Personal hygiene among military personnel: developing and testing a self-administered scale
Environ Health Prev Med
Personal hygiene among military personnel: developing and testing a self-administered scale
Mohsen Saffari 0 1 2 3 4 5 6
Harold G. Koenig 0 1 2 3 4 5 6
Amir H. Pakpour 0 1 2 3 4 5 6
Hormoz Sanaeinasab 0 1 2 3 4 5 6
Hojat Rshidi Jahan 0 1 2 3 4 5 6
Mohammad Gamal Sehlo 0 1 2 3 4 5 6
0 A. H. Pakpour Department of Public Health, Qazvin University of Medical Sciences , Qazvin , Iran
1 H. G. Koenig King Abdulaziz University , Jeddah , Saudi Arabia
2 M. G. Sehlo Zagazig University , Zagazig , Egypt
3 M. G. Sehlo Department of Psychiatry, King Abdulaziz University , Jeddah , Saudi Arabia
4 M. Saffari (&) Health Research Center, Baqiyatallah University of Medical Sciences , 1435814783 Tehran , Iran
5 H. G. Koenig Department of Psychiatry and Behavioural Sciences, Duke University Medical Center , Durham, NC , USA
6 M. Saffari H. Sanaeinasab H. R. Jahan Department of Health Education, School of Health, Baqiyatallah University of Medical Sciences , 1435814783 Tehran , Iran
Objective Good personal hygiene (PH) behavior is recommended to prevent contagious diseases, and members of military forces may be at high risk for contracting contagious diseases. The aim of this study was to develop and test a new questionnaire on PH for soldiers. Methods Participants were all male and from different military settings throughout Iran. Using a five-stage guideline, a panel of experts in the Persian language (Farsi) developed a 21-item self-administered questionnaire. Face and content validity of the first-draft items were assessed. The questionnaire was then translated and subsequently back-translated into English, and both the Farsi and English versions were tested in pilot studies. The consistency and stability of the questionnaire were tested using Cronbach's alpha and the test-retest strategy. The final scale was administered to a sample of 502 military personnel. Explanatory and confirmatory factor analyses evaluated the structure of the scale. Both the convergent and discriminative validity of the scale were also determined. Results Cronbach's alpha coefficients were [0.85. Principal component analysis demonstrated a uni-dimensional structure that explained 59 % of the variance in PH behaviors. Confirmatory factor analysis indicated a good fit (goodness-of-fit index = 0.902; comparative fitness index = 0.923; root mean square error of approximation = 0.0085). Conclusions The results show that this new PH scale has solid psychometric properties for testing PH behaviors among an Iranian sample of military personnel. We conclude that this scale can be a useful tool for assessing PH behaviors in military personnel. Further research is needed to determine the scale's value in other countries and cultures.
Personal hygiene; Validity; Reliability; Scale; Development
Improvement of personal hygiene (PH) has been an
important achievement in public health [
]. Hygiene is
defined as those states or activities by which individuals
maintain or promote good health through achieving
personal cleanness and cleanliness in their surroundings [
Hygiene can be separated into two main categories: PH and
environmental hygiene [
]. PH behaviors are the activities
of washing/cleaning the body that keep skin, hair, and nails
in good condition, of paying attention to oral health and
eye and ear care, and of maintaining clean clothes that
helps prevents the transmission of contagious diseases [
]. PH includes behaviors such as bathing, hand-washing,
dressing, grooming and activities of daily living that
maintain cleanliness .
