The Get Talking, Get Tested Campaign: A Social Sciences Critique and Recommended Improvements – Dana Greeson

HIV/AIDS has been a highly stigmatized illness since the epidemic began in the United States in the early 1980s. The “4 H’s” referred to the groups who were most associated and often blamed for the spread of the virus: homosexuals, heroin addicts, Haitians, and hemophiliacs (1). HIV has had a devastating impact on these groups and each has reacted in different ways. In recent years, with the advent of antiretroviral treatment, HIV has shifted from a death sentence to a chronic disease in high-income countries. The Office of HIV/AIDS within the Massachusetts Department of Public Health provides services such as prevention, education, counseling, testing, client services and health and support services (2). The MDPH emphasizes multicultural health and recognizes that minorities and those living in poverty face a high burden of HIV/AIDS (2). The Get Talking, Get Tested campaign through the MDPH encourages African Americans and other black residents in Massachusetts to get HIV testing and talk about it with their loved ones (3). While this campaign targets one of the highest-risk populations in the state, the message is too narrow, with certain key issues ignored. In this paper I will use principles from the social and behavioral sciences to critique the Get Talking, Get Testing Campaign (GTGTC) and present ways to improve the campaign based on these principles.

Get Talking, Get Tested

According to MDPH Commissioner John Auerbach, "this campaign encourages people to get tested, not just for their own sake, but for the sake of their family and for their community as a whole. We want people to know that testing is fast, free and confidential, and to understand that getting tested for HIV should be a regular part of their health care routine" (3).

Campaign posters state “HIV testing is fast, free and confidential.” There are three styles of posters: one with two black men, another with a black man and a black woman and a third with two black women (see Annex 1). The relationships between the pairs are ambiguous. For example, the poster with the two women can be perceived as two friends, sisters, a mother and daughter, or partners.

Why Focus on the Black Population

The African American and black populations in Massachusetts carry an inequitable burden of HIV/AIDS compared to other race ethnicities. Data from the MDPH show that 50% of recently diagnosed women and 25% of recently diagnosed men are black non-Hispanic (4). Among those living with HIV/AIDS, 41% of women and 23% of men are black (4). Aside from race, country of origin also plays a role in the HIV/AIDS disparity. From 2004 through 2006, 44% of women and 22% of men diagnosed with HIV were born outside of the U.S. (4). Different populations differ in their modes of exposure to HIV/AIDS and therefore require separate interventions. For example, drug use is the primary exposure for white women where as heterosexual sex is the primary exposure for black women (4).

The Biopsychosocial Model of Health

The first social science approach that I will use to critique the Get Talking, Get Tested campaign is the Biopsychosocial Model created by Dr. George Engel in 1977 (see Annex 2). Dr. Engel was a psychiatrist who sought to address the shortcomings of the biomedical model of health. He recognized that the gap between the fields of medicine and psychology was negatively affecting patients. Dr. Engel stated that health and disease were strongly influenced by society, culture, and psychology and that providing patients with quality care required practitioners to look beyond biology and physiology (5).

Although there are effective testing and treatment methods for HIV/AIDS that fit within the biological circle of the Biopsychosocial Model, the sociological and psychological circles require more attention. Within the U.S., there has been substantial HIV/AIDS social marketing that promotes prevention and testing. Although these campaigns have aimed to reduce HIV/AIDS stigma, it remains deeply embedded in many cultures. In this sense Positive Deviance (PD) may be an effective approach in targeting specific cultures and communities and enhancing the sociological circle of this campaign. PD is a behavior change approach based on the idea that community problems have existing solutions within the community (6). This approach takes advantage of existing community resources and solutions and often leads to more practical interventions than those that come from outside of the community (6). Using Positive Deviance to decrease HIV/AIDS stigma could work by presenting respected HIV positive community members, who are leading productive lives, to the specific cultural groups of which they are members (these people are referred to as “positive deviants”). For example, if gender inequity was an issue within a culture, a campaign could show a well-respected man in the community supporting his wife or girlfriend getting tested. This could effectively reduce stigma and decrease gender barriers to testing.

The Lazarus Effect is a phenomenon that can also be used to reduce HIV/AIDS related stigma. This refers to the idea that antiretroviral drugs (ARVs) can transform a person from nearly dead to relatively healthy and could also be applied the sociological circle of this campaign (see Annex 3). This effect received its name from the bible, where Jesus raises Lazarus from the dead, which is essentially what ARVs are doing for people living with HIV/AIDS. The Lazarus effect is perhaps the most effective type of social marketing for community members as it provides proof of the efficacy of ARVs and the benefits of being tested and taking appropriate medications. Positive Deviance and the Lazarus effect are some examples of how the sociological circle can be improved.

The psychological circle of the Biopsychosocial Model should be addressed through culturally appropriate counseling and support groups. Although the Office of HIV/AIDS provides counseling, the Get Talking, Get Tested Campaign does not mention counseling in its advertisements. This information should be more explicit for target populations. Studies have shown that fear and avoidance play a large role in why many people go unscreened for a variety of illnesses (7). Counseling has been one effective method of addressing these fears (8).

The Political Economy Approach

Although HIV was originally associated with homosexual men, prevalence among women has been steadily increasing in Massachusetts (4). As discussed above, incidence in women is higher within cultures and communities where women are marginalized. Risk factors for women are related to socioeconomic status, country of origin, religion, education level and power differentials within romantic relationships.

Political Economy provides a macro level approach to understanding and addressing these types of disparities in health. There are three key components to the Political Economy approach. The first step is to think of a health issue as the result of certain societal interactions such as those mentioned above (class, gender, etc.) (9). Next, this approach looks at health issues as being part of a trajectory of risk, which is influenced by relationship patterns in society (9). The Political Economy approach states that public health interventions must address societal relationships that contribute to the issue (9).

The Get Talking, Get Tested campaign addresses societal components of HIV/AIDS, but not some of the most important ones. The campaign recognizes that HIV/AIDS prevalence is higher for black residents than white residents in Massachusetts. Black residents make up six percent of the Massachusetts population, but account for 28 percent of residents with HIV/AIDS (3). They are 11 more likely to have HIV/AIDS than white residents (3). The campaign has been effective at targeting black communities through health care centers and advertisements in the Massachusetts cities with the highest incidence of HIV among black residents (32-61%: Boston, Springfield, Worcester, Lynn and Brockton) (3) (10).

