Challenging Dogma - Fall 2007

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

Monday, December 10, 2007

Wet, Wash, Lather, Rinse. Let’s Spread Hand Hygiene, Not Disease.-Fiat Vongpunsawad

What a simple step! It seems to be the easiest and the most effective way to sanitize our hands, but in fact, there are not very many who are compliant to this good and safe hand hygiene. The current facts stated that globally, the biggest childhood killers are diarrheal diseases. It kills over 2 million people annually (1). By the steps of hand washing with soap, especially after contact with fecal matter, diarrheal diseases can be reduced by 42-47% (2). Hand hygiene, or prevention of cross-transmission of microorganism, is possibly the most effective intervention that can be executed to reduce mortality and morbidity in children less than five years of age. Several studies have been shown that reducing the risk of contracting acute respiratory infections can be attributed to hand hygiene sanitation (3). But why don’t most people wash their hands when it is known that it is the right and safe procedure to follow? This is a question that public health workers (PHW) are continually trying to understand and figure out.
My public health critique will be in the area of hand washing hygiene in Southeast Asia in the refugee camps of Thailand. Currently, there is a lack of an intervention along the border of Burma and Thailand. There are currently 154,000 displaced Burmese refugees are currently living along the western border of Thailand in 9 camps; the sizes of these camps are about 3,600 to 48,000 people. The Burmese refugees are there primarily because of the military conflict that is happening in that country. They do want to return to the country only after the conflicts have been settled (4). The paper further stated, “The 3 most common sources of morbidity in these camps are respiratory infections, skin infections and diarrhea. All could be controlled to a greater extent with improved hygiene.” (4).

After having spoken with the author herself, McDougal recommended that in order to promote and establish a public health intervention, the focus should be on safe hand hygiene. There is currently a small program that is in place. The Thai government allotted and rationed soap to each of the families within the camp, but does not teach any of its members within the families how to use it, when and why. This critique will be assessing and suggesting many various ideas that can help not only this camp, but practically within any population group or setting, from the low-resources countries to the most affluent communities.

When washing hands, rinsing them with water is just not sufficient. Washing with soap, lathering the hands together for about 30 seconds, and then rinsing off again with warm water are the proper steps for safe hand hygiene. How easy is that? The spread of many infectious diseases such as the common cold, sore throat, chronic respiratory disease, flu, and even avian influenza, etc. are the main concerns of PHW throughout the world. “Public concerns about SARS (sever acute respiratory syndrome) and current efforts to identify community practices to respond to avian influenza outbreaks or pandemic influenza have returned hygiene concepts to the public sphere. Home hygiene and community hygiene are now recurrent themes in public health messages.” (5). Many of these diseases and germs are communicable and also preventable. They are easily spread from person to person through touching surfaces that are inhabited by these germs and bacteria. “Consistent environmental cleaning with detergent, especially of frequently touched objects is also recommended.” (5). The best way to prevent the contraction of communicable is clearly the practice of safe hand hygiene.

The actual process of hand washing takes about less than a minute. PHW in developing countries and low-resource communities suggested humming the tune of Happy Birthday twice while washing our hands. This would measure the appropriate length of time in hand washing. By performing this act correctly, one can kill and eliminate a great percentage of germs that are the major source of communicable disease. The public health intervention critique that should greatly change the behavior of people in correct hand hygiene promotion more are first, applying the diffusion of innovation theory. Second is the strategic placement of hand sanitizers in vast places of public settings. Third is by using the normative re-educative strategy by persuading the population to change the behavior.

Diffusion of Innovation Theory
The improvement of health literacy can be done using the theory of diffusion of innovations. This theory is defined as the “study of how, why, and at what rate new ideas and technology spread through cultures.” (6). “Many years of study of hygiene and hygiene motivation in different countries and theory drawn from multiple disciplines have led us to a new approach (7). The range of disciplines includes psychology, consumer science and marketing, which are effective in changing consumer behavior (8). We propose that for behavior to change, constraints in the environment need to be minimalized to facilitate change, and ingrained habits shifted through an understanding of behavioral motivations, not just biomedical models of disease causation.” (9). Another author cited that promoting proper hand hygiene is twice as effective when compared with the improving the quality of water supplies (although it has other benefits) and making water more available. (10).