Good PH behavior helps to protect humans against
many threats to their physical, social and emotional health
and well-being [
]. For example, the transmission of a wide
range of parasites, bacteria, and viruses can be prevented
by paying attention to PH [
]. In addition, for those who
pay attention to their PH, the risk of social isolation is
lower, and the person is more likely to be regarded as a
normal and creditable member of society, thereby affecting
the emotional and mental health of that individual [
Studies show that poor hygiene is often the cause or the
result of a range of psychological disorders [
Causal relationships have been established between
hygienic behaviors and the risk of many infectious illnesses
]. These diseases account for about one-half of deaths in
developing countries and are responsible for nearly 4 % of
deaths in developed countries [
]. Some studies indicate
that the hygienic behaviors of hand-washing can on its own
result in a decrease the incidence of respiratory infections
and gastrointestinal disease by 21 and 31 %, respectively
Knowledge, beliefs, and practices regarding PH are
substantial determinants of future health status and quality
of life [
]. Moreover, these components are related to
productivity and performance and have a contributed to the
general development of society [
]. Many outbreaks
of contagious diseases in recent decades have had a
negative impact on community resources [
research on infectious diseases during the recent past has
mainly focused on secondary and tertiary levels of
prevention and, unfortunately, primary prevention measures,
such as PH, have been overlooked [
At the present time, the high frequency of antibiotic
prescriptions has caused drug resistance and increased
susceptibility to many already controlled infectious
]. Also, emerging infections, such as acute
respiratory syndrome and novel forms of influenza, are
presenting new threats to human health [
]. Even in
developed countries with strict public health regulations,
these types of disorders remain common [
because exposure to pathogenic microorganisms is an
everyday event that can only be avoided by adherence to
good PH behaviors [
Despite the importance of PH for individual and social
health, there is as yet no widely used measure to evaluate
this state systematically. One explanation is the difficulty
in measuring PH, which consists of behaviors that may not
be readily observable [
]. However, it is important to have
valid and reliable instruments to measure PH. Self-reported
scales may be useful in this regard [
Personal hygiene is relevant to many population groups
]. People who work and live in the crowded areas may be
at particularly high risk for poor hygienic behaviors [
Military settings are a prime example of such a high-risk
population as military personnel live and work closely
together in performing their duties as soldiers [
these individuals receive rigorous training related to their
duties, many activities that relate to their health may be
]. In addition, there are numerous infectious
diseases related to respiratory, gastrointestinal, and skin
disorders that are easily preventable through attention to
proper hygiene [
6, 22, 23
]. The results of a number of
studies indicate that behaviors such as regular brushing of
teeth, respiratory etiquette, and hand-washing receive little
attention among army personnel [
military personnel often live in environments that are poorly
equipped with health facilities and equipment and are often
responsible for handling unsanitary substances [
Therefore, this population can be exposed to conditions
that facilitate the transmission of infectious diseases. The
aim of this study was to develop a brief self-rated measure
to assess the behaviors of military personnel with regard to
Materials and methods
Design and sample
This was a cross-sectional study in which we developed
and tested a new scale to assess PH behaviors in military
settings. In total, 594 participants from ten different
military settings throughout Iran were included across all
stages of the study. The military settings were selected
using a simple random sampling method. Participants in
each setting were recruited as a sample of convenience.
Inclusion criteria were voluntary participation and at least
1 year of experience in the military.
All participants signed an informed consent before
entering the study. The survey was approved by
institutional review board of the Iranian Department of Military
Research. The study was conducted during a 2-month
period from October to December 2012.
Development of the scale
The method described by Emami et al. [
] was used to
develop and test the scale. This method involved six
phases: (1) identify items by a comprehensive literature review
and use of experts; (2) assess the face and content validity
of items in the initial draft by experts; (3) backward and
forward language translation of the scale; (4) assess
reliability; (5) evaluate content validity by pilot testing; and
(6) develop the final version and use this version in a large
As a first step, a panel of experts was formed. This panel
comprised four health education specialists, two nurses
with a background in research and in PH, two nurses and
one physician with experience caring for soldiers in
military clinics, an expert in instrument development, and a
statistician. Five members of the panel were bilingual in
Farsi and English, and almost all were familiar with the
English language. A comprehensive literature review
identified three scales related to the topic of the study (PH)
18, 28, 29
], but many PH domains were not contained in
these scales. The panel of experts decided to add more
items to cover the missing domains, leading ultimately to a
total 21 items that covered all of the relevant domains of
PH, as agreed to by consensus of the panel.
