Do you wash fruit and vegetables before you eat them?
8. After using the toilet, do you wash your hands?*
9. When you use a public toilet, do you cover the seat with paper?
10. How often do you usually clean your teeth?*
Household hygiene
11. How often, in the last month, has your bathroom at home been
cleaned?
12. How often, in the last month, has your toilet at home been cleaned?
13. How often, in the last month, has your kitchen at home been cleaned?
14. How often, in the last month, has your fridge at home been cleaned?*
Food-related hygiene
15. After handling raw foods and before handling cooked foods, do you
wash your hands?
16. After handling raw foods and before handling cooked foods, do you
wash the utensils used?
17. Do you use separate chopping boards for raw and cooked foods?
18. Is your kitchen chopping board cleaned with bleach, detergent or
boiling water?*
Hand hygiene technique
19. When warm water is available, do you wash your hands with warm
water?
20. After washing your hands, do you dry your hands completely?
21. When soap is available, do you wash your hands with soap?
22. When you wash your hands, approximately how long do you wash
them for?
23. Do you use antibacterial gel or wipes to clean your hands?
Personal hygiene
24. Do you wear the same top or shirt two days in a row?
25. Do you wear the same skirt or pants two days in a row?
26. Do you wear the same underclothes two days in a row?
27. Do you go without a wash, shower or bath two days in a row?
*Items deleted in the final version of the scale (ie the H123).
options were provided for questions 3 (‘‘don’t touch
them’’), 4 (‘‘never eat with hands’’), and 9 (‘‘never use
public toilets’’), all scored as 4 (ie, hygiene-related
response). Additional response options also were in-
cluded for questions 5 (‘‘never prepare food’’), 6
(‘‘never prepare food’’), 15 (‘‘never handle raw food’’),
16 (‘‘never handle raw food’’), 17 (‘‘don’t use them’’),
and 18 (‘‘unsure’’). If an additional response was
endorsed, then an average score (ie, 2.5) was given.
Question 1 had the following response options:
‘‘never’’ (scored as 1), ‘‘1 to 5’’ (2), ‘‘6 to 10’’ (3), and
‘‘111’’ (4). For question 10, response options were
‘‘less than once a day’’ (scored as 4), ‘‘once a day’’ (3),
‘‘twice a day’’ (2), and ‘‘more than twice a day’’ (1).
For questions 11 to 14, response options were ‘‘never’’
(scored as 1) ‘‘once’’ (2) ‘‘twice’’ (3) ‘‘three times or
www.ajicjournal.org
Vol. 37 No. 7
more’’ (4), and ‘‘unsure.’’ ‘‘Unsure’’ responses were
coded with an average score (ie, 2.5). For question 22,
the response options were ‘‘under 5 seconds’’ (scored
as 1), ‘‘6 to 10 seconds’’ (2), ‘‘11 to 20 seconds’’ (3),
and (21 seconds or more’’ (4). Question 23 had the re-
sponse options ‘‘often’’ (scored as 4), ‘‘sometimes’’ (3),
‘‘rarely’’ (2), and ‘‘never’’ (1). Finally, questions 24 to 27
had response options ‘‘never’’ (scored as 4), ‘‘rarely’’
(3), ‘‘sometimes’’ (2) and ‘‘often’’ (1).
Next, we provide specific details about each study.
Study 1
The purpose of study 1 was to collect data examin-
ing the relationship between disgust sensitivity and dis-
ease.16 Participants completed several questionnaires,
including an infectious diseases inventory, the HI50,
the Disgust Sensitivity Scale (DS), the contamination
subscale of the Padua Inventory, the Whiteley Index
of Hypochondriasis, the DASS, and the short form of
the Marlowe-Crowne Social Desirability Scale.17 Vari-
ous biographical data were obtained, including
whether the participant had any children under age 5
years, income, age, education, and sex. Occupational
data were collected for community participants (ap-
proximately 50% of this sample).