While it is extremely important that the black community receive targeted HIV/AIDS messages, it is also important that gender inequality is addressed. Gender inequality is a relationship pattern that can contribute to a trajectory of risk for HIV/AIDS within and outside of the black community. Some of the highest-risk residents in Massachusetts are immigrant and refugee women who do not speak English, have low levels of education, are uninsured, and face substantial gender inequality within their relationships (4)

In a recent lecture, Dr. Nicole Prudent, a Haitian physician at Boston Medical Center, discussed some of the societal obstacles for young Haitian immigrant women related to HIV. She explained that Haitian women are valued most in their roles as wives and mothers (11). Many of these women have already experienced trauma when they arrive in the U.S. They have difficulty finding jobs and gaining financial independence and are unsure how to access health care. If they are in a relationship, they probably lack decision-making power. If they are not in a relationship, they are likely feeling pressure from their families. These women also come from a culture in which HIV has been highly stigmatized. Dr. Prudent explained this scenario so that we could understand all of the factors that might prohibit young Haitian women from getting tested for HIV. These women are already feeling completely overwhelmed and the possibility of being diagnosed with HIV is terrifying. If a married Haitian woman is diagnosed with HIV her husband may abuse her and/or leave her. If a single woman is diagnosed she is unlikely to fulfill the valued role of wife and mother and may be shunned by her family. While Dr. Prudent agreed that testing is absolutely necessary, she explained that it cannot be the first step in a HIV campaign. Although this example is about Haitian women, it is generalizable to other marginalized groups who are already struggling with an overwhelming amount of issues and cannot imagine facing one more challenge.

The GTGTC does not mention anything beyond the test itself. What kind of support will be provided for those who test positive? Are there examples of people from similarly marginalized groups who are better off for being tested? What kinds of treatment barriers exist for undocumented persons with HIV? These are important societal questions that would be addressed in the Political Economy Approach.

The Communications Theory

The Communications Theory is based on the communication process where the goal is for the message receiver to interpret and act based on the message (9). The first thing to consider when disseminating public health messages is whether the target population can relate to the messenger. The messenger must encode the message to have the optimal effect on the population. A major communications challenge with HIV/AIDS campaigns is that high-risk people speak a variety of languages and literacy rates are sometimes low. The GTGTC has only printed materials in English. This is a major flaw in the campaign. In the Haitian community, a respected Haitian woman, such as Dr. Prudent, might be the ideal messenger since she shares a cultural background with the target population. The GTGTC could distribute materials in various other languages depending on the venue and target population. Of course, this still leaves the issue of illiteracy in ones native language, which can be addressed through other channels such as the health radio program that Dr. Prudent does in French Creole. Another ideal channel within the Haitian community is church since the population is almost exclusively Catholic and attendance is high. This may prevent many women who cannot read from missing out on important information.

Improving the Get Talking, Get Tested Campaign

In this section of the paper I will explore improvements that can be made to the Get Talking Get Tested Campaign by applying the three social science models previously discussed. The goal of these improvements is to better reach high-risk subgroups within African American and other black communities in Massachusetts.

Improvements based on the Biopsychosocial Model of Health

I explained earlier how the GTGTC falls short of meeting the Biopsychosocial Model of Health and how other approaches, such as Positive Deviance, may be more effective in addressing the sociological and psychological circles within the model. Positive Deviance looks to solutions already present within a community and relies on respected community members to disseminate health messages. Several ideas that I will present in this section can also be applied to the Communications Theory.

Kalichman and Coley designed a study to test the idea that people are more receptive to messages delivered by someone who they perceive as similar. Factors that one may have in common with the messenger are age, race, sex, ethnicity, religion, education level and socioeconomic status. They randomly assigned 100 black women in a health clinic to watch one of three videos on HIV testing. The narrator in the first video was an African American man. An African American woman narrated the second and third videos, but the third video also included culturally relevant consequences of not getting tested such as not living long enough to raise ones children (12). Results showed that the women rated the narrator in the third video as being significantly more concerned about them, their families and their communities. Of the women who watched the third video and stated intention to be tested within two weeks, 63% followed up compared to 23% who watched the second video and none who watched the first video (12).

Although the GTGTC did not use video as a communication channel, an issue I will discuss below, I would recommend that the MDPH partner with trusted organizations within the black and immigrant communities of Massachusetts. Berlo and colleagues state that trustworthiness and expertise are the most important factors that one considers in determining whether a source is credible (13). Currently, the only emblem on GTGTC material is the one for the Massachusetts Department of Public Health. Since the state government runs the DPH, there may be issues of trust for undocumented immigrants, and black people in general, who have a history of being mistreated by the government and medical institutions. If these subgroups see that trustworthy organizations are partnered with the Department of Public Health on the HIV testing initiative they will likely be more apt to get tested, just like the women in the Kalichman and Coley study. The Multicultural AIDS Coalition, run through the African Health Initiative Boston, is an example of an organization that works specifically with the immigrant and black populations and is therefore likely to be perceived as more trustworthy.

Levy and colleagues studied the reasons for delayed HIV presentation among immigrants and found that it was associated with a lack of knowledge, secrecy, stigma and symptom specific health seeking behavior (14). Undocumented immigrants who avoid testing due to fear of deportation would likely be more apt to get tested if they could identify a trustworthy organization in partnership with the campaign. At the very least, they could seek guidance and have their concerns addressed by the organization. The Lazarus Effect could also be incorporated into campaign materials to demonstrate that diagnosis can lead to better health and quality of life. While source credibility, Positive Deviance and the Lazarus Effect address the sociological circle of the Biopsychosocial Model, the campaign should also communicate the availability of appropriate counseling services and supports to address the psychological circle.