As a second step, the face validity of the scale was
evaluated using the impact score method. As described by
Anastasi, this type of validity refers to what the scale seems
to measure?not what it factually measures [
]. A number
of untrained observers which were part of the target
population were asked to examine the scale. To this end, 20
questionnaires were distributed to members of the target
group (military personnel) with the request that the
recipient rate the importance of each item on a Likert scale
ranging from 1 (not at all important) to 5 (very important).
This method was used to calculate impact scores for each
item by multiplying the percentage of participants that
indicated 4 or 5 for an item by the mean score of
importance. All items with an impact score of [1.5 were retained
in the scale [
]. In addition, during a 60-min session
involving ten military personnel, the relevancy, ambiguity
and difficulty level of each item were discussed. All 21
items were retained, and only minor wording changes were
made to improve item clarity.
We next examined content validity using the content
validity index (CVI) and content validity ratio (CVR). This
was done by sending the draft scale to ten other specialists,
including three experts in health education, four in nursing,
and three in public health. The CVI based on simplicity,
specificity, and clarity of items was assessed by this panel.
A CVI score of C0.79 is considered to be acceptable. The
CVR, a method initially proposed by Lawshe, evaluates
agreement between raters on how essential the items are to
the scale. When more than half of the raters indicate that an
item is essential, the item is considered to have acceptable
content validity. In this study with ten expert raters, a CVR
of C0.62 was considered to be acceptable [
The third step consisted of translating the scale into
English by two bilingual researchers and then
back-translating the English version into Farsi by two independent
translators without previous exposure to the original scale.
Agreement between the backward and forward translations
was determined. This step is known to assist in
international comparisons of scales [
]. Readability of the
English version was determined using the Flesch Reading Ease
(FRE) method and determining the Flesch?Kincaid Grade
(FKG) Level index using Microsoft Word software
(Microsoft, Redwood, WA). We used a 100 point measure,
with higher scores indicating greater ease in readability
(FRE). A score of [60 is considered to be acceptable. The
FKG indicates the grade reading level for the scale [
In the fourth step comprised an assessment of the
stability of the scale stability in which 2-week test?retest
reliability was determined in a sample of 20 military
personnel using the Spearman correlation. Internal consistency
was determined by calculating Cronbach?s alpha and the
item?total score correlation. To further assess content
validity of the scale, we also asked 30 military personnel to
complete the Farsi version of the scale; the English version
was also examined in 12 military personnel who were
bilingual in Farsi and English. Comments by these groups
were used to further improve the readability and clarity of
items on the scale in these two languages.
Finally, the resulting scale was used to assess PH
behaviors in a separate group of 502 military personnel
(main sample), with the sample size calculated using
Cohen?s tables for descriptive studies. The construct
validity of the scale was examined using exploratory factor
analysis, the principal component method with varimax
rotation was utilized to extract factors, the Kaiser?Mayer?
Olkin (KMO) test was used to assess the adequacy of the
sample, and the number of components was determined
based on the Kaiser?Gutmann rule and on a diagram of the
scree plot. Bartlett?s test of sphericity examined the
multicollinearity of scale items. A confirmatory factor analysis
(CFA) was performed to assess the dimensionality of the
model, and model fitness was determined using the root
mean square error of examination (RMSEA), the
comparative fit index (CFI), and the goodness-of-fit index (GFI).
SPSS for Windows ver. 20 and its add-on module
AMOS (SPSS Inc., Chicago, IL) were used for the
statistical analyses. Mean, standard deviations (SD), percentage,
and frequency were used to describe the data. The Student
t test was used to assess discriminative and convergent
validity. The Spearman correlation between the score on
the PH scale and health status was computed. All analyses
were considered to be statistically significant at a p B 0.05.
