Challenging Dogma - Fall 2007

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

Tuesday, December 11, 2007

The Best Laid Plans: Why the World Health Organization’s Hand Hygiene Campaign Will Fail – Matt Pappas

Imagine that you’re a young physician in a busy outpatient practice. You have only seven minutes with each patient and you’re booked through lunch. You leave one patient’s room, pick up the next patient’s chart, and knock on the door. Looking through the chart absentmindedly, you notice that Mr. Smith has asked you to come in, so you open the door. He extends his hand, and you reciprocate. In that moment, you have failed.

Hospitals are dangerous places. In 2002, according to the Centers for Disease Control and Prevention (CDC) (1), the U.S. saw 1.7 million health care-associated infections and almost 99,000 deaths associated with those infections. Methicillin-resistant Staphylococcus Aureus (MRSA) alone is responsible for over 18,000 deaths annually, with most of those cases contracted in the course of receiving health care (2). Handwashing has been known to reduce transmission of (specifically) staphylococci since the 1960s (3), and to reduce nosocomial infections for over 150 years (4). The problem with handwashing is inconsistency: health care workers simply don’t wash their hands often enough.

The World Health Organization (WHO) is in the midst of what it calls an “unprecedented global initiative” to address handwashing among health care workers. It’s hard to fault their thoroughness: they have leaflets, instruction sheets, brochures, situation analysis grids, a 64-page guide and a 40-page manual, all designed to get physicians to undertake the simple task of washing their hands.

What they don’t have are the makings of a successful campaign. Unfortunately, the WHO’s approach will not improve health care worker handwashing because it fails to account for the paradox of choice, has not selected the best intervention for its target audience, and does not improve physicians’ sense of self-efficacy.

Simplicity is Everything

This “unprecedented global initiative” is really multiple programs; this distinction, however, is difficult to extract from the unwieldy names and labyrinthine organization. There’s the “Global Patient Safety Challenge,” the “World Alliance for Patient Safety,” the “Clean Care is Safer Care” theme (also called in some of the WHO’s literature a program in its own right), a “Multimodal Improvement Strategy,” pilot and complementary testing, task forces, an office called the “Joint Commission International Center for Patient Safety,” information sheets, leaflets, posters, banners, and a screen saver (5). The documentation is awash with consultant buzzwords, which aren’t clear to health care professionals. Such an information overload prevents the WHO from issuing a simple, clear message.

The methods are as complicated as the materials. One instruction sheet, obtained by writing to the WHO, portrays rubbing hands with a hand sanitizer gel as an 8 step process, with step 1 further subdivided into “1a” and “1b.” In this instruction sheet, the health care worker is told to:

Apply a palmful of product in a cupped hand, covering all surfaces, rub hands palm to palm, right palm over left dorsum with interlaced fingers and vice versa, palm to palm with fingers interlaced, backs of fingers to opposing palms with fingers interlocked, rotational rubbing of left thumb clasped in right palm and vice versa, rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa.

The problem of handwashing, though, isn’t the lack of rotational rubbing of the left thumb clasped in the right palm – it’s handwashing at all. By providing a 9-step process for hand sanitizing, the WHO has obfuscated the important step: use sanitizer. This instruction sheet is only one of several such documents incorporating instructions for handwashing and/or hand sanitizing, every one of them just as complicated.

This level of detail is counterproductive. As Iyengar and Lepper (6) found, too much choice frequently leads to indecision. They presented either six or 24 flavors of jam at a supermarket, and found that customers bought more jam when presented with only six varieties than when presented with 24. By providing so many messages and programs, the WHO is encouraging physicians to stop listening. Because of the “paradox of choice,” (7) health care workers presented with so many different slogans, instructions, and programs are more likely to remain at the status quo than if the WHO had proffered a single, clear message.

I Know What You’re About to Say

Furthermore, The World Health Organization’s focus on educating health care workers is inappropriate in the industrial world. Chin and Benne would categorize the WHO’s efforts as rational-empirical, focused as they are on education of the target audience. An approach aimed at persuading health care workers – Chin and Benne’s normative-re-educative category – would have been more appropriate. Western physicians know that lack of handwashing transmits disease. Semmelweis first badgered his employees into scrubbing their hands with chlorine in 1847 (4), and Lister published his seminal article on antisepsis in 1867 (9). After 150 years, continued efforts at education are unlikely to have dramatic impacts in the West.

This is not to say that gaps do not exist. One 5-year educational program improved awareness that touching patients without handwashing contributes to spread of antimicrobial-resistant pathogens from (a surprisingly low) 75% of health care workers to (a still surprisingly low) 82% (10). The industrial world is not immune to misconceptions. Still, a 7% improvement over five years is inadequate in a country with 1.7 million health care-associated infections (1). A normative-re-educative approach is better suited to the existing knowledge base of the western world, and more likely to have significant impacts than a rational-empirical approach.

