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This research investigated the effects of descriptive prompts on the hand washing behaviors of restroom patrons. Outcome data were collected from two female and two male restrooms on a university campus. All four restrooms experienced three conditions: (1) baseline (no intervention); (2) posters prompting hand washing were posted; and (3) the display of posters focusing on the transmission and seriousness of influenza ("the flu") along with the previous hand washing prompt. Results suggest that, females wash their hands more often than males. It appeared that the initial prompts increased hand washing for both genders in only one building tested. However, the second treatment (ie, the sign with the flu warning) returned most conditions to near or below baseline. Prompts may be effective for increasing hand washing in specific settings. The type of prompt utilized should be further investigated, as fear-arousing health-related messages may inadvertently decrease the desired behavior.

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This research investigated the effects of descriptive prompts on the hand washing behaviors of restroom patrons. Outcome data were collected from two female and two male restrooms on a university campus. All four restrooms experienced three conditions: (1) baseline (no intervention); (2) posters prompting hand washing were posted; and (3) the display of posters focusing on the transmission and seriousness of influenza ("the flu") along with the previous hand washing prompt. Results suggest that females wash their hands more often than males. It appeared that the initial prompts increased hand washing for both genders in only one building tested. However, the second treatment (i.e., the sign with the flu warning) returned most conditions to near or below baseline. Prompts may be effective for increasing hand washing in specific settings. The type of prompt utilized should be further investigated, as fear-arousing health-related messages may inadvertently decrease the desired behavior.

During fall and winter months, influenza or "the flu" is a major topic of concern among many Americans. According to the Center for Disease Control, the flu virus is a serious and contagious disease that is mainly spread when people with the flu cough, sneeze, or talk, and leave droplets of the disease on other people and on various surfaces (CDC, 2013). The flu virus presents with symptoms such as fever, headache, cough, and sore throat; however, the symptoms may progress into vomiting, diarrhea, hospitalization and occasionally death. According to the CDC (2013), during the 2012 - 2013 season, the following types of flu virus have been identified in the United States: Influenza A, Influenza B, and HINT Some people are at higher risk for developing flu-related complications, including women who are pregnant, children, people with asthma, the elderly and infirm, and people suffering from obesity (CDC, 2013). Additionally, areas with high population densities, such as in collegiate settings, increase the likelihood of the spread of the virus. Due to the potential seriousness and pervasiveness of the illness, reducing the spread of the flu is a significant concern in the scientific community.

A person may have the flu vims and not exhibit symptoms for 24 hours; thus, lack of immediate symptoms increases the risk of unknowingly spreading the virus. In addition to the spread of the flu virus through direct contact with an infected individual, transmission can also occur when an individual touches a surface or object infected with the virus droplets and subsequently touches his/her nose or mouth (CDC, 2013). The latter form of transmission is a particular concern in the collegiate setting. People who use public facilities should be wary of the spread of the flu virus as it is possible for the virus to spread quickly and exponentially (i.e., multiple students in one infected classroom or bathroom per day). One way that students, faculty, and other collegiate personnel can help reduce the spread of the virus and decrease their risk of contracting the virus is by simply washing their hands (CDC, 2013).

Good hand hygiene practices are taught and encouraged in health care settings, in child care settings, and in the food service industry. In 2007, Seigel, Rhinehart, Jackson, Chiarello and the Healthcare Infection Control Practices Advisory Committee published guidelines for preventing transmission of infectious diseases. These guidelines were created specifically for use within the health care setting and noted that hand hygiene is the single most important standard precaution to prevent the spread of disease (Siegel, et al., 2007). Stephens and Ludwig (2005) examined hand sanitizing behavior of Certified Registered Nurse Anesthetists in a hospital. Baseline measurements of hand sanitizing behaviors were collected and then graphic feedback was presented to the participants. Participants were then trained on proper hand sanitizing procedures and graphic feedback on participant hand sanitization behavior was presented throughout the study. The results showed an increase in hand sanitizing behavior; however, the behavior decreased once the intervention ceased (Stephens & Ludwig, 2005).

Student hand washing behavior in a university setting was observed by Monk-Turner, et al. (2005). Hand washing behavior was observed inside the bathroom in full view of the patron at the restroom sink from either behind a slightly opened stall door or while the observer was at the sink. Observations revealed that women washed their hands more often than men and women used soap more often than men (Monk-Turner, et al., 2005). Another collegiate study conducted by Edwards, et al. (2002) found that individuals who know they are being observed are more likely to wash their hands. Both studies noted that the amount of hand washing is still relatively limited among college students.