Improvements based on the Political Economy Approach

The subgroups of the population that are most negatively affected by HIV/AIDS mirror many of the subgroups that are vulnerable to poor health outcomes in general. According to the Political Economy approach, interventions must consider various societal interactions, such as class and gender, which may put people at increased risk of various health outcomes. (9). One of the most concerning factors is that the relative risk of HIV infection is 11 for blacks compared to whites. This disparity is exacerbated among women of color who make up 83% of new HIV diagnoses among women in Massachusetts (2). People of color living with HIV/AIDS also face increased mortality compared to whites with the virus. Another trend is for immigrants to be diagnosed much later than those born in the U.S. A significantly higher percentage of immigrants are diagnosed with AIDS within two months of their HIV diagnosis (36% versus 25%) (2). These statistics show the importance of targeting not only the black population as a whole, but also immigrants and women within it.

The Political Economy approach is another example where a positive deviant within a community can set a good example. In this case, a respected male can encourage other men to respect the women in their lives, both in general and in regard to health. Similarly, respected black men can encourage their peers to come together and get tested in an effort to decrease stigma and the spread of HIV within the black community. A positive deviant woman or a group of women can strategize safe and realistic ways of gaining power and respect within their relationships, families and communities. Since contracting HIV is often a product of marginalization, increasing women’s self efficacy and power, which is certainly easier in theory than practice, should serve to decrease their vulnerability to contracting the virus and delayed testing. Campaigns that promote HIV testing, must emphasize and provide adequate support both pre and post-testing. The more marginalized a person is who is being tested, the more severe consequences s/he may face upon testing positive.

Improvements based on the Communications Theory

Since I have already addressed the importance of perceived similarity, trustworthiness and expertise in health messengers, I will focus on the channel and language components of the Communications Theory. The GTGTC material is only presented on billboards and other printed media, which may be missing the most vulnerable subgroup: immigrant women of color who do not read English. Instead, I propose that airing short commercials on specific television channels watched by these populations would be more effective in reaching this target audience. Women from the various subgroups should be consulted for their ideas and opinions throughout the creation of these commercials. Research is needed to determine the channels and times of television viewing among specific population subgroups. Next, several versions of the commercial would be piloted among subgroups to ensure cultural and linguistic appropriateness. This channel of communication would reach those who cannot read English or do not commute to work and are therefore less likely than their male counterparts to see advertisements on buses and billboards. Other communication channels to consider are beauty parlors, churches and antenatal clinics depending on the specific subgroup.

Conclusion

While the Get Talking, Get Tested campaign is off to a good start in that it targets high-risk populations, it does not delve deeply enough into the trauma associated with HIV testing and the cultural barriers that may inhibit someone from being tested. Applying the Biopsychosocial Model of Health to this campaign emphasizes the need for some cultures to have more positive examples of people they can relate to who have been tested and/or are HIV positive and leading productive and meaningful lives. Culturally appropriate counseling and support groups may help with the avoidant behavior associated with testing. The Political Economy approach encourages campaigns to look at the big picture in order to understand the societal barriers that people face in seeking health care. Finally, the Communications Theory stresses the importance of using appropriate messengers, language and channels in disseminating public health messages. Applying these three social science theories to the Get Talking, Get Tested Campaign could help it to impact the most vulnerable members of society through increased HIV testing and use of comprehensive HIV/AIDS services.

References

(1) Gallo RC. A reflection on HIV/AIDS research after 25 years.. Retrovirology 2006, 3:72 2006 10/20/06;3(72).

(2) Massachusetts Department of Public Health HIV/AIDS Bureau. An Added Burden: The Impact of the HIV/AIDS Epidemic on Communities of Color in Massachusetts. World AIDS Day December 1, 2007. 2007 12/1/07:1-14.

(3) Health and Human Services. Get Talking, Get Tested. DPH Office of HIV/AIDS Expands Awareness Campaign. 2009; Available at: http://www.mass.gov/?pageID=eohhs2pressrelease&L=1&L0=Home&sid=Eeohhs2&b=pressrelease&f=090203_get_talking_tested&csid=Eeohhs2. Accessed 4/2, 2009.

(4) Massachusetts Department of Public Health. Massachusetts HIV/AIDS Data Fact Sheet. Women at Risk of HIV Infection. 2008 6/08:1-3.

(5) Engel G. The Need for a New Medical Model: A Challenge for Biomedicine. Science, New Series 1977 4/8/77;196(4286):129-136.

(6) Sternin M, Sternin J, Marsh D. Designing a Community-Based Nutrition Program Using the Hearth Model and the Positive Deviance Approach - A Field Guide. 1998 12/98:1-85.

(7) Vermunda SH, Wilson CM. Barriers to HIV testing-where next? The Lancet 2002 10/19/02;360(9341):1186-1187.

(8) Irwin KL, Valdiserri RO, Holmberg SD. The acceptability of voluntary HIV antibody testing in the United States: a decade of lessons learned. AIDS 1996 12/96;10(14):1707-1717.

(9) Edberg M. Essentials of Health Behavior. Social and Behavioral Theory in Public Health. Sudbury, Massachusetts: Jones and Bartlett Publishers; 2007.

(10) Goodhue T. Executive Office of Health and Human Services Department of Public Health, Memo. 2008 6/6/08:1.

(11) Prudent N. 2009 4/2/09;Lecture.

(12) Kalichman S, Coley B. Context framing to enhance HIV-antibody-testing messages targeted to African American women. Health Psychol. 1995;14:247-254.

(13) Berlo D, Lemert J, Mertz R. Dimensions for evaluating the acceptability of message source. Public Opin. 1969;33:563-576.

(14) Levy V, Prentiss D, Balmas G, Chen S, Israelski D, Katzenstein D, et al. Factors in the Delayed HIV Presentation of Immigrants in Northern California: Implications for Voluntary Counseling and Testing Programs. J Immigrant Health 2007;9:49-54.