Most people in developing countries and in poor communities (such as the Burmese refugee camps in Thailand) around the world do not have the luxuries that most Americans do such as cable television, paved roads, cellular phones, fine clothes, and among many other. Media is available through forms of posters, billboards, advertisements on local buses, televisions and radios. Currently, there is not much promotion at all using these kinds of media for health promotion such as hand hygiene. By applying the diffusion of innovation theory, one can facilitate a change in this public health intervention. The ideas and implications are to promote the explanation of how hand hygiene knowledge can spread through the community by using these media. Greater emphasis can be made in publishing pictures on poster boards of hands being washed with soap suds. Brief sentence can be given to promote the idea of hand sanitation. In these Burmese refugee camps, there are nothing like this going on. This change for improving hand hygiene needs to be in placed to prevent any spread of infectious diseases.

The downfall of the Thai government is that there is no support being given to making this a high priority. Local health workers in these refugee camps are spending most of the time in curative medicine, instead of preventative care. Through prevention, the chances of people contracting these infectious diseases can be prevented through knowledge and exposure of information. Instead of filling local clinics with patients, one way to ease the burden is filling the classrooms with people to educate them with safe hand hygiene.

Other than using the media, classes should be offered to inform the community about transmittable diseases. Local HCW can support the classes through promotions in public settings such as restaurants, public buildings, markets, or street signs. Instructional classes could be offered in school buildings after local children are out. One implementation would be that when parents pick up their children from school, local HCW can talk to the families about hand hygiene. Promotion and motivation of kids washing their hands before leaving school could be a safe way from passing on the germs they are exposed to throughout the day. When children wash their hands before meeting their care givers, this would prevent the spread of diseases from the school to the homes. A reminder would also be given to both children and parents to sanitize their hands when they arrive home. If this practice is in placed, the chances of spreading germs could be eliminated at that point in order for it to spread even more.

Another way that health literacy of hand hygiene could be promoted is by a brief commercial spots in the evening time in both the television and radios. People enjoy having television on at home during the evening time. A promotion of advertisements can be promoted by local stations to remind families to wash their hands before handling foods and meals. The wide spread of this knowledge can definitely be in placed, since there is none such that is currently happening. Through constant exposure of safe hand sanitation, this knowledge can be diffused to the homes of the people within the community. Good habits need to be instilled in young children. By encouraging young children to develop this good habit, the behavior will lead on to adulthood. This behavioral change could possibly be accomplished in young children. Thus, children can help influence the adults in the home by leading with example. The valuable knowledge is then spread.

Strategic Placements of Hand Sanitizers
Germs and bacteria are prevalent everywhere. There is no single surface on this earth that is not infested by them. Some are not dangerous to the human body, but there are many that are harmful to the human health. The challenge in the public health intervention is make sure that people do not contract the germs and bacteria that cause diseases. The only way that this can be prevented is through hand sanitation. Most restrooms in the developed countries and communities have soap dispensers that are near every water basin. Unfortunately, in developing countries and in poor communities, running water and soap are not present in restrooms. Are there any other ways to sanitize hands without the use of water and soap?

A study has shown that waterless hand sanitizers have generated enthusiasm that compliance by health care workers with hand hygiene will increase when compared with the consistently poor implementation of hand washing. Centers for Disease Control and Prevention concluded that alcohol-based hand rubs (AHR) are more effective than washing hands. It requires less time, no water, and can be made more accessible. (11). These waterless AHR are antiseptic and can be minimally applied by using only a small amount (3 ml.) It is applied to the hands and are rubbed together covering all the hand surface until the solvent is dried.