Opportunities to spread infection could be decreased by increasing the hand washing behavior of college students. Based on a literature review, Pittet (2000) recommended several ways to increase hand washing. Those suggestions included education, observation, feedback, reminders in the workplace, and promoting individuals' hand hygiene (Pittet, 2000). The CDC also recommends several ways to reduce the spread of infection, including washing hands with soap and water and the use of reminders or prompts in the workplace (CDC, 2002).

The use of prompts to change behavior is well researched and has generally been found to be effective. For example, using a multiple baseline across settings design, Clayton and Blaskewicz (2012) found that visual prompts were highly effective in reducing urine splatter on the floor of the men's restrooms and the behavior change persisted four months after removal of the prompts. Visual prompts have been successfully employed to persuade restroom patrons to turn off the lights after use (Sussman & Gifford, 2012). Patrons were eight times more likely to turn off the lights when visual signage was present, and large signs appeared to be more effective than smaller signs. Visual prompting was also employed by Wiesenthal and Hennessy (2005), who found that visually prompting motorists to stop increased complete stops and decreased rolling stops. Mueller, Moore, Tingstrom, and Doggett (2001) conducted a study on a university campus utilizing a sign prompt to successfully increase the number of chairs students would push back under the table at the end of class. Other applications of visual prompting have not been as successful. When trying to increase the use of food composting, Sussman and Gifford (2013) determined that a behavioral model was necessary to enact change whereas written prompts did not affect behavior.

Although prompting behavioral changes can be effective in many settings, it can also lead to behaviors inconsistent with the prompt due to psychological reactance. There are many factors that can affect compliance with visual prompts. Repeated or mere exposure tends to increase the favorability to the exposed message; however, this favorability can decrease if there is excessive exposure (Miller, 1976). Moderate exposure has been found to be more effective in attitude change than excessive exposure. Excessive exposure can cause a boomerang effect; however, the boomerang effect can be countered by a period of non-exposure (Miller, 1976). With regard to health-related messages, the magnitude of the request affects behavioral changes; messages requesting greater magnitudes of change are less likely to yield change than lower magnitude messages (Rains & Turner, 2007). Rains and Turner (2007) theorized that smaller requests resulted in less psychological reactance and were not viewed as an imposition by the message receiver. Health-related messages are also more likely to be attended to and perceived as more important when the message uses concrete language as opposed to abstract language (Miller, Lane, Deatrick, Young, & Potts, 2007). Other factors affect psychological reactance; increasing similarity between message giver and receiver decreases reactance and leads to greater compliance (Silvia, 2005).

Psychological reactance and factors that increase reactance are important to consider when designing health-related visual prompts. The use of implicit persuasive messages is more effective than explicit persuasive messages in adolescent anti-smoking campaigns (Grandpre, Alvaro, Burgoon, Miller, & Hall, 2003). Grandpre et al. attributed the greater effectiveness of implicit messages to lower levels of psychological reactance. Changes in drinking behaviors among college students have also been targeted using messages containing normative statistical messages. Students were found to move in all directions from the message (i.e., no change, change toward message, or away from message). Those students whose attitudes moved away from the normative message demonstrated behavioral changes by engaging in less healthy drinking behaviors than the other groups, whereas students who moved toward the message engaged in healthier drinking behaviors (Campo & Cameron, 2006).

Across a variety of behavioral settings, previous research supports the notion that prompting is successful at changing behavior. The purpose of the current study was to use descriptive prompting procedures to increase hand washing behavior among patrons in the lavatories on a university campus. Since observation of patrons' hand washing behavior in the restrooms was not possible, an outcome-based measure of hand washing was recorded (i.e., soap usage). This study attempted to extend previous research by evaluating the effects of prompts on hand washing in a public setting. Soap usage was monitored in both men's and women's restrooms. In each setting, repeated baseline measures were taken followed by a simple hand washing prompt (i.e., first treatment condition). A second treatment condition followed and incorporated information regarding the spread of influenza in addition to the previous hand washing prompt. Based on previous research, it was expected that women would use more soap than men. Additionally, it was hypothesized that the use of sign prompts in both treatment conditions would lead to significant increases in hand washing over baseline as assessed through soap usage. It is important to note that the current study did not directly observe hand washing behavior because of Institutional Review Board for the Protection of Human Subjects (IRB) restrictions.