A Critique of the Screen for Life Colorectal Cancer Screening Campaign – Jeremy Hetzel

Introduction
Colorectal cancer is the second leading cause of cancer-related death in the United States. In 2008, an estimated 148,000 individuals were diagnosed with colorectal cancer and 50,000 individuals died from colorectal cancer.(1) Colorectal cancer is also preventable through screening interventions such as fecal occult blood test, flexible sigmoidoscopy, and colonoscopy. The United States Preventive Services Task Force currently recommends these screening interventions for all men and women over the age of 50.(2) However, less than half of the US population has received proper screening.(3) Clearly, public health interventions are needed to encourage screening behavior and subsequently reduce cancer related morbidity and mortality. In this paper, an existing public health campaign, the Screen for Life campaign, will first be critiqued. A new campaign, the Polyp Man campaign, will then be proposed to improve upon the shortcomings of the Screen for Life campaign.
In 1999, the Screen for Life campaign was launched by the Center for Disease Control and Prevention, the Center for Medicare and Medicaid Services, and the National Cancer Institute. The campaign is based extensive literature reviews, informant interviews, focus groups, conversations with medical experts, and guidance from a professional communications firm. The goal of the campaign is to raise awareness for colorectal cancer screening among all Americans over the age of 50, with a special focus on African Americans, Hispanics, Alaska Natives, and Medicare beneficiaries. The campaign consists of public service announcements via television and radio, as well as posters, brochures, fact sheets, and print advertisements.(4)
The Screen for Life campaign is grounded theoretically in the Health Belief Model. Subsequently, it shares benefits and flaws common to all Health Belief Model campaigns. The Health Belief Model posits that behavior is motivated by the balance of four factors: perceived susceptibility, perceived severity, perceived benefits of an action, and perceived barriers to taking that action. If the perceived benefits and susceptibility outweigh the perceived An individual weighs his perceptions of a behavior to formulate an intention regarding the behavior. The probability that the individual will act on his intention is dependent on the occurrence of an external event to motivate the action, known as a cue to action, and the individual’s belief in his ability to successfully change his behavior, known as self-efficacy(5; 6) The intention of the Screen for Life campaign is to alter individuals’ perceptions of colorectal cancer screening to minimize the perceived barriers and maximize the perceived benefits, severity, and susceptibility. The campaign also offers cues to action and attempts to increase individuals’ self-efficacy.
The campaign assumes sufficient causes
A fundamental assumption of the Screen for Life campaign is that insufficient knowledge of colorectal cancer and colorectal cancer screening causes a reduction in the probability that an individual will undergo screening. This assumption is well supported by previous studies. In a review of the literature, Subramanian and colleagues(7) found six studies that reported a statistically significant association between knowledge of prevention strategies and adherence to screening guidelines, and only one studied failed to find such an association.(8) Additionally, subjects who believed that screening was effective were more likely to undergo screening, and subjects with a fear of cancer or belief that cancer is incurable were less likely to undergo screening.(5; 9) The Screen for Life campaign subsequently aims to better the public’s knowledge of colorectal cancer screening, which it assumes will cause an increase in screening adherence.
The assumption of the Screen for Life campaign is flawed because it implicitly treats colorectal cancer screening knowledge as a sufficient cause of colorectal cancer screening adherence, when it is instead a component cause. This subtle yet important distinction is illustrated in Rothman’s heuristic model of causal inference,(10) which will be referred to here as the Causal Pie model. The basis of the Causal Pie model is that an outcome may be caused by the combined effect of many individual causes. Individual causes are named ‘composite causes’. Any combination of composite causes that results in an outcome is named a ‘sufficient cause’.
To demonstrate, three sufficient causes of colorectal cancer screening adherence will be defined. Sufficient Cause A is composed of colorectal cancer screening knowledge and physician recommendation. Sufficient Cause B is composed of colorectal cancer screening knowledge and socioeconomic status. Sufficient Cause C is composed of physician recommendation and socioeconomic status. In this example, perfectly educating the population of the benefits of colorectal cancer screening will result in increased adherence only if physician recommendation or a threshold socioeconomic status is also present. Adherence may also be increased by increasing physician recommendation and socioeconomic status without any increase in colorectal cancer screening knowledge. The important lesson is that increasing knowledge will complete a sufficient cause in some individuals but not all individuals.
There is reason to suspect that the population’s knowledge of colorectal cancer screening will reach a level where the causal component of knowledge will be satisfied for all individuals. Increasing the knowledge past this threshold will have no effect on adherence rates, since all non-adhering individuals will be lacking a different component cause. Jorgensen and colleagues admit that in 1998, when the four year formative focus group research for the Screen for Life campaign began, participants “showed a lack of knowledge and skepticism about the incidence of the disease, combined with discomfort discussing it”. During later years “participants were generally more aware of colorectal cancer and appeared more comfortable talking about the disease and the need for screening”.(4) This is evidence that the public awareness of colorectal cancer was already increasing prior to the launch of the campaign.