Study 2
This was an intervention study to determine
whether disgust could be used to improve hand
hygiene.5 As for study 1, participants completed the
DS, the HI50, and biographical questions. The experi-
mental phase then followed, with participants ran-
domly assigned to a disgust condition, an education
condition, or a no-intervention control. One week later,
the participants returned for the second session, during
which they engaged in a laboratory-based task to
assess hand hygiene. This involved progressive expo-
sure to items that were increasingly likely to carry
pathogens. For each item, after the participant had
touched it, he or she was offered a small snack, and
whether he or she engaged in any form of hand
hygiene behavior (ie, using a hand wipe, antibacterial
gel, or soap and water) before picking up the snack
was noted. Only data from the no-intervention controls
are reported here, for the purpose of examining the
relationship between hand hygiene behavior and the
HI23, because unlike the other 2 groups, this group
was not exposed to an intervention to promote hand
hygiene. Finally, all participants completed the HI50
again, allowing evaluation of test–retest reliability.
Study 3
This study collected data from an older sample of re-
spondents using Web-based delivery of the HI50, the
Stevenson et al. 559
DS, the GHQ, the Padua Index, and biographical ques-
tions (as for study 1).
Study 4
This study explored the relationship between dis-
gust and immune function—namely, whether experi-
encing this emotion results in an acquired humoral
immune system response (as measured by salivary
IgA) (R. J. Stevenson, et al, unpublished data). Partici-
pants completed the GHQ, DASS, DS, and HI50 before
being randomly assigned to an experimental condition
(disgust induction) or control condition (negative emo-
tion induction). Baseline measures for the immune
marker (used here) were obtained in the week preced-
ing the experimental phase of the study.
Study 5
This Web-based survey used the HI23, the DS, the
Padua Index, the Big Five mini-markers, the Perceived
Vulnerability to Disease (PVD) Scale, age, and sex. The
intention here was to evaluate the reliability and valid-
ity of the revised scale, and to use confirmatory factor
analysis to test the factor solution obtained from the
foregoing data.
RESULTS
Development of the Final Scale
An initial factor analysis on the HI50 was conducted
to identify potential subscales. The data were appropri-
ate for this technique [Kaiser-Meyer-Olkin index 5
0.82; Bartlett’s test; x2(1225) 5 10,877; P , .001]. Six-
teen factors had an eigenvalue .1, but a scree plot sug-
gested that only the first 5 factors should be
considered. Factor 1 comprised 10 questions (7.2% of
the variance after varimax rotation), including hand
and general hygiene items (Table 1). Factor 2 comprised
4 questions (4.8% of the variance) covering household
cleaning items (household hygiene). Factor 3 com-
prised 4 questions (4.6% of the variance) related to
food-related hygiene. Factor 4 comprised 5 questions
(4.5% of the variance), including items dealing with
hand hygiene technique. Factor 5 (accounting for
4.5% of the variance) dealt with personal hygiene.
Examination of the item–subscale correlations and
the item–scale correlations indicated that several items
warranted removal because they had corrected item to-
tal correlations , 0.3 (Table 2). Consequently, questions
8, 10, 14, and 18 were eliminated, as indicated in Tables
1 and 2.