METHOD

Participants and Setting

Participants were male and female college students, faculty, auxiliary staff, and visitors on a university campus. The settings were male and female restrooms in two similar buildings, education and business. The two buildings are mirror images of one another and are physically identical. Each male restroom contains four urinals, three toilet stalls, and three soap dispensers, while each female restroom contains six toilet stalls and four soap dispensers.

Materials

Hand washing prompts. Laminated 8.5 x llinch posters were used to prompt patrons to wash their hands in two different experimental treatments. One poster was a simple instructional guide for hand washing. The poster described to patrons how to thoroughly wash their hands, including a step-by-step process in an easy-to-read format (i.e., a bulleted list of steps). The second poster included information on how to decrease the likelihood of contracting the flu virus, the importance of good hand hygiene in the prevention of disease transmission, as well as how to wash their hands.

Measurement of restroom traffic. The Electronic Pedestrian Counter- IRD1 (EPC-IRD1) is a microprocessor that uses an infrared beam to sense and record pedestrian traffic. One EPC-IRD1 unit was installed either on the door frame or on the door itself for each restroom. The EPC-IRDl's counter buzzer was disarmed and a security code feature was enabled to prevent tampering by non-research personnel. Thus, if an individual entered one of the monitored restrooms, the corresponding EPC-IRD would record that a patron entered the restroom.

Daily hand soap usage. Premeasured industrial hand soap was ordered for the experiment. The soap was in prepackaged bags; when dispensed a foam-based soap was produced. At the start of the experiment, all soap dispensers were replaced with the testing soap, which did not differ from the usual hand soap available. Hand soap measurements were taken five days a week at the same time each day. Data collectors entered the restroom and measured the amount of soap used by pouring the soap into standard 1000 ml plastic liquid measuring cups. After the soap was measured, the soap was then poured back into the soap dispenser. The amount of soap usage for each day was calculated by subtracting each day's amount of soap from the previous day's amount. In addition, restroom traffic was also measured to ensure that any effects found were not due to differences in number of patrons at each of the four testing sites. Thus, after measuring the soap, data collectors then recorded the amount of restroom traffic by reading the number displayed on the people counter and dividing that number by two (the EPC-IRD1 is a unidirectional counter). The data collectors then reset the traffic counter to zero for the next day's traffic count. The amount of hand washing was measured by calculating the per person soap usage in each restroom per day. The amount of per person soap usage in each restroom was derived by dividing the amount of soap used by the number of entries into that restroom.

Experimental Design and Procedure

An ABB' multiple baseline across settings design was used, where A is baseline, B is prompt alone poster, and B' is health-related information plus prompt poster. Thus, the experiment occurred in three phases. Multiple measures were taken throughout each condition at all sites.

Baseline. The purpose of this condition was to establish the level of hand washing prior to the intervention. During this condition, participants used the restrooms without the prompting interventions. The EPC-IRD1 was installed prior to baseline so restroom traffic could be recorded during this phase. In addition, the soap levels in each dispenser were recorded daily.

Prompt alone. Following baseline, posters consisting of hand washing instructions were posted in each bathroom. The posters were positioned in various areas in the restroom to help ensure patrons would read them (i.e., on the inside of the restroom doors, on the inside of the restroom stall doors, above the urinals, and near the sinks). Data were collected as described above.

Health-related information and prompt. During this phase, the hand washing posters were removed and the posters warning of the transmission of the flu virus and the importance of hand washing were then posted in the same locations as the previous posters. Data collection procedures were the same as those described above.

RESULTS

A second research assistant also scored 67% of all observation sessions (i.e., hand soap usage) to assess inter-observer agreement and ensure the soap was measured consistently across settings and conditions. Point-by-point agreement was calculated by taking the number of agreements and dividing by the number of agreements plus disagreements and then multiplying by 100. Inter-observer agreement averaged 93%, indicating high levels of agreement between raters and consistent measurements throughout the trials.

Soap usage per person for the education women's restroom was 1.41 ml (SD = .43) during baseline, 1.95 ml (SI) = 1.62) during the prompt alone phase, and 1.23 ml (SD = .68) during the prompt and information phase, respectively. Thus, in the women's room in the education building, soap usage significantly increased during the first treatment following baseline, but then fell below baseline on the second treatment (i.e., warning of influenza transmission). Soap usage per person for the business women's restroom during baseline was 1.13 ml (SD = .64) during baseline, 1.15 ml (SD = 1.01) during the prompt alone phase, and .94 ml (SD = .59) during the prompt and information phase, respectively. Interestingly, in the business building, women's soap usage did not change significantly from baseline to first treatment, but decreased slightly on the second treatment. Additionally, overall women in the business building appeared to use less soap than women in the education building.