The introduction of AHR can significantly reduce the future incidences of children contracting communicable diseases and thus lowering the cases of morbidity and mortality of children from contracting diarrhea, skin infections, and upper respiratory infections. Waterless hand hygiene agents are an important and promising addition to health promotions in the battle against to prevent transmission of pathogenic microorganisms to vulnerable children and other nosocomial infections. (12).

Introduction of AHR can be presented to children and adults alike. Right now in Southeast Asia, the focus is currently on soap awareness and soap-making. If local HCW along with other Non-Government Organizations can couple and integrate in team efforts to introduce the AHR, there can definitely be some positive changes in the health of the refugees. Several studies have shown that artificially contaminated hands with various micro-organisms can be eliminated by using AHR. AHR is more effective in than its counterpart of hand washing with unmedicated or antiseptic soap. (13).

The critique is that there are no AHR dispensers in public areas. These dispensers are cost effective and can easily refillable. The placement of these AHR dispensers can be strategically placed in schools, outside public wash rooms, inside restaurants, and other public settings. If the AHR are introduced, the compliance of using it could possibly go rise since the length of time when applying AHR till evaporation takes less than 30 seconds. One limitation on the use of AHR is such that it does not eliminate hand washing completely, it merely is a complement to hand hygiene. Developing the habit of hand washing is still critical and important, but AHR do not replace this behavior. Also, AHR are not effective in disinfecting and eliminating bacterial spores. (14).

Coupled with hand washing, AHR serves as an effective regimen in maintain hand hygiene. If the introduction of AHR is present in refugee camps, more people will be using it since the resources for clean running water may not be adequate. Only in situations where water may not be as abundant, teaching people to use AHR may be the simplest way from cross contamination of diseases. Promotion of AHR can be funded by NGO by giving out small bottles that people can carry around in pockets and around the necks. The important factor to this possible successful intervention is the ease of accessibility to the AHR. They must be ever present for compliance to increase, meaning that it has to be everywhere for people to use. Many studies have been shown that frequent use of AHR will eliminate transmission of bacteria. The use of AHR will improve the health of children more.

Normative Re-educative (Persuasive) Strategy
Since the intervention of hand sanitation so far covered the diffusion of innovation theory where the public is exposed to advertisements and having strategic placements of hand sanitizers, another way to reinforce the change in behavior is the implementation of normative re-educative strategy, (a technique that persuades the greater population to develop a change in behavior.) This is done through persuasion to the greater public that will reinforce them through education. People can be greatly influenced through teaching the facts that hand sanitation is crucial in maintaining a good health and prevention of transmittable diseases.

One persuasion method is by informing the population about the benefits of preventative care of hand hygiene with less visits to the medical clinics. Most do not enjoy going to the clinics because of the rising cost of medical care. Going and seeking medical assistance can come at a great financial burden and cost. The preventative measure through this is by persuading that hand washing and the use of AHR often can prevent the unnecessary trip to the clinics. Most refugees in this rural area are not wealthy and do not have much income. By applying the normative re-educative theory, the public health officials can persuade the population that sanitizing their hands can prevent the trip to the clinics.

How will the public health officials effectively persuade the general public? Since it was mentioned in the first argument that most people in the refugee camps see billboards and advertisements mostly, conveying the idea of hand hygiene to them would have to be very concise and very powerful. Pictures and of real life people will be portrayed instead of cartoon pictures because the association to people have been shown to have greater compliance. These pictures would represent a happy family setting where soap or AHR would be pictured as well. Captions would convey the idea that happiness in the family and home can originate from healthy clean hands.

Another way of persuasion is to have the NGO subsidize the cost of soaps and AHR. This would encourage the local HCW to promote the use of hand hygiene easier and better. By persuading that the cost of soaps and AHR are far less than its actual cost, this may somehow promote the adherence and compliance of hand hygiene. Persuasion through the media of television commercials, use of posters and billboards, teaching local HCW to teach the community, and making sure that AHR are strategically placed can influence the adherence use and behavioral change within this community.