Description of the scale
The PH scale which we have developed and tested is a unique
and unprecedented measure to assess PH behaviors
considered to be particularly important for preventing infectious
diseases. It contains items on 11 main areas of PH that are
recommended by the World Health Organization (WHO)
and UK Department of Health [
], including oral hygiene
(4 items), bathing (3), hand washing (2 items), hair care (2
item), nail care (1 item), foot care (1 item), wearing clean
clothes (2 item), respiratory hygiene (2 item), attention to
body odor (1 item), eye care (2 items), and ear care (1 item).
These 21 items were selected from a pool of items extracted
from existing scales as well as items suggested by our expert
panel. Respondents are asked to choose from one of four
options ranging from 0 (never) to 3 (always) for each item
(see Appendix 1). The total score is arrived at by summing
the scores of all 21 items and ranges from 0 to 63. Higher
scores indicate better PH behaviors. There is no
recommended cutoff score for the scale at this time.
We also assessed such demographic characteristics as
age, marital status, number of children, educational level,
background diseases, and sources of information about PH.
In addition, participants were asked to rate their current
health status on a horizontal line from 0 (very poor) to 100
All participants were males. Mean age of the main sample
(n = 502) was 33.04 (SD 6.83). More than 80 % were
married. Only 14.8 % had received a post-graduate
education. Average time in the military was 13.54 years (SD
6.29). More than 90 % reported no illness at the time of the
survey. TV and radio were the most common sources of
information on PH. The mean health status score was 86
(SD 14.9), and the average score for the PH scale among
participants was 44.17 (SD 10.05). Table 1 provides
detailed information on the demographic characteristics of
the pilot sample and main sample.
Validity and reliability of PH scale
In the assessment of face validity using the impact score
method, no score was \1.5 per item, and so all items were
included in the PH scale. The CVI and CVR were 0.83 and
0.78, respectively. Scores on the readability indices for the
English version were acceptable (FRE 86.9; FKG 3.7). The
scale?s Cronbach alpha in step 4 was 0.82; the 2-week test?
retest reliability in this step was 0.88. Internal consistency
was also approved in the main study among the 502
participants (a = 0.89). The KMO index (construct validity)
was 0.91, which is acceptable. The Bartlett test of
sphericity was significant (p \ 0.001), and there was no
evidence of multicollinearity between items. Both the Kaiser?
Gutmann rule and the scree plot showed a single dimension
for the scale. The eigenvalue for the first factor was 12.49,
and this one-factor solution explained about 59 % of the
variance of the PH scale score. The values for the
communalities of shared variance were [0.50. The CFA
confirmed a single-factor structure for the PH scale and
Table 2 Descriptive analysis, item reliability, and factor loadings of
the personal hygiene scale (n = 502)
demonstrated good fit for the model (GFI 0.902; CFI
0.923; RMSEA 0.0085). Descriptive analysis and validity
and reliability psychometrics for the PH scale are presented
in Table 2. A significant correlation (r = 0.29, p \ 0.001)
was found between the PH scale score and the self-rated
health status score, thereby providing some support for
convergent validity. Other indicators of convergent and
discriminant validity are presented in Table 3.
Here we describe the development and testing of a new
scale to assess PH behaviors in military settings (which
might also be useful in other group settings). The results
support the validity and reliability of the scale and its
The scale was developed using a multi-stage procedure
used previously in establishing the psychometric properties
of another new scale [
]. Two approaches are suggested
when developing a self-rated scale for use in a different
culture. First, a new scale may be developed, but it must be
assessed using empirical data, and a solid theoretical
rationale must exist for the scale?s content. A second
approach involves translating a pre-existing measure into
the target language using assistance from specialists [
Although the former is difficult and time-consuming work,
in our case there was no scale currently available to assess
PH behaviors, forcing us to develop a new scale.
Guidelines have been published to assist researchers in
developing new scales. For example, Cotrell and Mckenzie
proposed a 14-stage framework for developing new
measures in health education and promotion programs [
Other researchers have developed a 12-step procedure for
developing a new scale for use by healthcare professionals
]. Our study followed a six-stage protocol for
developing the PH scale, and our results indicate that this
approach was successful.