Reliability coefficients were calculated for the HI23
and for each of its subscales. The coefficient alpha
was 0.85 for the HI23, 0.81 for the general hygiene sub-
scale, 0.82 for the household hygiene subscale, 0.71 for
560 Stevenson et al. American Journal of Infection Control
September 2009

Table 2. Item, scale, and subscale statistics Table 3. Relationships among the Hygiene Inventory
subscales and other variables
Subscale Item–sub-
question Mean (SD) scale Item-scale HIT GH HH FRH HHT PH
number (n 5 847) Range correlation correlation
HIT — 0.86 0.49 0.54 0.69 0.58
Hygiene 2.92 (0.39) 1.52 to 3.85 — — GH — — 0.24 0.41 0.46 0.34
inventory HH — — — 0.12 0.26 0.26
total FRH — — — — 0.17 0.10
General 2.91 (0.51) 1.10 to 3.90 — — HHT — — — — — 0.31
hygiene DS 0.34 0.33 0.13 0.10 0.23 0.22
1 2.58 (0.69) 1 to 4 0.44 0.38 Padua Index 0.46 0.48 0.14 0.14 0.38 0.18
2 2.38 (0.99) 1 to 4 0.59 0.54 Crowne-Marlowe 0.15 0.12 0.10 0.03* 0.10 0.14
3 2.94 (0.93) 1 to 4 0.56 0.53 Scale
4 2.76 (0.89) 1 to 4 0.67 0.62 Age 0.10 0.05* 0.12 20.07 0.09 0.17
5 3.34 (0.77) 1 to 4 0.63 0.60 Income 0.04* 20.04* 0.18 20.18 0.10* 0.16
6 2.51 (0.99) 1 to 4 0.49 0.51 Whiteley Index 0.12 0.12 0.01* 0.01* 0.15 0.03*
7 3.28 (0.86) 1 to 4 0.52 0.48 GHQ 0.19 0.13* 0.12* 20.05* 0.09* 0.33
8* 3.92 (0.33) 1 to 4 0.28 0.29 DASS-S 0.01* 0.03* 0.01* 0.04* 0.01* 20.06*
9 2.58 (1.14) 1 to 4 0.38 0.36 DASS-A 0.00* 20.09 20.05* 0.05* 20.05* 0.00*
10* 2.81 (0.62) 1 to 4 0.21 0.24 DASS-D 20.09 20.05* 20.11 20.05* 20.02* 20.11
Household 3.12 (0.58) 1.25 to 4.00 — —
hygiene NOTE: n for correlations between HIT and for subscales (GH, HH, FRH, HHT, PH),
847; DS, 835; Padua Index, 697; Marlowe-Crowne Scale (social desirability), 622; age,
11 3.32 (0.79) 1 to 4 0.71 0.40
850; income, 355; Whiteley Index (health anxiety), 618; GHQ, 123; DASS stress,
12 3.39 (0.77) 1 to 4 0.68 0.42
anxiety, and depression, 665.
13 3.57 (0.70) 1 to 4 0.50 0.27 HIT, hygiene inventory total; GH, general hygiene; HH, household hygiene; FRH,
14* 2.22 (0.86) 1 to 4 0.27 0.34 food-related hygiene; HHT, hand hygiene technique; PH, personal hygiene; GHQ,
Food-related 3.19 (0.66) 1.00 to 4.00 — — general health; S, stress; A, anxiety; D, depression.
hygiene *All correlations are significant at greater than P , .05, except where indicated with
15 3.30 (0.87) 1 to 4 0.59 0.42 an asterisk.
16 3.37 (0.81) 1 to 4 0.54 0.36
17 2.86 (1.07) 1 to 4 0.43 0.29
18* 3.24 (0.96) 1 to 4 0.29 0.24
Hand hygiene 2.62 (0.55) 1.00 to 4.00 — — subscales correlated moderately to strongly with the
technique HI23 score.
19 2.72 (0.95) 1 to 4 0.41 0.31
20 2.76 (0.83) 1 to 4 0.44 0.39
21 3.40 (0.76) 1 to 4 0.46 0.41 Validity
22 2.17 (0.74) 1 to 4 0.44 0.40
23 2.05 (0.93) 1 to 4 0.36 0.40 The HI23 and all of its subscales correlated signifi-
Personal 2.83 (0.60) 1.00 to 4.00 — — cantly with the DS and with the Padua Index (Table
hygiene 3), providing convergent validity for our new scale.
