Sustenance of Hand and Respiratory Hygiene Behaviors
Updated: Jul 30
It is not just COVID19, but respiratory infections like tuberculosis have long been the leading cause of illness, morbidity, and mortality across the world. The burden of respiratory tract infections has been estimated to contribute to more than four million deaths per year, with influenza infections accounting for an additional 250,000 to 500,000 deaths per year and a cost in the range of billions of dollars per year. Hygiene behaviors like cough etiquette and hand-washing have been well understood and acknowledged to serve as effective prevention strategies against such contagious diseases. Though vaccinations are still the cornerstone to prevent highly infectious diseases, hygiene behaviors provide strong interim measures to break or reduce the chain of transmission. Prevention of the spread of disease is critical in the realms of population disease management. It begins with the person infected by recognizing their symptoms, as well as the awareness of them and those around them to maintain the necessary standards of healthy hygiene.
There have been an array of interventions based on both behavioral science and design aimed to increase the uptake of good hygiene behaviors. Some of them are:
1. Environmental Nudges
Visible cues like painted walkways/footsteps from the area of contamination or possible disinfection to the hand-wash area are provided to reinforce hygiene behaviors.
Alleys/pathways from the toilets to the hand-washing stations have been painted with bright colors, in community toilets, and in school settings.
To increase positive valence good fragrance is maintained near wash stations or sinks
Water taps have been color-coded to indicate the intended purpose. For instance, different colors for drinking, washing, hand washing taps.
2. Threat/Disgust Messaging
Messages have been framed to elicit emotions of disgust or threat, which can act as a deterrent to risky behavior or facilitator of hygiene behavior “That’s pee you know, wash your hands” or visible posters that display graphic risks.
3. Comparison of Behaviors
Electronic hand hygiene monitoring and feedback system are being used to create dashboards to create comparison charts, and insights providing risk of infection associated with the hand hygiene data collected.
4. Hygiene Promotion
Promotion of good hygiene behaviors by leveraging source credibility such as the WHO guidelines for hand-washing and respiratory hygiene, or involving public figures who endorse and adhere to hygiene behaviors.
5. Educational Packages
Education programs that are both instruction and participation-based have been developed where hygiene messages are displayed and communicated, discussion sessions are held to understand scenario-based decisions, and student and staff are involved in regular hygiene activities.
6. Infrastructural Improvements
Hand-wash areas are maintained by checking leaky taps, wet surroundings, clean & repaired walls, and placing hand-washing taps away from the toilet areas to remove any physical constraints for access.
Placing sanitisers and hand-wash outlets at prominent and comfortable locations and near to the point of action.
7. Personas Reinforcements
Hand hygiene campaigns slogans like the one in Tanzania Mikono Yenye Fahari (“hands to be proud of”) intend to tap into the aspirations and identity of mothers/caregivers.
“SuperAmma” campaign created a loving and dotting “Super Mother” who is a forward-thinking rural mother teaching her son good manners and ensure they both adhere to hand-washing.
8. Rewarded Engagement
Hand-washing practice is encouraged among children by making it fun and goal-oriented with, for instance, making a colorful, translucent bar of soap with a toy embedded in its Centre.
9. Antecedents Awareness
Communication and messaging to make people aware of relevant antecedents for hand-washing behavior like coughing, using toilets, before having a meal, after playing, etc
Via IDinsight/Nhu Le
Via Roger Dooley
Via SAVE THE CHILDREN
1. Visible cues around acceptable behaviours
Use of audiovisual cues (often translated) to promote relevant respiratory hygiene practices in schools like showing how to sneeze or cough.
2. Preventing Face Touching
Providing access to gloves, tissues and other face touching alternatives to prevent coughing in open and cleaning of hands after coughing
3. Projecting Consequences
Use of static or dynamic illustrations to convey the movement of germs/viruses in the absence of proper respiratory and cough etiquettes, and the subsequent consequences
Via B&O Railroad Anti-Spitting card 1917
4. Making Spitting Anti-Social
Civil Society along with public health departments like the The New York City health department and private groups like the Women’s Health Protective Association, and the Brooklyn Anti-Tuberculosis Committee promoted anti-spitting slogans such as "Spitting Is Dangerous, Indecent, and Against the Law," "Beware the Careless Spitter," and "No Spit, No Consumption".