Many other component causes for colorectal cancer screening adherence have been identified. Physician recommendation of screening was always found to be associated with adherence in Subramanian and colleagues’ review of the literature.(7) In one study, subjects were 12 times more likely to comply with screening guidelines if recommended by their physician.(11) Other potential component causes include continuity of care, education, health insurance, sex, smoking, family history of colorectal cancer, and race.(12) Future campaigns could improve upon the Screen for Life campaign by targeting these additional component causes.
The campaign is urban-centric
Jorgensen and colleagues explicitly state that racial minorities were a target audience of the Screen for Life campaign. Televised, radio, and print media were tailored to African-American, Hispanic, and Native Alaskan sub-populations after extensive focus group research.(4) However, the campaign has been criticized for being urban-centric and ignoring rural populations. In a focus group study, Appalachian residents aged 50 years or more reported that the actors in the Screen for Life advertisements were too old, appeared less active and healthy than the study participants, and lacked simple eye-catching messages.(13)
Campo and colleagues conducted a series of studies in rural Appalachia to monitor the effectiveness of the Screen for Life campaign and assess discrepancies in the campaign aims and needs of individuals living in rural Appalachia.(13) Appalachia residents are particularly susceptible to reduced colorectal cancer screening adherence due to reduced access to health care facilities, economic vulnerability, and reduced health care coverage.(14) A quasiexperimental trial comparing the effect of the Screen for Life education materials to unexposed controls in Appalachia demonstrated that individuals exposed to the Screen for Life education materials were no more likely than the unexposed individuals to plan to undergo screening or to understand the risks of colorectal cancer and benefits of screening.(13) A survey of 905 individuals revealed that less than 50% could correctly identify the recommended age to begin colorectal screening surveillance, age 50. In a 2007 study of 356 individuals at a primary care facility in Boston, 74% correctly identified the recommended age to begin surveillance.(12)
The Screen for Life campaign is an evidence based public health campaign, however it is based on racially diverse yet regionally homogenous focus group research. The educational materials of the campaign were developed to appeal to urban individuals, however the campaign fails to address the complex interactions between cultural, sociopolitical, and economic conditions across the United States, especially in rural areas.(15)
The campaign assumes behavior follows intent
The failure of the Screen for Life campaign to modify the behavior of colorectal cancer screening in the Appalachian cohort is also illustrative of a third flaw common to all Health Belief Model Interventions: behavior does not follow from reasoned intent.(16) An assumption of the Screen for Life campaign, and all Health Belief Model campaigns, is that individuals intending to undergo screening actually will undergo screening. Although being exposed to the logical argument that colorectal cancer screening reduces the risk of morbidity and mortality, Appalachian residents reported being more concerned that the Screen for Life advertisements depicted subjects who did not look like Appalachians and used messages that were neither simple nor eye-catching.(13)
A study conducted by Vanderpool and colleagues provides anecdotal evidence that the increased awareness of colorectal cancer screening does not yield increased adherence. The study interviewed directors of the community based Appalachia Cancer Network, a National Cancer Institute funded special populations network created to address cancer disparities in Appalachia. The Appalachia Cancer Network was responsible for disseminating television, radio, and print media at the local community level. The authors concluded that the aims of the Screen for Life campaign were not well executed at the community level. The authors reported that the sentiments of the directors were summarized by the following quote, “Screen for Life is a great idea. It's good for national awareness, but it needs another level to actually impact CRC screening”.(17) The director acknowledges that the campaign succeeds at creating a national awareness of colorectal cancer screening, however this does not result in changed behavior at the local level. Further evidence for a lack of change in behavior resulting from the increased awareness is difficult to assess given a lack of longitudinal studies assessing both knowledge of screening and screening rates. However, the most recent estimates of screening adherence alone in the United States from the Behavioral Risk Factor Surveillance System. The overall adherence has risen slightly from 56.8% in 2004 to 60.8% in 2006.(18) While a 4% rise is a change in the right direction, it is unknown what proportion if any of the change is attributable to the Screen for Life campaign.
Conclusion
The Screen for Life campaign is a Health Belief Model based public health intervention. As such, it assumes that providing individuals with rational evidence in support of screening behavior will result in an increase in adherence behavior. Theory suggests that this logic is flawed, and anecdotal reports from the directors distributing the material suggest that there is a disconnect between national awareness and local adherence. Furthermore, the campaign is urban-centric, having been developed in urban focus groups, and fails to address the complex interactions between cultural, sociopolitical, and economic conditions in differing regions. Finally, by only addressing the knowledge deficit of colorectal cancer screening, the campaign focuses on only one component cause of screening adherence. Failure to incorporate other component causes into future public health interventions may result in stagnation of the screening rate.

