Over the past few days, two news articles found their way into the headlines revealing that handwashing has increased over the last few years to an astonishing 85% in one study and 70% in the other.  Both demonstrate an increase over previous studies and to some extent are considered to be an achievement.

I agree that this is an achievement.  Yet if you ask me, it’s not about the improved handwashing rates that they should be celebrating.

At a video conference earlier today, I asked another expert in the study of hand hygiene about whether these rates are real or whether they may be due, in part, to a Big Brother Effect, also known as the Hawthorne Effect.  It’s a phenomenon in which people will tend to perform certain actions when they know they are being watched.  He admitted that this indeed may be the case.

The key to these studies, and others that show high levels of handwashing compliance, is that they are observational in nature, that is, they are conducted using a person in the washroom who ‘discreetly’ observes the actions of people in washrooms.  The term discreetly refers to the fact that the observers are not washing their hands nor making any attempt to influence people.  The assumption is that people will not feel encouraged nor threatened by the presence of the person, thereby taking away from the Hawthorne Effect.  But as anyone will tell you, just the mere sight of another person in an environment will affect the way a person acts…most of the time.

I actually encountered the Hawthorne Effect a few months ago in New Orleans at a conference.  In the washrooms, there was always at least one person, dressed in white, standing in the corner, broom in hand.  The person was most likely there to maintain the cleanliness of the washroom yet I believe there was another purpose served, if only by accident.  I observed a few people in the mirror while I performed by own handwashing and realized that several of them performed two very simple and yet very important tasks.  The first was to observe the room for any presence of an individual, and the second was to head straight to the sink while keeping an eye (whether discreetly or purposefully) on the attendant.  Once the individual finished handwashing, he would scurry out of the washroom as if for some reason attempting to get out of the sights of some larger power.

It was in essence, the Hawthorne Effect.  And it works!

In the same video conference, I found it interesting that one of the proponents of the study suggested that if indeed, the Hawthorne Effect was at play, then the levels of handwashing would not be improving over the years.  Yet if one looks back at say, an article from the New York Times in 2005 and another article from 2003, the numbers are pretty similar.

I’ll take it a step further.  Studies done before 2001 showed only about 50-60 percent of people washed their hands.  After that date, the number went up to the now standard 70-80%.  I won’t speculate on the reason but it surprises me that this year was a key for change and not 2003, when SARS scared the world, or 2009, when the pandemic flu raged.  In my estimation, the change was a result of something much greater than the realization that soap and water are critical to prevent infection.

I understand that many experts in hand hygiene want the public to appreciate the necessity for proper hand hygiene but unless it becomes a tenet of integrity, a driving factor, such as the fear of shame, may be the only way to keep the observed handwashing rates.

It’s not an easy thought to swallow but in this post-9/11 world, there may be some credence to the idea of keeping a sentry at the gates, so to speak.  If the compliance stays high, then there will be a noticeable reduction in infection spread and eventually, the numbers will be seen statistically and soon enough the public will get the message.

My only question is: how do we get that 30% who just don’t care about Big Brother to start washing their hands?

I should note that I haven’t given any statistics relating to handwashing without observation, however these studies are understandably rare.  There has been one study of note, however, in which the actual hand hygiene rates for health professionals “when no one is looking” was only 12%.

I hate to say it but in my perspective, that’s more like it.