Principal component analysis revealed that the PH scale is
a uni-dimensional scale; this result was further supported by
the CFA. Although our PH scale is assessed here using
questions that focus on hygienic behaviors with regard to
different parts of the body (e.g., mouth, eyes, ears, hands, and
feet), these behaviors are correlated with the overall concept
of PH [
]. Many studies have found that subjects who pay
attention to their PH in some parts of their body parts are
usually attentive to have good PH in other parts of their body
as well [
6, 8, 10
]. Thus, the one-factor structure of the scale
also appears to be logical from a theoretical perspective as
In terms of the psychometric properties, the Cronbach?s
alpha in both studies (pilot and main study) were
acceptable ([0.7), thereby supporting the internal consistency of
the scale. The high test?retest reliability coefficient also
confirms the reliability of the scale. We also assessed scale
validity using several methods. Both face validity and
content validity were established. Factor analysis also
demonstrated a fit structure for the scale. A scale is also
expected to have good construct validity, as evidenced by
good convergent and discriminant validity, as we
]. We predicted that a person who shows respect
for their PH will also have a better health status, which we
have now demonstrated using the PH scale. Such
relationships have been found in similar studies [
The PH scale takes only about 10 min to complete.
Tests of scale readability also demonstrated that it was easy
to read at the level of a 4th grader. The completion rate of
participants in the main study was about 96 % with almost
no missing data, supporting the ease of scale
administration. We therefore conclude that this scale is brief and easy
to complete and that it assesses important dimensions of
PH that most military personnel can identify with.
Overall, respondents in the main study reported moderate
levels of PH behaviors, suggesting that such behaviors are
generally recognized by military personnel as being
important. However, this assessment represents an average, and
there were numerous soldiers with either superior or low
scores on the scale, indicating need for improvement. These
results suggest that educational programs are needed to
reinforce the need for military personnel to perform
behaviors to maintain their PH. The need for such an educational
approach is support by the results of other studies in which
some researchers report poor hygienic conditions among
military personnel that increase their risk of contracting
]. Two other studies suggest that negative
attitudes regarding various PH behaviors, such as
handwashing, are widespread among soldiers [
Little hygiene-related research has focused on military
personnel, making it difficult to compare the results of our
study with those of comparable studies in other
populations. Nevertheless, our findings underscore the need for a
better understanding of hygienic behaviors in military
troops or other occupational fields. Similar research could
be conducted in other high-risk populations, such as
healthcare professionals, food handlers, or workers in
difficult occupations, such as miners or farmers. Assessing
such groups using our scale could provide a rationale for
developing a program that addresses issues related to the
hygiene and self-care for these special groups in order to
improve the health of the whole community.
This study has several limitations which must be
considered when interpreting the findings. First, this scale
was developed and tested only for use in men. However,
many females are currently enlisted in military forces, and
their hygienic behaviors should also be monitored [
Our scale may also be useful in women, but this
possibility needs to be established in future studies. Second,
although we translated the scale into English, we did not
have access to a sufficiently large population of native
English speakers in which to evaluate the psychometric
properties of the scale. This will need to be established in
English-speaking populations in future studies. Third,
since no prior scale assessing PH exists, it was not
possible to establish the concurrent validity of the scale.
However, we used several other methods for establishing
the scale?s validity here.
In conclusion, our survey of PH behaviors among military
and other closed populations is needed to monitor behaviors
that are likely to prevent the spread of infectious and other
diseases. Assessment tools with solid psychometric
properties are needed. Om our study, we developed and tested a new
scale for monitoring PH behaviors among military
personnel. This scale may be used not only as a monitoring tool in
military and other settings for primary prevention, but it may
also be used in research studies that seek to establish
connections between PH and the transmission of disease in
population groups that work and live closely together.
Follow-up studies are then strongly encouraged in different
samples and cultures using this psychometrically sound
Acknowledgments The authors wish to thank Prof. Fazlollah
Ahmadi and Prof. Bradley J. Cardinal for their valuable comments on
developing the questionnaire. We are also grateful to the Iranian
Department of Military Research and Baqiyatallah University of
Medical Sciences for their support in conducting the study.