Proposal for the Polyp Man Campaign
In 1999, the Screen for Life campaign was launched by the Center for Disease Control and Prevention, the Center for Medicare and Medicaid Services, and the National Cancer Institute, to improve screening adherence. Although based on substantial research, the campaign suffers fundamental flaws which are addressed in an accompanying article. Here, I propose an alternative campaign, named the Polyp Man campaign, which is a national and regional advertising campaign aimed multiple barriers to screening and sensitive to regional contextualization. Common to the advertisements is an anthropomorphized polyp attempting to interfere with the daily lives of hard working Americans, only to be squashed, allowing the Americans to return to their daily, jovial activities. The Polyp Man campaign is inspired from the American Cancer Society campaign of the same name, but much expanded in scope.4 A brief example of a Polyp Man advertisement is provided to facilitate discussion.
A family is sitting around the television watching the show Jeopardy! Included are a grandmother, grandfather, father, mother, young boy, and a toddler-aged girl sitting in a highchair. The family is laughing and carrying on. The Final Jeopardy music begins to play. A man in a polyp suit, Polyp Man, slowly waddles through the door towards the grandmother. He resembles Curly from the Three Stooges. The laughter softens as Polyp Man approaches the grandmother, and the laughter stops as he begins to pull the grandmother and her chair away from the family. The family begins glancing at each other nervously as the grandmother is pulled farther away. As the third to last note in the Final Jeopardy song sounds, the toddler-aged girl knocks Polyp Man on the head with a toy, resulting in a loud ‘boink’. Polyp Man reacts in a fashion similar to the Three Stooges and runs away, leaving the grandmother behind. The toddler girl giggles, and the family resumes laughing and carrying on. The commercial closes with Alex Trebek saying, “And the answer is, ‘Squash the polyp, contact your doctor or visit squashthepolyp.com’”.
Advertisement theory escapes the fallacy of reasoned intent
The Polyp Man campaign improves on one flaw of the Screen for Life campaign by its foundation in advertisement theory instead of the health belief model.(6) A fatal flaw of the health belief model is that behavior follows from reasoned intent.(16) The Polyp Man campaign will be instead modelled after the Y&R Creative Work Plan (the Plan), an advertisement theory which does not rely upon reasoned intention. The components of the Y&R Creative Plan are the following: Key Fact, Problem, Advertising Objective, and Creative Strategy. In the Polyp Man campaign, the Key Fact is that unmet component causes are preventing subjects from adhering to screening recommendations , and the Problem is that failure to adhere to screening guidelines increases morbidity and mortality from colorectal cancer. The Advertising Objective is to increase screening adherence. However, the Objective is achieved by a Creative Strategy, not an appeal to reason. The Creative Strategy has an additional four components. First, the Prospect Definition is a description of the target audience. Second, the Competition is the status quo of not adhering to screening guidelines. Third, the Promise is the best argument in favor of screening given the key fact. Finally, a Reason why the campaign will deliver the promise.(19; 20)
Importantly, the Y&R Creative Plan does not appeal to the reason of the target audience and is adaptable to varying component causes and regional audiences. An appeal to reason is avoided, because the Promise is not about the attributes of screening, such as reduction in mortality statistics or descriptions of social norms regarding colonoscopy. Instead, the Promise is about a benefit of screening, which in the introductory example is continued membership in an American family. However, the Promise may be modified to best appeal to varying target audiences. The Reason why is not an explicit explanation of how screening prevents CRC or why other individuals have chosen screening colonoscopy, it is a simple implication that people undergoing screening achieve the Promise. In the introductory example, the Reason was that the Polyp Man was dispatched by a toddler, which hints at the protective effect of removing polyps, but without any reference to medical terminology or invasive procedures. Finally, the Polyp Man campaign is sensitive to the psychological and cultural differences between regional audiences, which is lacking in the traditional health belief model.(15) Regional focus groups will allow for the creation of regional advertisements that address Key Facts and target audiences specific to a region.
Sensitivity to regional contextualization
Although racial minorities were explicitly stated as a target audience of the Screen for Life campaign,10 the campaign has been criticized for being urban-centric and ignoring rural populations.11 The educational materials of the campaign were developed to appeal to urban individuals and fail to address the complex interactions between cultural, sociopolitical, and economic conditions across the United States, especially in rural areas.(15)
The Polyp Man campaign will improve on the Screen for Life campaign by separating the national and regional advertisement campaign efforts. The national campaign will focus on the general US population, with a long term goal of changing screening behavior by socialization methods.(21) The regional campaigns will be more sensitive to the sociocultural context of local communities. These regional campaigns will be managed by local teams which will rely on focus groups to develop material optimized for the regional community. For example, Campo and colleagues conducted focus groups of Appalachian residents aged 50 years or more and reported that the actors in the Screen for Life advertisements were too old, appeared less active and healthy than the study participants, and lacked simple eye-catching messages.(13) The Polyp Man regional campaigns in Appalachia will employ young, active image in order to contextualize the campaign messages to Appalachia. Additionally, as described in the previous section, the regional campaigns will address Key Facts of the specific region.
Focus on multiple component causes
A third flaw of the Screen for Life campaign is its focus on a single component cause of colorectal cancer screening behavior, namely subject knowledge of colorectal cancer. The Polyp Man campaign will improve upon the Screen for Life campaign by specifically addressing multiple component causes that have been exposed in the literature. For example, Subramanian and colleagues identified physician recommendation as a consistent predictor of colorectal cancer screening among 44 reviewed studies.(7) In a cross-sectional study by Zapka and colleagues, subjects were 12 times more likely to comply with screening guidelines if recommended by their physician.(11) Thus one component of the Polyp Man campaign will be aimed at physicians through advertisement campaigns in medical journals, related websites, and professional conferences. The campaigns will use advertisement theory methods, discussed later in this paper, to encourage physicians to recommend screening to patients and to make physicians aware of physician-patient communication barriers such as personal health beliefs, power, listening ability, trust, directness, and racial or ethnic discordance.(22)
Individual patient level component causes will be addressed by national and regional advertisement campaigns. These campaigns will focus on barriers to screening identified in the literature such as continuity of care, education, health insurance, sex, smoking, family history of colorectal cancer, race,(12) dislike for blood tests, time off from work, and transportation.(23) A lack of knowledge of the risks of colorectal cancer remains a barrier to screening, Subramanian and colleagues(7) found significant associations between knowledge of prevention strategies and adherence to screening guidelines in all but one study reviewed.(8) Additionally, subjects who believed that screening was effective were more likely to undergo screening, and subjects with a fear of cancer or belief that cancer is incurable were less likely to undergo screening.(9; 24) Thus the Polyp Man campaign will collaborate with national and regional television networks to incorporate colorectal cancer educational segments into news programming. However, unlike the Screen for Life campaign, patient education will not be the sole aim of the Polyp Man campaign.
Conclusion
The Polyp Man campaign is a national and regional advertising campaign aimed at multiple barriers to screening and sensitive to regional contextualization. The campaign improves upon the traditional health belief model based Screen for Life campaign in three important ways. First, by employing advertising theory, the Polyp Man campaign escapes the fallacy of reasoned intent. Second, the campaign is sensitive to contextual differences in regional populations. Third, the campaign focuses on multiple component causes, increasing the likelihood that sufficient causes will be fulfilled and screening adherence increased. Colorectal cancer is a major cause of morbidity and mortality in the United States. Traditional public health interventions have not substantially increased screening adherence. The Polyp Man campaign is a non-traditional alternative that aims to reduce the burden of colorectal cancer.

