Methods to Evaluate COVID-19 Preventive Hygiene Programs: Observed Mask Wearing, Handwashing, and Physical Distancing Behaviors in Public Indoor Spaces in Democratic Republic of the Congo

Abstract

The objective of our study was to develop and test observational methods to evaluate COVID-19 preventive hygiene behaviors and physical distancing, and to evaluate the effectiveness of a government mandate on indoor fully covered mask wearing. An observational study was conducted of 4,736 individuals from April to October 2021 using 5-hour and rapid (10-minute) structured observations and spot checks to evaluate mask-wearing, handwashing, and physical-distancing behaviors, and the functionality of handwashing stations in 161 indoor public spaces across Bukavu, Democratic Republic of the Congo (DRC). Sixteen percent of individuals entering indoor public spaces were wearing a mask that fully covered their nose and mouth (fully covered mask wearing). Fully covered mask wearing was lowest inside schools (1%), universities (2%), religious establishments (22%), and health facility wards (28%). Overall physical distancing of more than 1-m inside indoor public spaces was 22%, and was lowest inside schools and religious establishments (7%). Thirty-nine percent of handwashing stations had water and a cleansing agent present. Ten percent of individuals washed their hands with a cleansing agent before entering an indoor space. Overall, fully covered mask wearing was similar for 5-hour and rapid structured observations (16% versus 15%). The odds of fully covered mask wearing was significantly greater with increased government enforcement of mask wearing in public spaces through fines (odds ratio, 2.72; 95% CI, 1.02–7.30). This study presents rigorous methods using structured observations to assess government mandates and programs on COVID-19 preventive hygiene behaviors in indoor public spaces in settings globally.

A Qualitative Evaluation of COVID-19 Preventative Response Activities in South Kivu, Democratic Republic of the Congo

“…Even during enforcement of the mask mandate, it was noted that individuals were often not wearing their mask over both their nose and mouth. This is also consistent with our quantitative study which found that only 16% of >4600 observed individuals wore a mask completely covering their nose and mouth in indoor public spaces (George et al, 2022, In press) [ 27 ]. Engaging local leaders (e.g., religious leaders, community healthcare workers, and school officials) in raising awareness about mask wearing can help to increase compliance.…”

“…Community participants mentioned that the handwashing stations in public places often lacked water and cleansing agents. This is consistent with our parallel quantitative study which found that the majority (61%) of handwashing stations in indoor public spaces (e.g., entrances of health facilities, schools, and universities) in Bukavu did not have both water and handwashing agents present (George et al, 2022, In press) [ 27 ]. Community residents interpreted the lack of upkeep of handwashing stations and relaxing of masking mandates as meaning that COVID-19 transmission was less of a concern.…”

“…Community members included six adult males, six adult females, and four children (12 adults and 4 children) ( Table 1 ). A parallel quantitative study observed mask wearing, handwashing, and physical distancing behaviors in indoor public spaces within the same study population (George et al, 2022, In press) [ 27 ].…”

“…The parallel quantitative observational study (George et al, 2022, In press) [ 27 ] examined COVID-19 preventative behaviors (i.e., mask wearing, handwashing, and physical distancing) and the functionality of public handwashing stations in Bukavu. This study served to triangulate our qualitative findings, augmenting the credibility of our work.…”

“…Some phone companies (e.g., Orange and Airtel) have included messages about hygiene practices, physical distancing, and mask wearing in their ringtones. In the city of Bukavu, communal handwashing stations—alongside posters instructing about when and how to wash hands with soap or to use chlorinated water—have been placed in areas of high foot traffic such as markets, health facilities, and schools (George et al, 2022, In press) [ 27 ]. The government implemented a countrywide lockdown of schools and some workplaces, restricted movements between provinces, and closed international borders from April 2020 to September 2020.…”