Altering hand washing behaviour

4th of July 2014
Altering hand washing behaviour

We are constantly being reminded of the role that hand hygiene plays in preventing the spread of illness. But studies show that many people – even those working in hygiene-critical industries – are still failing to wash their hands as often as they should.

So why is this the case? Hand hygiene and behaviour change experts gave their views at a recent conference held in London.

Dirty hands have been proven to be a leading cause of disease and death. And the simple process of washing the hands with soap after using the washroom and before handling food is a potential life-saver.

But though most of us know this, many of us are still neglecting our hand hygiene. Numerous studies have been carried out regarding hand hygiene compliance among the public and in specific industries, and the results make depressing reading according to speakers at a recent hand hygiene conference.

Delegates at the London event, hosted by the Royal Society for Public Health, learned that in one observational study at a UK motorway services station only 32 per cent of men and 64 per cent of women were seen to wash their hands with soap after using the washroom.

A second survey carried out by the Food Standards Agency in 2002 revealed that 39 per cent of UK caterers would not routinely wash their hands after using the toilet, and only 48 per cent would wash their hands after handling raw meat.

And poor hand hygiene in healthcare institutions was claimed to be costing the UK’s National Health Service up to 1.2 billion euros a year, with 50 per cent of hospital-acquired infections considered to be preventable with the aid of an effective hand hygiene regime.

On a global level, the statistics were even more grave. Dr Valerie Curtis, a reader in hygiene at the London School of Hygiene and Tropical Medicine, cited poor hand hygiene as a major factor in the 0.85 million deaths caused by diarrhoea worldwide every year.

Why so many of us are neglecting our hand hygiene is difficult to fathom. But experts at the conference - which took the theme: ‘The science and behaviour behind hand washing at home, work and on the move’ - attempted to solve it. Several of the speakers examined the motives behind poor hand hygiene compliance and considered ways of persuading people to change their hygiene behaviour.

According to Dr Curtis: “Hand washing with soap could save 650,000 lives a year globally. It could help prevent SARS, AIDS, cholera, pandemic flu and malnutrition. But one of the problems of persuading people to wash their hands is finding out what is preventing them from following good hand hygiene practices in the first place. Most of us live our lives on rails - and we need strong levers to help us change track.”

As co-founder of the Global Public-Private Partnership for Handwashing with Soap, Curtis and a team of hygiene experts tried various methods of persuading people to wash their hands in a series of international trials. Studies were carried out in the UK and in developing countries in Africa and Asia, and a range of arguments was used to motivate people to wash their hands.

These included: Hand washing is good manners; Poor hand hygiene can lead to infant mortality; Good hand hygiene leads to success in life; Everyone else washes their hands; and Poor hand hygiene is disgusting.

Motivating factors

“We found ‘Hand washing is good manners’ to be a powerful motivator,” said Curtis. “People were also likely to be persuaded to change their behaviour by motives such as disgust and a keenness to fit in. However, fear for a child’s life did not work as a motivator since mothers felt the threat was too far removed from them and that it wasn’t relevant.”

The topic of what motivates us to act was also examined by Claire McDonald, behaviour change project lead for the NHS. McDonald works with smokers, alcoholics and drug addicts to persuade people to change their deeply-entrenched habits. This can be difficult, she says, but it is not impossible.

“Smart external organisations are always changing our behaviour – and sometimes we don’t even notice,” she said. As an example she quoted the recent introduction of supermarket self check-out stations and airport self-service check-in machines. “These innovations have changed the way we shop and fly and we have accepted them without question because they also make our lives easier.”

In order to change a person’s hand hygiene behaviour it is crucial to understand them, said McDonald. “You need to find out how they live their lives and what is important to them. You also need to consider what comes easiest to them and discover what they consider to be the real and perceived barriers to hand hygiene.”

She said any call to action should be precisely targeted to capture the recipient’s attention when they are most likely to act. As an example, she quoted an NHS breast cancer campaign in which self-examination reminders were placed strategically in women’s shower cubicles and in labels stitched into bras.

“It is important to present the right information in the right place and at the right time to change patterns of behaviour,” said McDonald. ”Sometimes it is these simple things that can make all the difference.”

The idea of presenting the right message at the right time was also behind a recent Lifebuoy campaign to improve hand hygiene in developing countries. Anita Gopal, global social mission
manager of Unilever’s soap brand Lifebuoy, told the conference that open-air festivals commonly held in India carried a high risk of spreading diseases through poor hand hygiene.

“In India these festivals are occasions where people gather to pray together and also to eat together – which they do using their hands,” said Gopal. “We wanted to spread the message that festival-goers should wash their hands with soap before eating.”

Since Indian roti bread forms the basis of much of the food served at Indian festivals, the company used a heat stamp to print the words: “Did you wash your hands with Lifebuoy?” on each roti. “This type of message can help to change behaviour at exactly the right moment,” said Gopal.

Talk about hand washing

Lifebuoy has now ‘adopted’ the Indian village of Thesgora as part of its Help a Child Reach Five campaign. The company is using various means to change hand washing behaviour in the village: for example, children are provided with fun materials to encourage hand washing practices while expectant mothers are taught in antenatal classes the importance of washing their hands before touching their babies.

Lifebuoy is also using a well-known Indian actress – Kajol – in an advertising campaign to persuade people to change their hand hygiene habits. “The idea is to get more people talking about hand washing,” said Gopal.

So hand washing behaviour can be changed through persuasive arguments, influential motivators and well-targeted campaigns. And if all else fails, try bribery says emeritus professor at the London School of Hygiene and Tropical Medicine Joy Townsend.

She quoted a study on hand hygiene compliance that was carried out over a four-year period in three Taiwan hospitals. This used several tools to effect behaviour change: strategically-placed hand sanitisers, staff training courses and posters at point of care.

But in order to make the argument even more persuasive, financial incentives were offered to units with outstanding performances while fines were threatened for non-compliance. As a result of these tactics, hand hygiene compliance at the three hospitals improved from 43.3 per cent in 2004 to 95.6 per cent in 2007.

Sometimes poor hand hygiene can simply result from a lack of available facilities, according to management committee member of the British Toilet Association (BTA) Gillian Kemp. She highlighted the fact that mobile workers such as delivery drivers, police officers and traffic wardens have no toilets or hand washing facilities available to them when out and about. And the problem was particularly difficult for drivers of large lorries according to Kemp.

“There tend to be few truck stops and service facilities in laybys, and there is also a lack of suitable parking for large vehicles in town centres,” she said. “The lack of available hand hygiene facilities is a particular concern since lorry drivers handle the goods that are delivered to the end user - or in other words, us.” The BTA has now begun a campaign to improve toilet and hand hygiene provision for lorry drivers in the UK.

But our motives behind poor hand hygiene compliance is usually more complex than a mere lack of facilities, says Claire McDonald. And discovering those motives is crucial.

“You need to respect the reasons why people do the things they do and find out what motivates them,” she said. “Perhaps they like to break the rules and are kicking against what they consider to be a nanny state, or perhaps they simply think a bit of dirt is good for them. We often have good reasons for doing the things we do, but we are not always rational in our decisions.”

She said other barriers to change could be the fact that hand hygiene is time-consuming, while some people might neglect to wash their hands when they can see no visible dirt. “We just have to figure it out,” she said. “The airports and supermarkets have been smart and they have worked out how to change our behaviour. That is all we have to do as far as hand washing is concerned.”


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