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Heart Disease is the Leading Killer of Women - The Go Red Campaign’s Contribution – Susan Palmer

Introduction
What do you think of when you hear the term “heart disease”? Most admit to only thinking that it is the leading cause of death among men. Many do not know that heart disease is the leading cause of death among women as well. Heart disease includes any disorder affecting the heart’s ability to function properly. This term is defined by the International Classification of Diseases (ICD) and used by Center for Disease Control's (CDC) National Center for Health Statistics (NCHS), to include “acute rheumatic fever, chronic rheumatic heart disease, hypertensive heart disease, coronary heart disease, pulmonary heart disease, congestive heart failure, and any other heart condition or disease” (1). Heart disease is the leading cause of death for both men and women in the United States (US), and accounted for approximately 28% of the 1,244,123 deaths among women in 2002 (1-2). According to the CDC’s Division for Heart Disease and Stroke Prevention, “awareness of heart disease is the number one killer of women… only 13% of the women in [a] 2003 survey perceived heart disease as their greatest health problem” (1).
There is a surprising lack of public health campaigns currently in action for prevention of heart disease, especially considering the disease is the leading cause of death among women in the US. The American Heart Association (AHA), the largest voluntary health organization, has a mission to build healthier lives free of cardiovascular diseases and stroke (3). Their Go Red for women campaign launched as recently as February of 2004 and aimed to “educate women that heart disease is their leading cause of death” (4). Unfortunately, the campaign is not as recognizable as other public health intervention campaigns such as Lance Armstrong’s “LIVESTRONG” campaign for cance or Susan G. Komen’s “for the cure” for breast cancer campaign. The Go Red campaign incorporates a forgettable catch phrase and uses a red dress as their symbol, which is incidentally the same symbol for the National Heart, Lung, and Blood Institute (NHLBI) Heart Truth campaign. In a study of 81% of women reporting they had heard about heart disease within the past 12 months, only 23% of those women had “seen, heard, or read any information about the ‘red dress’ symbol” (5). Oddly, the AHA does not have the campaign advertised on their main webpage and it takes a bit of searching to find a link to the Go Red campaign. The Go Red campaign is seemingly just a slogan suggesting that women wear red to show their support for the fight against heart disease. But it is not clear how that “fight” is being employed. How is wearing red really going to get the word out there that heart disease is the number one killer of women? The failure of this public health campaign contributes to lack of awareness of heart disease among women.
A Flawed Foundation
One major flaw of the campaign is that it seems to have been designed upon the Health Behavior Model (HBM). Based on the HBM, the campaign assumes that a woman will rationally consider her susceptibility to heart disease and the severity of heart disease if action is not taken (6-8). The campaign attempts to educate the possible risks and severity of heart disease if left untreated by providing heart disease statistics and literature on their website. It is assumed that if a woman perceives a high risk and severity of heart disease, she will then contemplate the benefits and barriers to a proposed action. The campaign’s aim is to empower women to the benefits of talking to their doctor about heart disease. By providing a “Go Red Heart CheckUp” on their website, the AHA is providing a forum upon which women can check their heart disease risk online and then print the results to bring to their next visit to the doctor. The idea here was to show women that the costs of assessing heart disease are low and access to information is plentiful, and thus the barriers are low. Upon determining that the benefits are high and the barriers are low, the campaign assumes a woman will move forward with intent to lower her heart disease risk.
In theory, this campaign would educate and persuade a woman to take preventative action against heart disease. However, few studies have evaluated whether perceived susceptibility to heart disease is associated with action to lower that risk (5). The campaign does not account for the social and environmental factors that influence a woman’s decision, such as language barriers, and lack of access to a computer or internet to utilize their website (6-8). It also does not account for those who lack access to healthcare because they do not have health insurance or do not live within close proximity to a hospital or doctors office. Additionally, the campaign does not have motivational measures in place. For example, a woman may have heard of the Go Red campaign, accessed the website, decided to assess her risk of heart disease using the “Go Red Heart CheckUp,” and found that she was indeed at risk for heart disease. When prompted at the end of the “CheckUp” to print the information out to bring to her doctor, she did so intending to schedule a visit. However, as in most cases, her doctor could only schedule her for a visit 2-3 months later, and during that lapse in time between the intention and the action, the woman decides it is not as important as originally thought, or she has a scheduling conflict, and cancels her appointment. The woman is not motivated to see her doctor or address her risk of heart disease and six months later she has a heart attack. The campaign has failed its mission.
Undermining the Call to Action
The Go Red campaign encourages awareness through informational education, but lacks tools to promote self-efficacy. Self-efficacy in this case is a woman’s belief that she can perform a certain behavior (6-8). Specifically that would mean taking steps to preventing heart disease by lowering her risks. This campaign does not translate the message into real world action to prevent heart disease. The idea of “action” for this campaign is to wear red and be educated on heart disease risks. In reality, action should be promoted not only as a chat with your doctor about your risks, but by getting involved in exercise programs or smoking cessation classes to lower risks. A 2006 study reported that women who expressed self-efficacy believed their actions could impact their risk of heart disease (5). These women were more likely to take part in physical activity and to have lost weight in the previous year (5). The study also reports that the five most common motivators for taking action to lower their risk were 1) wanting to improve health, 2) wanting to feel better, 3) wanting to live longer, 4) wanting to avoid taking medications, and 5) did it for their family (5). So it seems that there is not a lack of “wanting” to be healthy, and that the real problem may be that women are not provided with the tools to help them take action.
The Go Red campaign’s attempt to advocate action includes long “to-do” lists of ways to decrease the risk of heart disease. Such lists include “make easy lifestyle changes,” “tips for women at work,” “tips for moms on the go,” “tips for traveling for work/play,” “love your heart: relaxation tips,” with each list containing at least five actions (4). While providing helpful tips for heart-friendly activities is a step in the right direction, long “to-do” lists may prove to be more overwhelming than anything else. Tools to promote self-efficacy by showing her how to take action are not provided.
In most cases, an individual who learns a behavior by observing others and builds the skills to do that behavior will be more likely to do that behavior, especially if they believe that the behavior will lead to a positive outcome. Simply providing lists of heart-healthy activities is not enough to promote self-efficacy. Women need to feel as if they can be successful and will receive positive reinforcement for engaging in these activities. Offering AHA sponsored activities such as free heart disease risk assessment, physical activity classes, and heart-healthy nutrition seminars may help build self-efficacy. By providing women with the skills and motivation, as well as interaction with others who have heart disease risks, it will motivate them into action. Without provision of self-efficacy tools, women will feel helpless despite their “want” to take action to reduce heart disease risks. The campaign has failed its mission.
Missing the Target
Despite the reality that heart disease is the leading cause of death among women in the US, a survey conducted by the AHA in 1997 indicated that 62% of women believe cancer is the greatest health threat for women (9). Since that survey was taken, and new public health interventions have been implemented, an increase in awareness of heart disease risk has been documented (2, 5, 9, 10, 11). However, it remains inconclusive whether greater awareness has led to increased preventative actions among women (5). The Go Red campaign may only be targeting women who already perceive themselves as having a high risk of heart disease, and not those that are unaware of their risk. A study run by the AHA found that awareness was significantly greater among those who perceive themselves as having a high to moderate risk compared to those at low risk (5).
