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

Discussion

Findings from this study 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 a final examination during the COVID-19 pandemic shutdown in the spring of 2020. Both male and female students demonstrated this behavior although the area of the face touched varied by gender.

In a recent systematic review on the frequency of T-zone touching, amidst the COVID-19 pandemic, no significant difference in face-touching behavior between sexes was identified in nine out of the ten reviewed studies.¹ The review included studies from different settings and regions of the world and it was concluded that the participants touched their eyes, nose, mouth, and chin approximately 69 times per hour.¹ Extrapolating the results from this study from twenty minutes to an hour, there would be an estimated occurrence of 46.5 touches to the T-zone, hair, ears, and/or glasses, indicating rates lower than those of the systematic review.

While there is limited research reporting on the face-touching behaviors of medical/health professionals or students, 5,12 clinicians and staff in medical offices in a study were found to have touched their T-zone an average of 19 times over a two-hour period12 These rates were lower than those observed in the current study. However, face-touching behaviors of health care providers in medical practices might differ based on the setting. In this study, oral health care students were engaged in a stressful activity outside of the clinic setting and unconscious face-touching behavior might have differed due to the environment.

Little has been reported in the literature regarding self-inoculation of respiratory viruses through contaminated hands coming in direct contact with mucous membranes.¹ However, some studies have shown that reducing the frequency of touching eyes, ears, and mouth also reduces the likelihood of respiratory tract infections.^7,12 The question remains as to why future health care providers would continue to exhibit unconscious face-touching behaviors that promote the potential to transfer pathogens to themselves and to others. Researchers believe one of the difficulties 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 in the home environment.¹³

The mismatch between expressed intentions and the actual behavior of the participants in this study is similar to the now widely accepted belief that certain processes that determine behavior are unconscious.¹³ Unconsciousness or unconscious influence 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 participants, such as face-touching behavior or removing their glasses, could be an inherent characteristic of human cognitive decision making, based on the causality between the glasses and eye pain, or skin sensitivity to pressure and pain.¹⁵

Therefore, not all behaviors are necessarily unconscious. Sax et al., observed nurse hand hygiene within an intensive care unit following participation in simulation-based hand hygiene training a few days earlier and 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.¹⁶ Moreover, the participants 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.¹⁶ The 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 Similar outcomes would be assumed of the students in this study in regard to self-inoculation risks from face-touching behavior. Both groups of students have undergone training and would have scored high on intention to act, based on their verbalized attitudes and positive beliefs regarding the outcomes of infection prevention. However, the face-touching behaviors of the participants were observed frequently, which could present significant risk factors for pathogen transfer and infection.

One reason face-touching may be a difficult habit to correct is due to the soothing effect of touching the face where the trigeminal and facial nerves are close to the surface (for example, the supraorbital nerve of the trigeminal at the supraorbital foramen, and the suborbital nerve of the trigeminal at the suborbital foramen). These points have been used in alternative and complementary medicine (acupressure, acupuncture, tapping) for relief of pain and stress. Perhaps increasing awareness of the underlying aspects of these habits will be beneficial in avoidance of face-touching behavior in a clinical setting.

Unsafe behaviors committed unconsciously may be corrected with the proper mental model. Creating mental models allows individuals to make inferences about the outcome of future events based on their previous experiences with similar events.¹³ Researchers have suggested a pragmatic approach for behavioral change, the Easy, Attractive, Social, and Timely (EASY) model, that addresses face-touching behavior.¹⁸ One simple suggestion is to provide tissues in convenient locations so that fingers or hands are not needed to touch the face.¹⁸ Another suggested application of the framework is to advance the 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

If health care workers were to visualize 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.¹³ Furthermore, short-term training in and of itself may not suffice for long-term behavior change. Educational principles recommend reinforcement and overlearning of behaviors.¹⁹ Most large medical/dental facilities, along with credentialing and licensing agencies, recognize the importance of reviewing and updating infection control practices and have requirements in place for ongoing continuing education.²⁰ Future research is needed to determine evidence-based educational strategies for behavioral changes that have positive implications for the reduction of disease transmission for both health care providers and patients.

This study had limitations. Participants were from two courses in one university and the small sample size reduced the generalizability of the findings. However, the small sample size was free from non-response bias as all students taking the exam were part of the study. Videos for this study were from an off-campus examination location and were recorded outside of the health care setting. Test taking is a stressful activity and unconscious face-touching behavior might be different during such a stressful situation. However, the finding of high frequency of face-touching behavior is of concern, given that the study participants are future health care providers who had completed required infection control educational modules specifically addressing COVID-19 transmission factors. Future studies should take place on the clinic floor in educational settings.