Conflict of interest The authors declare that they have no conflict
We are interested in information about personal hygiene
behaviors. Our hope is to identify potential problems in this
regard. Please circle one number for each item as it applies
Never Sometimes Often Always
I shower at least once a 0
I comb my hair at least 0
once a day
1. Aiello AE , Larson EL , Sedlak R . Personal health. Bringing good hygiene home . Am J Infect Control . 2008 ; 36 : 152 - 65 .
2. Holt GR . Importance of personal hygiene techniques in public health . South Med J. 2012 ; 105 : 5 .
3. Bland A , Mawson L , Burden S. Developing healthcare skills through simulation . London: SAGE Publications; 2012 .
4. UK Department of Health. Essence of care: benchmarks for personal hygiene 2010 . Available from: https://www.gov.uk/ government/uploads/system/uploads/attachment_data/file/153464/ dh_119976.pdf.pdf.
5. Frey Rebecca J. The Gale encyclopedia of senior health: a guide for seniors and their caregivers . Detroit: Gale; 2009 .
6. Liao Q , Cowling BJ , Lam WW , Fielding R. The influence of social-cognitive factors on personal hygiene practices to protect against influenzas: using modelling to compare avian A/H5N1 and 2009 pandemic A/H1N1 influenzas in Hong Kong . Int J Behav Med . 2011 ; 18 : 93 - 104 .
7. Griffiths J . Meeting personal hygiene needs in the community: a district nursing perspective on the health and social care divide . Health Soc Care Community . 1998 ; 6 : 234 - 40 .
8. Weyant R . Interventions based on psychological principles improve adherence to oral hygiene instructions . J Evid Based Dent Pract . 2009 ; 9 : 9 - 10 .
9. Newton JT . Psychological models of behaviour change and oral hygiene behaviour in individuals with periodontitis: a call for more and better trials of interventions . J Clin Periodontol . 2010 ; 37 : 910 - 1 .
10. Parker L. Infection control: maintaining the personal hygiene of patients and staff . Br J Nurs . 2004 ; 13 : 474 - 8 .
11. Bloomfield SF . Home hygiene: a risk approach . Int J Hyg Environ Health . 2003 ; 206 : 1 - 8 .
12. Aiello AE , Coulborn RM , Perez V , Larson EL . Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis . Am J Public Health . 2008 ; 98 : 1372 - 81 .
13. Miko BA , Cohen B , Conway L , Gilman A , Seward SL , Larson E. Determinants of personal and household hygiene among college students in New York City, 2011 . Am J Infect Control . 2012 ; 40 : 940 - 5 .
14. Mbawalla HS , Masalu JR , Astrom AN . Socio-demographic and behavioural correlates of oral hygiene status and oral health related quality of life, the Limpopo-Arusha school health project (LASH): A cross-sectional study . BMC Pediatr 2010 ; 10 .
15. Barretto EPR , Pordeus IA , Ferreira EF , Paiva SM . Quality of infantile life: influence of the habits of oral hygiene and of the access to the dental services . J Dental Res . 2003 ; 82 : 205 .
16. Fewtrell L , Kaufmann RB , Kay D , Enanoria W , Haller L , Colford JM . Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and metaanalysis . Lancet Infect Dis . 2005 ; 5 : 42 - 52 .
17. Turabelidze G , Lin M , Wolkoff B , Dodson D , Gladbach S , Zhu BP . Personal hygiene and methicillin-resistant Staphylococcus aureus infection . Emerg Infect Dis . 2006 ; 12 : 422 - 7 .
18. Timmer K , Bock E , Tumena T. Personal hygiene assessmentsimple instrument for the assessment of personal hygiene . Z Gerontol Geriatr . 2004 ; 37 : 51 .
