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Emotional motivators might improve hand hygiene among healthcare workers

BMJ 2015; 351 doi: (Published 28 July 2015) Cite this as: BMJ 2015;351:h3968
  1. Layla McCay, secretariat director, Global Public-Private Partnership for Handwashing, 1825 Connecticut Avenue NW, Washington, DC 20008, USA
  1. laylamccay{at}

Campaigns that use feelings such as disgust might help to reduce healthcare associated infection better than rational campaigns that teach infection prevention, writes Layla McCay

Something about articles on hand hygiene in healthcare tempts us to turn the page. Hand hygiene: that bastion of infection control, inspiration for a thousand dog-eared posters proclaiming the critical moments, creator of chapped hands, consumer of time that could otherwise be spent with patients, general guilt inducer.

We know this. We all learnt the importance of hand hygiene back in medical or nursing school. We all sat through the mandatory training and read the hospital policies. We recognise that globally 5-15% of hospital patients acquire a healthcare associated infection during their stay.1 We have seen the studies: healthcare associated infections are being transmitted on the hands of healthcare workers all the time, whether we are measuring blood pressure,2 moving around the patient area,3 or handling fluid secretions.4 We know all about hand hygiene.

Not sufficient to drive action

And yet, we also know that our knowledge is not sufficient to drive action. Worldwide, health workers clean their hands only 40% as often as the World Health Organization considers essential to deliver safe care5—and even less often in low and middle income countries.1 Rather than ignorance or wilful negligence, hand hygiene sometimes just fails to make the cut in our subconscious cost-benefit analysis. Wards might be understaffed, clinics overfilled, and workdays long and intense, with numerous competing demands on our time. There might be no soap or running water nearby, or no convenient access to alcohol based hand rub. Even when we have adequate facilities, have read the policies and protocols, and have every aspiration to protect our patients from harm and provide high quality care, hand hygiene doesn’t always make the all important transition from good intention to systematic habit.

To understand why we are not achieving safe hand hygiene in healthcare perhaps we should look beyond the hospital doors to global public health. Sure enough, we soon find an important clue: telling people that they should wash their hands to prevent infections doesn’t work well.6 In fact, it can even be counterproductive.7 This raises the question of why we continue to focus efforts for improving hand hygiene in healthcare on rational arguments, education, posters, and policies, which have only limited long term impact on human behaviour.

If rational arguments aren’t enough to get us to wash our hands, then what would work? Again, we can appropriate inspiration from hand hygiene studies outside healthcare. Globally, only 19% of people wash their hands with soap at critical times at home.8 As good hand hygiene can prevent four in 10 cases of diarrhoeal disease9 and nearly a quarter of acute respiratory illnesses,10 hand hygiene is a key focus for global health practitioners.

Sizeable and lasting impact

A recent study took a new approach to increase mothers’ handwashing in rural India, and the results have taken the international development community by storm.11 The SuperAmma study found that using emotional motivators (disgust, nurture, status, and affiliation) to promote hand hygiene had a sizeable and lasting impact on mothers’ handwashing behaviours that far exceeded the improvements achieved by most other studies, particularly those that focused on educating people about the rational benefits of handwashing on prevention of infection—the approach used so often for health professionals.

The advent of Ebola, with its accompanying flurry of fear driven handwashing, showed us that health professionals are not rational robots (with selectively faulty handwashing programs): we respond to emotional drivers. Although rationally knowing that in many parts of the world pathogens like Clostridium difficile, vancomycin resistant enterococcus, and meticillin resistant Staphylococcus aureus posed a far more likely risk to our patients than Ebola virus,12 for many, it was our fear of Ebola that drove us to enact extra-meticulous hand hygiene.

The behavioural impact of fear might be temporary,9 but other emotional motivators last longer. To make progress on hand hygiene and reduce healthcare associated infections, we must capitalise on the fact that health professionals are not automatons; when it comes to what motivates our behaviours, we are probably not so different from those SuperAmma mothers. If we strive to identify these motivators, we can systematically augment or even replace the delivery of rational hand hygiene education in healthcare, using the latest evidence to evoke feelings of disgust around contaminated hands, appeal to the impulse to nurture those in our care, activate our human urge to conform to social norms, and achieve peer group affiliation—or some entirely different emotional motivators. Looking beyond the boundaries of healthcare, a wealth of research can potentially be applied to healthcare settings in creative, effective ways. Pinning up hand hygiene posters has got us only so far. It’s time to learn from other sectors and to try something new.


Cite this as: BMJ 2015;351:h3968


  • research, doi:, editorial, doi:10.1136/bmj.h3728 10.1136/bmj.h3931
  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: I am the secretariat director of the Global Public-Private Partnership, which promotes handwashing. The organisation receives financial contributions from USAID, UNICEF, FHI 360, WSSCC, Procter and Gamble, Colgate-Palmolive, Unilever, and Dow Chemical, all of whom promote handwashing with soap and recognise hygiene as a pillar of international development and public health.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.


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