24 2.53 (0.87) 1 to 4 0.59 0.35 Greater reported disgust and contamination sensitivity
25 2.03 (0.87) 1 to 4 0.52 0.38
26 3.34 (0.86) 1 to 4 0.42 0.31
were associated with increased hygiene-related behav-
27 3.43 (0.72) 1 to 4 0.39 0.33 ior. Correlations between the HI23 and the 8 DS sub-
scales were also computed. The HI23 score was most
*Items deleted in the final version of the scale.
strongly associated with the hygiene subscale of the
DS (r (844) 5 0.42; P , .001). The magnitude of this
correlation significantly exceeded that of the next-larg-
the food-related hygiene subscale, 0.67 for the hand est association (z 5 3.07; P , .002; 1-tailed Williams
hygiene technique subscale, and 0.69 for the personal test, after correction for multiple comparisons). We
hygiene subscale. The final 23-item scale (values then investigated for sex differences on the HI23. Males
reported here are based on the HI23) had a mean of reported significantly less hygiene-related behavior
2.90 (6 SD of 0.42), 8 general hygiene items (2.80 6 compared with females [mean, 2.76 6 0.41 vs 2.99 6
0.60), 3 household hygiene items (3.43 6 0.65), 3 0.40; t (839) 5 7.90; P , .001], as was the case across
food-related hygiene items (2.18 6 0.73), 5 handwash- all of the subscales, even when disgust sensitivity and
ing technique items, and 4 personal hygiene items social desirability were included as covariates (using
(Table 2). The HI23 and each of its subscales were analysis of covariance).
normally distributed. The subscale scores (obtained Social desirability was significantly associated with
by averaging items within each subscale) were all cor- hygiene behavior, with greater propensity to generate
related (Table 3), with correlations ranging in strength socially desirable answers correlating with higher
from weak to moderate. Not surprisingly, all of the scores on the HI23 (Table 3). Social desirability was
www.ajicjournal.org Stevenson et al. 561
Vol. 37 No. 7

positively related to all subscales except food-related Table 4. Regression analyses for illness rate data
hygiene.
Dependent Zero-order r Semipartial r
Previous studies have found that disgust sensitivity variable with dependent with dependent
declines with age. The HI23 showed the opposite trend, predictor variable variable variable variable t P
being higher in older participants, but this was not con-
sistent across the subscales (Table 3). For socioeco- Influenza rate
Sex 0.09 0.07 1.78 .08
nomic variables, household income was positively DASS-stress 0.20 0.14 3.53 .001
associated with household hygiene and personal Health anxiety 0.21 0.14 3.64 .001
hygiene, was negatively associated with food-related GH 0.13 0.15 3.88 .001
hygiene, and was not associated with overall score, FRH 20.04 20.11 2.87 .004
general hygiene, or hand hygiene technique (Table 3). HHT 0.01 20.08 2.06 .04
Food poisoning rate
There were no significant associations with education. Sex 20.06 20.08 2.08 .038
As expected, health anxiety was positively associ- DASS-stress 0.12 0.10 2.56 .011
ated with the HI23 score; this trend was evident across Health anxiety 0.11 0.07 1.74 .083
all of the subscales (Table 3). Also as expected, higher HH 20.06 20.07 1.73 .085
GHQ score was associated with a greater HI23 score PH 0.07 0.10 2.54 .01
Cold rate
(ie, a reaction to poor health and anxiety about health). Sex 0.19 0.16 4.01 .001
For mental health–related variables, the most consis- DASS-stress 0.12 0.07 1.79 .074
tent relationships were with depression. Participants Health anxiety 0.12 0.08 1.96 .05
reporting more depressive symptoms on the DASS HH 0.11 0.09 2.20 .028
had lower household hygiene scores, lower personal GH, general hygiene; HH, household hygiene; FRH, food-related hygiene; HHT, hand
hygiene scores, and lower overall scores (Table 3). hygiene technique; PH, personal hygiene.
The participant’s occupation was known in 356
cases; 41 participants worked in health-related fields.