19. Burford B , Hesketh A , Wakeling J , Bagnall G , Colthart I , Illing J , et al. Asking the right questions and getting meaningful responses: 12 tips on developing and administering a questionnaire survey for healthcare professionals . Med Teach . 2009 ; 31 : 207 - 11 .
20. Wardell DW , Czerwinski B. A military challenge to managing feminine and personal hygiene . J Am Acad Nurse Pract . 2001 ; 13 : 187 - 93 .
21. Linton DS . ''War dysentery'' and the limitations of German military hygiene during World War I. Bull Hist Med . 2010 ; 84 : 607 - 39 .
22. Surgeoner BV , Chapman BJ , Powell DA . University students' hand hygiene practice during a gastrointestinal outbreak in residence: what they say they do and what they actually do . J Environ Health . 2009 ; 72 : 24 - 8 .
23. Cowdell F. Older people, personal hygiene, and skin care . Medsurg Nurs . 2011 ; 20 : 235 - 40 .
24. [No authors listed]. Dental classification and risk assessment prevention of dental morbidity in deployed military personnel . Proceedings of an international workshop. Mil Med . 2008 ; 173 : 1 - 59 .
25. German V , Kopterides P , Poulikakos P , Giannakos G , Falagas ME . Respiratory tract infections in a military recruit setting: a prospective cohort study . J Infect Public Health . 2008 ; 1 : 101 - 4 .
26. Van Camp RO , Ortega HJ . Hand sanitizer and rates of acute illness in military aviation personnel . Aviat Space Environ Med . 2007 ; 78 : 140 - 2 .
27. Emami A , Momeni P , Hossein MA , Maddah SS . Developing a questionnaire for conducting cross-national studies-'Self-reported health and needs among elderly Iranians and Swedes' . Scand J Caring Sci . 2010 ; 24 : 372 - 9 .
28. Stevenson RJ , Case TI , Hodgson D , Porzig-Drummond R , Barouei J , Oaten MJ . A scale for measuring hygiene behavior: development, reliability and validity . Am J Infect Control . 2009 ; 37 : 557 - 64 .
29. Webb AL , Stein AD , Ramakrishnan U , Hertzberg VS , Urizar M , Martorell R . A simple index to measure hygiene behaviours . Int J Epidemiol . 2006 ; 35 : 1469 - 77 .
30. Anastasi A , Urbina S. Psychological testing. 7th edn . Upper Saddle River: Prentice Hall; 1997 .
31. Polgar S , Thomas SA . Introduction to research in the health sciences, 5th edn . Edinburgh: Elsevier; 2008 .
32. Cottrell RR , McKenzie JF . Health promotion and education research methods: using the five-chapter thesis/dissertation model, 2nd edn . Sudbury: Jones and Bartlett Publishers; 2011 .
33. Heilman CB . Readability of patient education materials . World Neurosurg . 2011 [Epub ahead of print].
34. World Health Organization. Personal, domestic and community hygiene (database on the Internet ); 2010 . Available from: http:// www.who.int/water_sanitation_health/hygiene/settings/hvchap8. pdf. Accessed 13 May 2013
35. Sakharova OB , Kiku PF , Gorborukova TV . The impact of social and hygienic lifestyle factors on health status of students . Gig Sanit . 2012 : 54 - 8 .
36. Avshits IV , Shirinskii VA . Health status hygienic assessment of primary military education establishment pupils . Gig Sanit . 2010 : 76 - 8 .
37. Buunk-Werkhoven YA , Dijkstra A , van der Wal H , Basic N , Loomans SA , van der Schans CP , et al. Promoting oral hygiene behavior in recruits in the Dutch Army . Mil Med . 2009 ; 174 : 971 - 6 .
38. Mehrabi A , Esmi N , Khubdel M. Soldiers ' knowledge on hygiene status in a military training center . J Mil Med . 2009 ; 10 : 293 - 7 .
39. Chalyi NN , Bazhenov VG . Experience with the health and hygiene and epidemic control support for the troops and the population under extreme situations (a review of the literature) . Voen Med Zh . 1994 : 14 - 7 .