Now, the WHO’s program has enrolled countries as disparate as the U.S. and Uganda. A rational-empirical approach may well be optimal in participating countries with less rigorous medical training or smaller health care expenditures. Such countries could see improvements far greater than 7% over 5 years from educational programs. The United States, though, is not among them.

Don’t Tell Me What To Do

In providing extrinsic solutions, rather than empowering health care workers to solve problems, the WHO does not provide health care workers with a sense of self-efficacy. As Ozur and Bandura have pointed out, self-efficacy is a critical component of behavioral change (11). Campaigns attempting to change a behavior as refractory as handwashing would do well to heed their work.

Indeed, in one of the few handwashing campaigns that seems to have succeeded in recent years, Jerry Sternin and colleagues have been using an approach called “positive deviance.” Positive deviance is intended to solicit suggestions for improvement from the target audience rather than imposing the conclusions of a consultant upon them (12). As Sternin described their approach later, “if we had any dogma going in, it was: Thou shalt not try to fix anything” (13).

It might seem odd to set out to improve handwashing by “not try[ing] to fix anything.” Still, the difference between this approach and earlier attempts isn’t what was attempted – replacing hand gel dispensers, placing sinks where they would be most convenient, and so forth – but who suggested those solutions. Something about changes suggested by members of the target audience, rather than an “outsider” (read: consultant) made the changes more likely to “stick.” Instead of fixing health care workers’ problems, the positive deviance approach encouraged health care workers to find and fix them.

Sternin and his colleagues, among other things, forced health care workers to improve their sense of self-efficacy. They persuaded physicians and nurses that the ability to improve handwashing practices was not only within their power, but also within their collective wisdom. They used self-efficacy to their advantage. The World Health Organization could stand to do the same.

This is not the End

In fairness, the WHO’s is not the first, and will not be the last, thwarted handwashing attempt. As penicillin has become passé, polio has been eliminated from the western world (and is nearing global eradication), as artificial hips and automatic defibrillators have come into practice, the simplest, best-supported intervention imaginable – consistent, rigorous handwashing – has proven to be one of the most difficult to implement. We still need satisfactory solutions. So handwashing improvement campaigns will continue. For now, a “positive deviance” technique, with well-considered, unambiguous messages focused on a normative-re-educative approach, appears most likely to be successful. Because the World Health Organization’s design incorporates none of these elements, its campaign will be only the latest in 150 years of impassioned but unsuccessful pleas to improve handwashing.


(1): Klevens RM et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports 2007; 122:160-166.

(2): Klevens RM et al. Invasive Methicillin-Resistant Staphylococcus Aureus Infections in the United States. Journal of the American Medical Association 2007; 298:1763-1771.

(3): Mortimer EA, Wolinsky E, Rammelkamp CH. The transmission of staphylococci by the hands of personnel (pp. 187-99). In: Maibach HI, Hildick-Smith G, ed. Skin bacteria and their role in infection. New York, NY: McGraw-Hill, 1965.

(4): Nuland S. The Doctors’ Plague: Germs, Childbed Fever, and the Strange Story of Ignac Semmelweis. New York, NY: Norton, 2003.

(5): The World Health Organization. WHO | The first Global Patient Safety Challenge. Geneva, Switzerland:

(6): Iyengar SS and Lepper MR. When Choice is Demotivating: Can One Desire Too Much of a Good Thing? Journal of Personality and Social Psychology 2000; 79:995-1006.

(7): Schwartz B. The Paradox of Choice: Why More is Less. New York, NY: HarperCollins Publishers Inc., 2004.

(8): Chin R and Benne KD. General Strategies for Effecting Changes in Human Systems (pp. 22-45). In: Bennis WG et al., ed. The Planning of Change, Third Edition. Holt, Rinehart and Winston, Inc., 1976.

(9): Lister J. Antiseptic Principle of the Practice of Surgery. The Lancet 1867; 90:353-356.

(10): Wisniewski MF et al. Effect of Education on Hand Hygiene Beliefs and Practices: A 5-Year Program. Infection Control and Hospital Epidemiology 2007; 28:88-91.

(11): Ozur EM and Bandura A. Mechanisms Governing Empowerment Effects: A Self-Efficacy Analysis. Journal of Personality and Social Psychology 1990; 58:472-486.

(12): Zeitlin M, Ghassemi H, and Mansour M. Positive Deviance in Child Nutrition - With Emphasis on Psychosocial and Behavioural Aspects and Implications for Development. Tokyo, Japan: United Nations University Press, 1990.

(13): Gawande, A. Better: A surgeon’s notes on performance. New York, NY: Metropolitan Books, 2007.

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