Soap usage per person for the education men's restroom during baseline was .37ml (SD = .23), .51 ml (SD = .58) during the prompt alone phase, and .37 ml (SD = .37) during the prompt and information phase, respectively. Although the amount of soap used by males in the education building appeared to increase during the first treatment (i.e., proper hand washing) the difference was not significant. Soap usage returned to baseline values on the second treatment. Soap usage per person for the business men's restroom was .63 ml (SD = .47) during baseline, .61 ml (SD = .56) during the prompt alone phase, and .40 ml (SD = .32) during the prompt and information phase, respectively. Thus, men using the restroom in the business building followed a different behavior pattern than the education building; there was no increase from baseline to the first treatment and then a marginal drop in usage on the second treatment. It is interesting to note that at baseline men in the business building used significantly more soap than those in the education building.

A 2 x 2 x 3 analysis of variance (ANOVA) was conducted to examine the effects of gender, location (building: education and business), and prompting condition (baseline, hand washing prompt, and influenza informational prompt) on the average amount of soap used per day by restroom patrons. A significant main effect was found for gender, F( 1, 208) = 52.71, p < .001, eta2 = .20, where women (M = 1.33, SD = 1.04) were found to use significantly more soap than men (M = .50, SD = .47). There was no main effect for location of the testing site (the education building and the business building), F( 1, 208) = 2.13, p = .15, eta2 = .01. The overall hand soap usage in the education building (M = 1.00, SD = 1.07) did not differ significantly from average overall hand soap usage in the business building (M = .84, SD = .71). The lack of a significant building effect was qualified by a significant interaction between Gender x Location, F( 1, 208) = 6.79, p = .01, eta2 = .03. Using 95% confidence intervals, it was determined that women in the education building used significantly more soap overall than women in the business building; there were no significant differences between men by building type.

A significant main effect was found for prompting condition, F(2, 208) = 6.79, p = .01, eta2 = .03. A post hoc LSD analysis revealed that overall baseline (M =.88, SD = .61) did not differ from the first prompting condition (M =1.05, SD = 1.17); however, there was a significant decline in average hand soap usage during the second treatment condition (i.e., influenza warnings; M =.75, SD = .64), with the second treatment not differing from baseline. There were no statistically significant findings for the remaining interactions: Gender x Condition, F(2, 208) = .67, p = .51, eta2 = .01; Location x Condition, F(2, 208) = .90, p = .41, eta2 = .01; or Gender x Location x Condition, F(2, 208) = .65, p = .52, eta2 = .01.

DISCUSSION

The current investigation was an outcome-based study on the effects of sign prompts to increase hand washing. Consistent with expectation, results showed that women washed their hands more often than men. The greater use of hand washing in women than men is consistent with past research (Monk-Turner, et al., 2005). This finding suggests that men should be targeted for a more intrusive intervention for hand washing. However, there were three soap dispensers in the men's room as compared to four in the women's room. Perhaps soap dispensers themselves serve as prompts for hand washing.

Although the average amount of soap usage appeared to increase after the implementation of the first hand washing prompt in all restrooms except in the men's business restroom, no statistically significant results were found. The lack of significant increase in hand soap usage following the first prompt is likely a function of the high levels of variability between observations, genders, and locations. However, soap usage actually significantly declined in every restroom to baseline levels or lower than baseline after the implementation of the second treatment, which included an informational message regarding the spread of influenza along with a hand washing prompt. This finding was unexpected due to the fact that the only manipulation difference between the prompt alone and the prompt plus information poster was the addition of information about influenza. Thus, the content of the message may have caused psychological reactance where persons engage in behaviors inconsistent with the message (e.g., Campo & Cameron, 2006). Several explanations for these findings include habituation to the signs in general and psychological reactance, causing patrons to disregard the message or act in a manner inconsistent with the message. Excessive exposure to a message can sometimes cause a boomerang effect (Miller, 1976). An alternative explanation is that with regard to hand washing, prompting alone is not sufficient to change behavior and that behavioral modeling is necessary to enact changes in hand washing behavior. The need for a behavioral model to enact change is supported by the findings of Sussman and Gifford (2013), who found that a behavioral model was necessary to increase composting behavior whereas written messages were ineffective.