We tested whether the HI23 overall and its subscales hygiene technique were associated with decreasing
differed by profession, in the expectation that health rates of influenza (Table 4). These types of bidirectional
professionals would have higher scores. This was the associations within the same scale are no surprise and
case for the HI23 score [t (351) 5 1.91; P , .05; resemble those obtained for disgust and contamination
1-tailed), with higher scores in health professionals sensitivity. We have argued that these associations
compared with other (mean, 3.03 vs 2.89). Significant reflect reactions to disease (positive associations) and
differences also were obtained for 2 subscales: general behavior associated with preventing disease (negative
hygiene [t (65.4) 5 3.02; P , .002; 1-tailed, equal var- associations).16 A similar picture emerged in the analy-
iances not assumed; mean, 3.02 vs 2.79] and food-re- sis of food poisoning rates. Again, the overall model
lated hygiene [t (353) 5 2.64; P , .005; 1-tailed; was significant [F (5, 587) 5 4.80; P , .001] and
mean, 3.42 vs 3.09]. We also expected to find higher accounted for 3.1% of the variance (adjusted R2). In
HI23 scores in parents of younger children. A total of this case, there was a marginally significant negative
270 participants reported having children under age 5 association with household hygiene and a positively
years. These respondents reported significantly higher signed association with personal hygiene (Table 4).
HI23 scores than participants without children or with Finally, for colds, the overall model was significant [F
older children [mean, 3.04 vs 2.83; t (845) 5 7.04; P , (4, 587) 5 9.45; P , .001] and accounted for 5.4% of
.001; 1-tailed]. This same pattern was evident for each the variance (adjusted R2). Here better household
subscale (t . 2.97). hygiene was associated with higher rates of colds
Study 1 allowed us to examine the relationships (Table 4).
between the HI23 and rates of infectious illness, for In study 2, a composite measure of hand hygiene be-
colds, food poisoning, and influenza. Using control var- havior on the experimental task was obtained for each
iables previously identified as important (sex, health participant in the control group, with higher scores in-
anxiety, DASS score), all 5 of the subscales were dicating better hand hygiene. This variable was not
entered in 3 regression models (using backward elimi- normally distributed, and thus Spearman’s correlation
nation) to determine whether any of the subscales coefficients were used to estimate the association
could predict illness rates for each disease. For influ- between this measure and the HI23 and subscale
enza, the overall model was significant [F (6, 856) 5 scores. As expected, there was a significant positive
10.53; P , .001] and accounted for 8.8% of the vari- relationship between overall score on the HI23
ance (adjusted R2). Whereas increases in general and hand hygiene behavior [r (31) 5 0.32; P , .05;
hygiene were associated with increasing rates of influ- 1-tailed]. Two subscales were significantly associated
enza, increases in food-related hygiene and hand with hand hygiene behavior: general hygiene [r (31)
562 Stevenson et al.
5 0.33; P , .05; 1-tailed] and household hygiene [r
(31) 5 0.33; P , .05; 1-tailed]. It also is important
to note that the HI23 score was sensitive to the inter-
vention tested in study 2. Here participants in the
treatment conditions reported a significant change
in HI23 from preintervention to postintervention
compared with the nonintervention control group
[t (101) 5 2.66; P , .01]. General hygiene [t (95.5)
5 2.00; P , .05; equal variances not assumed] and
handwashing technique [t (101) 5 3.10; P , .005]
were the only 2 subscales that differed; of course,
these subscales contained the most hand hygiene–
related items (all other t values , 1.19). These effects
were of comparable magnitude to the differences
obtained in the behavioral hand hygiene measure.
Participants in study 2 completed the hygiene inven-
tory on 2 occasions, 1 week apart. For all 103 partici-
pants (including those who had received the
intervention conditions), overall test–retest reliability
for the hygiene inventory was 0.82 (Pearson’s r). For
the 31 control participants, who received no interven-
tion, this value was 0.85 (Pearson’s r). For all partici-
pants, the test–retest reliabilities for the subscales
were 0.84 for general hyigiene, 0.76 for household
hygiene, 0.66 for food-related hygiene, 0.53 for hand
hygiene technique, and 0.85 for personal hygiene.
These values were largely similar for the 31 control par-
ticipants (0.90, 0.61, 0.63, 0.56, and 0.90, respectively).
