Improving hand hygiene with posters that focus on shock and shame

CLICK to Email
CLICK for Print Version

Improving hand hygiene with posters that focus on shock and shame

Studies show that posters can improve hand hygiene compliance when branded with the right message

After reading this article, you will be able to:

  • Explain ways in which posters can improve hand ­hygiene compliance
  • Justify using messages that elicit shock or shame
  • Describe the importance of storytelling to achieve compliance


Advertising 101 will tell you that sometimes the best way to get someone's attention is to grab it with a visually intriguing image or a message that provokes some sort of reaction.

The same may be true for hand hygiene ­compliance. Many healthcare facilities use posters or signs that encourage healthcare workers to wash their hands, but those posters often go ignored or unnoticed if they convey the same message over and over again.

A recent study published in the May American Journal of Infection Control indicated that placing posters near alcohol-based hand sanitizers in a hospital cafeteria improved hand hygiene compliance in both employees and visitors.

Over a five-week period, posters were deployed throughout a cafeteria and subjects were observed during three random lunch hours.

"We focused on the cafeteria because it was an easy way to do observation," says Douglas Powell, PhD, associate professor of the food safety department and diagnostic medicine and pathobiology at Kansas State University in Manhattan, and one of the authors of the study. "It was an open setting so we could have a ­researcher sitting there at a table not looking ­obvious. And we wanted to do observation because when it comes to hand washing, surveys are pretty much useless. Anyone can lie."

A total of 5,551 participants were observed, and researchers found that hand hygiene attempts (i.e., removing gloves, if worn, and placing hands in running water) occurred more frequently after the introduction of posters and alcohol-based hand sanitizer into the environment. "We showed a modest improvement," Powell says, "although I don't think it's nearly enough to get where these places want to go in terms of reducing hospital-acquired infections."


Utilizing shock and shame methodology

To see drastic improvements, hospitals need to start taking risks and using public messages that shock healthcare workers into washing their hands, Powell says.

In the American Journal of Infection Control study, the hospital did not want to experiment with different posters for fear that they might offend an employee or visitor.

"We suggested more outrageous things, which we've done before," Powell says. "Our whole thing on hand hygiene is there are two main routes that work: shock and shame. Shock is the really gross thing like a poster of a little kid with snot running down his nose. Shame is the social embarrassment angle, and hospitals are really getting into that social embarrassment thing."

The trick, he says, is finding a happy medium between over-the-top offensive and boring to the point the poster might as well not exist. "I think if they want continued long-term improvement, you're going to offend some people," Powell says. "But at the same time you can't lull them into complacency with the usual ‘employees must wash hands' slogan. Figuring out that balance is a tricky thing to do."


Learning from the food industry

Previously, Powell and his colleagues published studies on hand hygiene compliance in the food services industry.

In a study published in the Journal of Food Protection in 2010, researchers sought to develop food safety ­communication tools in the form of info sheets that specifically targeted food handlers. The info sheets were designed to elicit shock by connecting an employee's actions with potential negative consequences. Through in-depth interviews of food handlers, researchers found that to be effective, food safety posters needed to be flashy and colorful, include pop culture references applicable to that demographic, and focus on a verbal narrative or the magnitude of foodborne illnesses and outbreaks. In short, they needed to be creative.

For example, some of the posters included:

  • A picture of a skull in a bed of lettuce with FDA warnings about an E. coli outbreak
  • A news story about a hepatitis A outbreak at an event catered for Hollywood celebrities
  • "Dirty Finger Al," featuring a picture of a man with a ­finger in his nose


Data showed that implementing these types of posters improved hand washing attempts 6.7%, while the number of correct hand washing events improved 68.9%.

"It works because it is shocking and attention-­grabbing, but our demographic here is not the entire population, the demographic is 18- to 24-year-old males who work in the food service industry," Powell says.


Using effective storytelling

Although these posters may not elicit the same responses among healthcare workers, similar rules concerning shock and shame apply to all populations. Ultimately, what forces people to pay attention is a visual image or message that generates a discussion among staff members.

Stories are usually the best way to elicit that reaction, especially if those stories can aptly show the consequences of poor hand hygiene in the healthcare environment. "The whole idea behind this with whatever poster you use is just to get people talking, to get them engaged in some sort of conversation, and the secret to that is coming up with stories," Powell says. "So not signs that say, ‘Thou shalt wash thy hands,' but instead you tell stories of what happened to other people when they didn't. No one wants to be preached at over and over again, but if you're telling engaging stories, that's the secret to many of these compliance issues."

For IPs, posters and info sheets are attractive because they are inexpensive and easy to use. They don't require a lot of time or energy from the IP, apart from finding a theme that sticks with doctors and nurses and serves as sufficient motivation to wash their hands before and after patient care. "The whole goal really is fewer sick people," ­Powell says. "Whether it's a hospital-acquired infection, ­whether it's something in a restaurant, you just want fewer sick people, so you want to figure out how to get people to pay attention."