Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Sunday, April 20, 2008

Hand-Washing Campaigns : The Failure Of Public Health Communication Approach - Viviane Kamba

Good hygiene is essential to the public health mission of reducing the
transmission of diseases. Around the globe, hand-washing (HW) has been
identified as a highly effective way to limit the transmission of a range of
diseases(1). In our noisy world of competing messages aimed at people from all
directions, only the most effective campaign will lead to behavior change(2).
Improving HW practices remains one of the central challenges for the public
health community in the 21st century.

Barriers to HW are multi-dimensional in nature. Current knowledge- based HW programs do not adequately address internal and external barriers that influence people’s daily activities. Health interventions are intended to generate concrete results. Unfortunately, by neglecting to incorporate social sciences and industrial marketing principles into their messages, these interventions have generally failed. HW is a low-tech and a low cost health prevention measure that can improve the lives of millions of people(3). However, effective change in behavior is often expensive, time consuming and can result in partial or complete non-compliance. As simple and easy as it looks as a solution, HW is not always effectively implemented in health care settings, in the food industry or in the community. HW promotion campaigns have not failed because public health authorities have bad intentions but because they have been using the wrong approach. Specifically, although public health’s typical ways of communicating in campaigns, in training sessions, videos, pamphlets, posters e.g., have proven to be powerful tools for educating the population, they have not been strong enough to result in healthy behavior because they fail to examine the Psycho-socio-cultural environment or logistical barriers.

Public interventions like the “5 million lives campaign” to reduce Methycillin Resistant Staphylococcus Aureus (MRSA) infections (4), or the “wash your hands Florida” campaign ( do not sufficiently address the fundamental problem. The failure is due to the message emphasis on promoting the knowledge- based traditional Health Belief Model approach to behavioral change which increases people awareness and assumes rational decision making. Unfortunately, the messages do not address real social and psychological issues that influence health. In addition, they seek to intervene at the individual level of risk, rather than at a more comprehensive population-level.

Regardless of how conscious people are about HW, food workers and health care workers, for example, have mentioned time pressure, having to complete multiple tasks, lack of hot water or sanitation solutions, work environment and facilities design as factors that interfere with proper and frequent HW. While some workers blame their employers for the lack of HW training, others referred to the public health trainings available as just a “memorizing subject” that generate little or no impact on behavioral change. Even if the overall role of education and training is a factor frequently identified as an influence in changing behavior, public health interventions may be more effective if perceptions, history, culture and other societal factors are considered. Developing an understanding of how these factors can be incorporated in HW campaigns is critical.

Much of the current HW messages in schools, health care facilities and food businesses rely on the assumption that providing information will result in a change of behavior. However, research (5) suggests that knowledge alone is not sufficient and that other behavioral models should be considered in the design and implementation of educational programs. One example is the ecological model approach by Kenneth R. McLeroy et al which promote healthy behavior by taking into account socio-cultural environment factors and emotions surrounding people’s behavior(6). Based on this theory, public health programs should seek to improve the success rate of their health interventions and accept that people are vulnerable to social influences.
When exploring innovative ways to minimize or eliminate barriers, public health should always incorporate the underlying and powerful factors of people‘s culture. For example, some of the reasons people from different cultures and social backgrounds have given for failing to regularly wash their hand include: “ Soap makes luck run away (Senegal)”, “ Soap irritates hands”, “ Soap dries hands”, “ The scent in soap makes some people uncomfortable” and according to the Ganda culture (Uganda), one should not wash one’s hands before touching a child(2). These diverse beliefs can explain how, particularly in large cities, cultural differences, language diversities and geographical barriers may result in public health messages being altered, or simply ignored.

A more qualitative approach of focus group dialogue that highlights the details of these barriers in the community should be included in the development of educational programs. Integrating all these data may seem sensitive and
challenging, but it will effectively contribute to a broader understanding of
effective HW strategies and reduce the risk of infectious diseases(7).
Infection control campaigns seem to rely on hand-on training
programs, particularly in hospitals and food businesses, assuming that they are the most effective way to produce healthy behavior. But, as mentioned
earlier, these arguments have proven to be weak. With education as their main focus, public health has neglected to include the broad range of internal and external factors surrounding people’s choice of behavior. Implementing HW requires more than knowledge alone. The combine efforts of schools, the health care industry, the food industry, the soap industry, the media, the government, and others can better address and improve the infrastructure that is required to support and sustain good hand hygiene behavior.

A collaborative effort by all these groups must apply the expertise of social sciences in order to close the gap between socio-cultural differences and allow everyone to understand the common benefits of good HW practice. Correcting inaccurate information and improving work environments, especially in the health care and the food industries, would help strengthen and improve the employers and the employees’ management and organizational skills in order to reduce the failure to wash hands due to insufficient time, heavy workloads, understaffing, the lack of supervision or strict HW protocol.