What is likely to work
Let us now look at some of the behavioral levers that can play important role to promote hygiene behavior
Memory: High working memory capacity improves executive attention, thereby helping focus oneself on their own goals and actions, which include response selection, action planning, dissolving distractions, and temptations that might hinder the goals.
Motivation: Intrinsic motivations and extrinsic motivations both can work well to increase the affinity towards desired health behaviors by means of goal development, goal attainment and purpose.
Regret: Imagining an unpleasant future in expectation may elicit emotion in the present. Individuals aim to reduce the regret they expect to experience in the future. Thus, anticipating regret from taking risky action should discourage them, while anticipating regret from non-adherence should encourage healthy prosocial behaviors.
Pride: Aspiration and Affiliation embedded in hygiene can instil a sense of pride and shared objectivity.
Environment: Peer groups and socio-cultural norms may force or signal socially desirable behavior as much as they can signal the opposite. Creating normative elements attached around hygienic and healthy environments can create positive externalities
Risk: Finding the right balance of risk is essential to develop fear and compliance, and not tread into hopelessness and abandonment.
Adoption and Adherence to Hygiene Behaviors
a. Positive Appreciation
Making cleanliness and hygiene behavior as the pre-eminent metaphors to express pleasantness, attractiveness, and good health can make “being hygienic” as a norm for appreciation.
b. Manage Impression
Creating reputational incentives for good hygiene such as the importance of first impression, cough etiquettes, and showing respect to others builds an invisible arbitrator of good behavior
c. Develop negative Reinforcements
Activities/Habits/Actions that elicit “disgust” can act as a strong emotion that can help individuals/groups to avoid infection. Increasing the vividness of disgust around unhygienic behaviors can help generate disease avoidance behavior.
d. Remove Environmental Constraints
Obstacles/barriers that may hinder adoption of prosocial hygiene behaviors must be removed to increase goal conduciveness.
e. Bridge the “Intent-Action” gap
Hygiene products must be made easily available to increase adoption of hand washing and respiratory hygiene behavior.
f. Create the appropriate antecedent stimuli
Efforts should be made to associate hygiene with general good health and safety, and not to anchor the routine as a fight against COVID19 in particular.
g. Acknowledge negative cues
Negative peripheral cues like discomfort associated with wearing masks should be acknowledged rather than denied.
h. Contextualize Recommendations
Individuals have to be communicated the contexts where the hygiene behaviors are expected to be performed so as to increase the relevance.
a. Visualize Risk
Individuals can be assisted in visualizing risk by creating standard markers of “hygiene-safety” like safety badges for people who wear masks.
b. Reduce behavior prioritization
Consistent communication on the need to adopt all hygiene behavior must be done to avoid the creation of any one "super-behavior" which can take care of all other hygiene behaviors.
c. Maintain temporal proximity to risk
Care should be taken that hygiene behaviors are communicated as disease-avoidance measures and not disease-cure measures so that individuals or groups do not indulge in risk compensatory activates.
As we start looking to develop more resilience against future pandemic outbreaks, sustainability of hygiene behaviors will become essential. Understanding the stickiness of these behaviors, and their relationship to the nature of a health crisis can improve policy response.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5256350/ https://apps.who.int/iris/bitstream/handle/10665/44148/9789241598323_eng.pd https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-13-811 https://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm https://journals.sagepub.com/doi/10.1177/1010539517751746 https://www.lshtm.ac.uk/newsevents/news/2018/six-common-types-disgust-protect-us-disease-revealed-first-time https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4646757/
WONG, V. W. Y., COWLING, B. J., & AIELLO, A. E. (2014). Hand hygiene and risk of influenza virus infections in the community: a systematic review and meta-analysis. Epidemiology and Infection, 142(05), 922–932.