Study 4 obtained baseline measures of salivary IgA
before any intervention. These baseline measures
were not normally distributed, and again a nonpara-
metric approach was adopted. There was a significant
negative association between salivary IgA and HI23
score [r (42) 5 -0.42; P , .005], with poorer reported
general hygiene associated with higher levels of sali-
vary IgA. Similar negative associations emerged for
the subscales, but only the relationship with household
hygiene was significant [r(42) 5 -0.39; P , .01].
Study 5: Testing the Revised Scale
In study 5, the HI23 completed alone was reliable,
with a coefficient alpha of 0.82. Reliabilities of the sub-
scales were comparable to those in studies 1 to 4: 0.75
for general hygiene, 0.76 for household hygiene, 0.67
for food-related hygiene, 0.62 for hand hygiene tech-
nique, and 0.66 for personal hygiene.
Using confirmatory factor analysis (with the Amos
program), we tested 2 models of our data. The first
model used the factor structure obtained from the fore-
going analyses and assumed that all 5 factors were
independent. This model (with 230 degrees of freedom
[df]) was not a particularly good fit. Both the goodness-
of-fit index (GFI) and the conditional fit index (CFI) were
below the 0.9 level for fit adequacy (0.86 and 0.76,
American Journal of Infection Control
September 2009
respectively), the root mean squared error of
approximation (RMSEA) exceeded 0.06 (ie, 0.073), and
the Hoelter index was , 200 (ie, 158). The second model
allowed all of the factors to correlate (as of course they
do; see Tables 3 and 5), rather than assuming their inde-
pendence. This model (with 220 df) was a significantly
better fit than the first model [x2 [10] 5 339.20; P ,
.001], with all of the indices within the range judged to
represent an adequate model fit. Both GFI and CFI
were at or above the 0.9 cutoff (ie, 0.92 and 0.90, respec-
tively), RMSEA was below 0.06 (ie, 0.05), and the Hoelter
index exceeded 200 (ie, 250). Given the size of the sam-
ple and the number of free parameters, this suggests
that the original factor solution, allowing for correlation
between factors, provides an adequate fit of these new
data obtained using the HI23 alone.
The HI23 correlated significantly with the DS and
the Padua Index (Table 5), as before. Correlations with
the DS subscales also were computed; the HI23 score
was most strongly associated with the hygiene sub-
scale of the DS [r (507) 5 0.42, P , .001; z 5 2.24, P
, .013; 1-tailed Williams test, correcting for multiple
comparisons]. Sex differences in the HI23 were also
as before, with males having significantly lower HI23
scores than females [mean, 2.79 6 0.36 vs 2.97 6
0.37; t (505) 5 4.93: P , .001]. Correlations between
the revised hygiene scale and the 5 personality mea-
sures were then explored. Significant correlations
were obtained for the dimensions of extraversion,
agreeableness, and conscientiousness (Table 5). More
extraverted, agreeable, and especially conscientious in-
dividuals were more likely to have higher HI23 scores.
Whereas neuroticism was significantly associated with
the Padua Index and the DS (r 5 -0.19 and -0.20,
respectively), neuroticism was unrelated to HI23
scores, as with openness (Table 5). Finally, greater per-
ceived vulnerability to disease was associated with
higher reported hygiene behavior (Table 5).
DISCUSSION
Our aim in this work was to develop a measure
that can be applied in a range of settings to assess
various aspects of hygiene behavior. The final version
of our scale comprises 23 items and has demon-
strated good internal and test–retest reliability. Factor
analysis revealed 5 components corresponding to the
main domains of hygiene behavior: general hygiene,
household hygiene, food-related hygiene, hand hy-
giene technique, and personal hygiene. This factor
structure was confirmed in another sample that com-
pleted just the HI23. These factors were found to be
not independent, suggesting that hygiene behavior
in one domain is likely to predict hygiene behavior
in another domain.
www.ajicjournal.org Stevenson et al. 563
Vol. 37 No. 7

Table 5. Relationships among the Hygiene Inventory reported increased hygiene-related behavior, presum-
subscales for study 5 and other variables ably related to an attempt to manage such perceived
or actual risks. Based on previous findings in depressed
HIT GH HH FRH HHT PH
subjects,2 we expected that those reporting greater
HIT — 0.83 0.43 0.58 0.76 0.54 levels of depression would report reduced levels of
GH — — 0.15 0.36 0.53 0.23 hygiene behavior. This too was observed.