The countervailing Locus Model (BUSB721Spring2008 Pink team’s alternative model) can surely provide a way to acknowledge and balance these internal and external factors. People’s intentions and behaviors are shaped internally by knowledge, intelligence, priorities, self-efficacy and self-worth, perceived susceptibility and severity, values, individuality, pleasure, and are surrounded externally by social norms, social support, economic status, culture, education, physical environment, mass media, and government (8). Through this intrinsic and extrinsic perspective, public health HW programs can implement innovative interventions with a more focused approach that can uncover a range of factors specific to particular communities. Using product labeling as a mass communication tool and advertising channel, public health campaigns and the soap industry can ensure that the HW message is carried on all HW related products. Food companies could as well be encouraged to carry the message on a variety of food items to constantly remind people to wash their hands before eating or preparing food. Public health should strongly advocate for, and commit to improving the involvement of stakeholders such as schools, the soap industry, the media, the government and many others. To prioritize this complex issue, public health should reframe the HW message and sell it as a population- level initiative. This approach would correct the weaknesses of an educational and individual-based approach and coordinate the HW program based on the integrated relationship between internal and external factors existing in the population.

In real life, it is common for certain people to have the ability to lead and influence the people around them, while many others simply seek to identify themselves with the most affluent people. Using celebrities, CEOs, managers, teachers, “popular” kids in schools has proven to be useful when marketing innovative behavior. Their involvement in HW campaigns would help promote good HW behaviors. Using positive role models works because they tend to be able to communicate strong message without triggering rebellious attitudes. This approach has shown to be especially effective among the youth who are often neglected by public health interventions.

Instead, public health has tended to targets new employees, students, nurses, and other hands-on-staff. In addition, by assuming that higher ranked employees have already adopted the behavior, public health has minimize those employees susceptibility to the risks of being the causal agent or the receptor of communicable diseases and has also missed the opportunity to take advantage of those employees’ potential role and powerful influence as leaders.
The theory of Diffusion of Innovation is based on the tenets (9 ) that people tend to adopt new behaviors over time and that a constant exposure to a pattern of certain behavior can motivate change. Without dismissing individual decision making, the theory stresses that the group dynamic is a significant factor in the adoption of new behaviors. To succeed, this principle will require the segmentation of the target audience into groups with similar social and cultural experience. Public health promoters will have to address the needs of each group in the target audience, keeping in mind that the target is at the group level not at the individual level and that each group will have different characteristics that will require different strategies. Regardless of how the focus groups are segmented in the community, public health interventions must ensure that the message is adequately addressed to all groups and should not ignore the positive or negative influence of the prominent figures in each category and determine what kind of influence they have over the group.

It is now clear that promoting HW by utilizing interventions that focuses solely on individual perceptions of susceptibility, severity, and benefits to motivate behavior modification distracts public health from seeing how different cultures with different values and beliefs heavily influence behavior practices. The countervailing Locus model and the Diffusion of Innovations model should be made a part of strategy concerning HW promotion. They address the necessary changes of fundamental behaviors by making it a social movement led by members of the community and by including all internal and external factors that characterize people. According to Braude, “Just as patient acceptance is the final factor in successful health intervention, so is acceptance of an information system by its intended users the final stage in successful information systems implementation.” (10) Thus, a qualitative approach of community dialogue would provide rich and detailed information necessary to improve public health communication approach.


(1) Clean Hands saves lives.

(2) Handwashing Handbook: Health in your Hands; section: 2 Understanding the Consumer,22-32

(3) Black RE, Morris SS, Bryce J. Where and why are million children dying every years? The lancet (2003) 361:2226-34.

(4) Griffin FA. 5 million campaign. Reducing MRSA infection

(5) McGuire, W.J., Input and Output Variables Currently Promising for Constructing Persuasive Communications. In Rice, R. & Atkin, C. (Ed.). Public Communication Campaigns. 3rd Ed.
(6) An Ecological Perspective on Health Promotion Programs by Kenneth R. McLeroy, Daniel Bibeau, Allan Steckler, Karen Glanz
(7). 2001 Green, L., Selman,C., Radke, V., Ripley, D., Mark, J., Reimann, D, Stigger, T., Mottsinger, M., & Bushnell, L. (2006) Food worker handwashing practices: An observational study. Journal of food protection , 69, 2417-2433.

(8) Walker, O.C. Jr (1972), "The effects of learning on bargaining behavior", in Allvine, F.C. (Eds),1971 Combined Proceedings, American Marketing Association, Chicago, IL

(9) Rogers, E. M. (1983). Diffusion of innovations (3rd ed.) New York: Free Press.

(10) Braude R. People and Organizational Issues in Health Informatics. Journal of American Medical Informatics Association 4(2): 150-151, April 1997.

Larson, E., & Kretzer, EK. (1995). Compliance with handwashing and barrier precautions. Journal of Hospital Infection, 30,88-106.

Lillquist, D.R., McCabe, ML., & Church, K.H. (2005). A comparison of traditional handwashing training with active handwashing training in the food handler industry. Journal of Environmental Health, 67 (6), 13-16

Dubbert, P.M., Dolce, J., Richter, W., Miller,M., & Chapman, S. (1990). Increasing ICU staff handwashing: Effects of education and group feedback. Infection Control Hospital Epidemiology, 11,191-193.

Ehiri, J., & Morris, G. (1994). Food safety control strategies: A critical review of traditional approaches. International Journal of Environment Health Research, 4(3), 254-263.

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