Additionally, the message may have provoked fear in patrons that caused them to behave in a manner inconsistent with the message. Previous research has found that the element of fear in a message generally leads to changes in behavior (e.g., Floyd, Prentice-Dunn, & Rogers, 2000). However, the fear-based message may actually make the desired behavior changes less likely (e.g., Witte, 1992, 1994). Das, de Wit, and Stroebe (2003) found that individuals who feel more vulnerable to a threat (e.g., contracting influenza) are more likely to experience negative emotions and cognitive changes in favor of fear reduction; however, cognitive changes may not correspond with true behavior changes.

An alternative explanation for the decrease in hand washing following the posting of the influenza warnings may be a function of the content of the message. Results of the current study imply that in order to increase hand washing behaviors, a fear-based message may be a demotivating factor. According to the Terror Management Health Model (TMHM), messages that solicit a conscious fear of dying motivate individuals into changing a health-related behavior; however, according to TMHM, the health-related behavior may also be attenuated or avoided (Goldenberg & Arndt, 2008). Previous research indicates that messages resulting in subconscious thoughts of death are ineffective in changing health-related behaviors (Hunt & Shehryar, 2011). Thus, care should be given when determining the most effective method to increase hand washing. Coupling the possibility of becoming very ill and developing a potentially fatal illness with hand washing may result in an unconscious internalization of the fear-based message that may have resulted in avoidant behaviors. Future research should also examine changes in the number of persons seeking the influenza vaccines after exposure to the second treatment condition.

One major limitation of the current study was the methodological constraints of relying on average quantity of soap used per person because of IRB restrictions. Due to this limitation, individual differences in hand washing behavior may not have been detected, as hand washing behaviors were inferred based on total soap usage divided by the number of patrons. Individual differences in hand washing could not be observed and differences in soap usage were assessed using a secondary measure. The current methodology did not allow assessment of changes in the percentage of individuals who wash their hands or differences in the amount of soap used by different persons (i.e., the amount of soap pumps). Additionally, soap was measured using 1000 ml cups and on some days the soap usage appeared unchanged. The lack of differences in soap measurements between some days was partially attributed to the type of soap utilized; the soap was a foaming soap, where very small amounts of soap volume are in each foaming pump. With the current measures, differences could only be detected in 25 ml increments.

A curious finding of this research was the interaction effect of gender and academic building (i.e., education and business). Women in the education building used significantly more soap than women in the business building. One potential explanation for this is that the education building not only houses the education department but also contains the psychology department. Psychology students, who are predominantly women, may be more primed to respond to changes in the environment. The current research should be replicated to determine if the gender by building difference is enduring.

Anecdotally, another limitation occurred during the treatment condition phase because there were numerous instances when restroom patrons removed the signs. Signs were checked by the experimenters repeatedly throughout the day and those signs that were removed were replaced. However, all persons considered to be in the prompting conditions may not have been exposed to the prompting signage; thus the lack of a statistically significant difference in average hand washing between the baseline condition and the hand washing prompt may be an artifact of sabotage. The number of persons who missed the signs during the treatment conditions remains unknown.

Future research should be conducted to directly observe participants' hand washing behaviors. Such a study may help determine the conditions under which a person is more likely to wash his/her hands. In addition, knowing such information could lead to the discovery of how to increase the desired behavior. Different forms of interventions can be tested to determine the effects on hand washing, including verbal interventions, video interventions, peer-based interventions, and the use of a confederate model. Special efforts should be directed towards men, who use significantly less soap than women. Using a confederate model may be particularly useful in the men's room, considering that men engage in significantly less hand washing than women.

Sidebar

Note: Figure 1 depicts the data from the women's restroom in the education building and the women's restroom in the business building. Figure 2 depicts the data from the men's restroom in the education building and the men's restroom in the business building. These figures are available upon request from the authors.

References

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AuthorAffiliation

Ora L. Davis

Mexia State Supported Living Center

Rhiannon M. Fante

St. Clair County Community College

Lora L. Jacobi

Stephen F. Austin State University

Author info: Correspondence should be sent to: Dr. Rhiannon Fante, Social Science Division, 200 North Building, Port Huron, MI, 48061 [email protected].

Word count: 5002

Copyright North American Journal of Psychology Dec 2013