HH — — — 0.19 0.17 0.18 We recently reported that disgust and contamination
FRH — — — — 0.29 0.15
HHT — — — — — 0.34
sensitivity are influenced by illness and also influence
Disgust scale 0.37 0.40 0.06* 0.22 0.24 0.14 rates of illness.16 Similar patterns of reactive and pro-
Padua 0.46 0.53 0.08* 0.14 0.42 0.11 tective associations were observed here. Whereas these
contamination infection measures were obtained by self-report, we
Extraversion 0.10 0.04* 0.16 0.04* 0.08* 0.06* were able to compare the frequency of various ail-
Agreeableness 0.11 0.04* 0.15 0.09 0.06* 0.05*
Conscientious 0.19 0.16 0.19 0.05* 0.10 0.13
ments collected in this study to population-level health
Neuroticism 0.03* 0.03* 0.07* 0.03* 0.00* 0.00* studies conducted in our state.16 These comparisons
Openness 20.05* 20.07* 0.03* 20.06* 0.03* 20.08* confirmed that the frequency of many illnesses closely
Perceived 0.29 0.36 0.02* 0.11 0.21 0.10 followed population levels, suggesting that participants
vulnerability were broadly accurate in their medical self-reports.
to disease
We also found that caring for young children and
NOTE: n = 507 for all correlations. working in a medical field were associated with higher
HIT, hygiene inventory total; GH, general hygiene; HH, household hygiene; FRH,
food-related hygiene; HHT, hand hygiene technique; PH, personal hygiene. HI23 scores. In addition, more conscientious individ-
*All correlations are significant at greater than P , .05, except where indicated with uals also tended to have higher HI23 scores. More tell-
an asterisk. ingly, the HI23 both correlated with performance on a
behavioral measure of hand hygiene and was suffi-
A significant concern with any self-report instru- ciently sensitive to detect the effect of brief interven-
ment, especially one pertaining to socially desirable tions designed to improve hand hygiene. These
behavior, is that individual differences in hygiene be- findings are important, because they suggest that
havior will be masked by attempts to project a ‘‘clean what is reported actually does reflect behavior. Self-re-
image.’’ The data obtained here speak to this issue in ports of hygiene behavior also were correlated with a
several ways. Whereas there is a tendency to produce marker of acquired humoral immunity. Higher levels
socially desirable responses, as indicated by the posi- of secretory IgA were found to correlate with lower
tive association with the Crowne-Marlowe social desir- HI23 scores. Whether or not this was mediated by
ability scale, this relationship was weak, accounting for more frequent illness is not known, but there is
only 2.25% of the variance. More importantly, and as increasing interest in the nexus of disgust, contamina-
we discuss in more detail later, the weight of evidence tion (and hygiene), and immune function.19
points to our scale’s effectiveness in measuring In conclusion, we suggest that hygiene behavior, in
hygiene behavior. its various related forms, may be measured by self-re-
Visible and ‘‘invisible’’ dirt may engender a disgust port, and that this form of assessment is adequate to
response, and contact with such items may result in a capture useful variation, can be deployed in varying sit-
sense of contamination.18 On this basis, participants uations, and is sufficiently sensitive to detect hygiene-
who report greater hygiene-related behavior also related interventions.
should tend to score higher on measures tapping dis-
We thank the Australian Research Council for financial support and Mehmet Mahmut
gust and contamination sensitivity. This tendency was for assistance with the Internet-based studies.
confirmed by our data. In addition, the strongest asso-
ciation across the 8 disgust domains was found to be
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