Soap comes in different colors, scents, shapes, and sizes, but its function is still ever the same: to clean. Life in the refugee camp can be better when sicknesses are alleviated and its members maintain healthy life. To help lower the prevalence of diarrhea in children and the spread of transmittable communicable diseases, the best solution to this would be to practice hand hygiene. The hardest part of helping its members understand that having a clean hand is closely associated with a healthy life is letting the community know that it works and it can help. With its current situation, there is not much promotion to hand sanitation in the camps. This critique is some what a suggestion of an intervention that could be in placed. This is a new trek that is being made in this field by applying the behavioral change to this part of the world. Not much work has been going on in the refugee camps when it comes to assessing and critiquing what is currently happening therein to the topic of hand hygiene. This paper is to critique that not much work is being put forward and it is to create awareness that the problems can possibly be solved if hand hygiene is introduced to the refugees. It has been known through many scientific researches that the use of anti-bacterial products can significantly reduce the chances of transmitting disease. Why not use this knowledge and pass it along?

The promotion of the idea that using soap and AHR in the public health field is still a challenge. There is no monitoring or evaluation that is currently in placed within the refugee camps. One small way that this can be done is by measuring the sales of the soap in the local shops in rural areas and how much by volume is AHR being used in public dispensers. It still comes down to the individual to determine if one will apply hand hygiene or not. There is no one that can fully reinforce or force to general public to use soap, but through proper promotion and effectiveness of the diffusion of innovation theory, strategic placement of AHR, and trying to change one’s behavior through the normative re-educative theory. With these three, some improvements could possibly be made. Lives can be saved in the refugee camps when hand sanitation is practiced. By stopping the spread of various communicable diseases and infections, a motto or slogan that can be applied for this possible solution is, “Let’s spread the knowledge, not disease.”

1. Black RE, Morris SS, Bryce K. Where and why are 10 million children dying every year? The Lancet 2003; 361: 2226-34.

2. Curtis V, Cairncross S. Effect of washing hand with soap on diarrhea risk and in the community: a systematic review. The Lancet Infectious Diseases 2003; 3: 275-81.

3. Ryan MAK, Christian RS, Wohlrabe J. Hand washing and respiratory illness among young adults in military training. American Journal of Preventative Medicine 2001; 21: 79-83.

4. McDougal, Lotus. Case Study: Burmese Refugees in Thailand. Boston University School of Public Health. 2007.

5. Nicolle, Lindsay. Hygiene: What and why? Canadian Medical Association Journal March 13, 2007; 176-8.

6. Wikipedia. Acquired on December 10, 2007.

7. Curtis V. Hygiene: how myths, monsters and mothers-in-law can promote behavior change. Journal of Infections Control 2001; 43:75-9.

8. Buchholz A, Wordeman W. What makes winning brands different the hidden method behind the world’s most successful brands. Chichester, UK: Wiley and Sons. 2001.

9. Scott B, Curtis V, Rabie T, Garbrah-Aidoo N. Health in our hands, but not in our heads: understanding hygiene motivation in Ghana. Oxford University Press. Health and Policy and Planning 2007:22:225-233.

10. Curtis Val. Water, sanitation, and hygiene at Kyoto. British Medical Journal 2003; 327:4-5.

11. Pittet D. Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerg Infect Dis 2001; 7:234-40.

12. Langley J. Commentary: Waterless hand hygiene—if there’s a will, there’s a way. Pediatric Infectious Disease Journal 2002; 21:496-7.

13. Girou E, Loyeau S, Legrand P, Opein F, Brun-Buison C. Efficacy of handrubbing with alcohol based solution versus standard hand washing with antiseptic soap: randomized clinical trial. British Medical Journal 2002; 325; 362-.

14. Rotter ML. Arguments for alcoholic hand disinfection. Journal of Hospital Infections 2001; 48 (Suppl. A):S4-8.

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