The CDC reported in 2002 that age-adjusted death rates for heart disease were higher among African American women (169.7 per 100,000) than among Caucasian women (131.2 per 100,000) (12). A 2006 study reported that racial and ethnic minorities, such as African-American women, were less likely than whites to be aware of their heart disease risk (5). Of those who were aware of a risk, minorities were more likely than whites to underestimate their risk (5). The Go Red campaign uses television, print, radio, internet, and billboards to advertise the campaign. However, the number of advertisements is limited and they fail to target African American women, who are the highest risk group. Print advertisements in newspapers and magazines are most inclusive of African-Americans. In these ads, a picture of an African-American woman is used in tandem with the Go Red slogan and message to “Go Red in Your Own Fashion” (4). However, of women aware of heart disease information, more Caucasian women (46%) reported magazines as their source of information, compared to 28% of African-American women. The Go Red campaign does not use television, radio, or billboards to target the African-American group and only use Caucasian women in the advertisements (with a Hispanic radio version available dubbed in Spanish) (4). These forums should not be discounted by the Go Red campaign and may contribute to the lack of awareness among African-American women.
A 2000 study reported that less than 20% of African-American women mentioned that they were well informed about heart disease (10). When asked to list warning signs of heart attack, less African-American women than Caucasian women correctly identified chest pain, shortness of breath, pain in the arm, chest tightness, and nausea (10). For a public health campaign designed to raise heart disease awareness among all women, Go Red seems to mostly reach Caucasian women, and not the highest at risk group of African-American women. The campaign has failed its mission.
Conclusion
The AHA’s Go Red campaign’s mission to spread awareness that heart disease is the leading cause of death among women has failed. For one, the campaign’s foundation has cracked under the pressure of the HBM’s lack of consideration for irrational behavior. Social and environmental factors that influence a woman’s decision are not accounted for and contribute to the campaign’s failure to educate women. The campaign lacks the tools necessary to empower women to believe their actions could impact their risk of heart disease. Instead of only promoting the wardrobe choice of wearing red, the campaign should provide resources for women to join exercise programs or smoking cessation classes to lower heart disease risks. Additionally, the campaign contributes to the lack of awareness among African-American women by not targeting this high risk group in their campaign efforts. These awareness and preventive action gaps in the Go Red campaign contribute to preventable heart disease among women in the US and must be amended before more lives are lost.
Counter-Proposal to the Go Red Campaign for Heart Disease among Women
Introduction
Improvements must be made to the current approach implemented by the Go Red campaign, whose mission to spread awareness and prevent heart disease among women is failing. An alternative campaign will attempt to remedy the major flaws of that approach and feature a new design to support a shift towards empowerment. The new design will remove the Health Behavior Model (HBM) from the foundation and instead consider social and environmental factors, implement tools empowering women into action, and target African-American women, the most at risk group affected by heart disease.
The new public health campaign proposed will promote heart disease awareness through organized walk/run/bike events in all major cities throughout the year, focusing on team participation and fundraising efforts. Participants will have the option of signing up individually or with a “team,” and to raise a minimum amount of money by the day of the event. The funds raised will go towards heart disease advocacy efforts. This campaign is modeled after two of the most renowned public health campaigns, the Susan G. Komen breast cancer Race for the Cure and the Lance Armstrong LIVESTRONG for cancer. Both campaigns heavily promote advocacy for cancer awareness through physical activity and fundraising events such as walk/run or bike races. The new campaign will frequently advertise the events using various media including television, radio, internet, billboards, and magazines. Paired with popular sponsor involvement (New Balance, Nike, Powerade, etc.), the cause will be able to reach a wide audience. In addition to promoting physical activity on the day of the event, the sponsors will provide free local heart disease risk assessments/screenings, heart healthy physical activities and nutritional seminars throughout the year in effort to provide women with the tools to live healthy lifestyles and stay motivated.
Building a Strong Foundation
The HBM is a weak foundation upon which to design a public health campaign because it does not take into account all factors that influence an individual’s decision on whether or not to do a behavior. Upon studying the HBM, researchers have reported that despite various preventative measures provided free or at low cost, people fail to take advantage of early detection (7). This new heart disease awareness campaign aims to take advantage of alternative health models which are based on the theory that behavior is irrational, people are influenced by expectations, have difficulty with self control, and place a high value on ownership.
The new campaign will be based upon the Social Network Theory (SNT), the main premise being that groups of people change together. The relationships that people have with each other, such as families, work groups, or other social groups, influence each others’ beliefs and behavior (6). People exist in social networks and change as social networks, not only as individuals. This campaign strives to work with this theory to provide women at risk for heart disease the tools to build a heart disease social network. This social network will be the forum upon which they become empowered by each other to address the disease in a proactive manner.
Specifically, a woman at risk or who already has heart disease will become a member of an event team working together to improve their physical, nutritional, and emotional health in tandem with promoting awareness. Team members involved in working towards the walk/run/bike event will recruit others into the team (or “network”). Whereas the SNT typically identifies small networks to disseminate information, the new campaign builds upon the theory to appeal to a larger population. An article assessing the dynamics of a large social network on smoking cessation, describes how people seemed to be under the “collective pressure” within networks to quit smoking (13). This can also be applied to promoting healthy behavior such as heart healthy physical activity.
While the campaign may start with one person deciding to join a heart disease awareness event, that one person can recruit others to become a member of their “team,” thus spreading awareness to others (6, 13). Where the Go Red campaign was hitting barriers, the new campaign’s efforts would not be negatively impacted by lack of access to a computer or internet, or lack of access to healthcare, since the events would be locally available to all participants. Motivational measures would be in place and awareness of heart disease among women would spread.
A Time to Act
The Go Red campaign failed to translate their message into action by only advocating education on heart disease risks and wearing the color red. The new campaign aims to provide women with the tools needed to promote self-efficacy. Women have reported the intent to participate in healthy behavior, but they need to believe they can lower their risk of heart disease, and be shown how to do that (5). The new campaign offers events to get people participating in heart disease awareness activities.
Sponsored activities such as free heart disease risk assessment, physical activity classes, and heart-healthy nutrition seminars will help raise awareness and build self-efficacy. Encouraging women and their teams to not only participate in a local walk/run/bike event, but also to participate in free health activities will motivate life-long healthy behavior. The most important factor in the decision to do a behavior is the idea of “self-efficacy” where the individual has self-confidence in the ability to do that behavior. This new campaign will encourage women to participate in an event that is heart healthy, offers encouragement through a team atmosphere, and aids in holding participants accountable through fundraising efforts.
The “team” factor will not only be the primary motivator on the day of the event, but will also be a source of continuous support during the time leading up to the event. Participants will be more likely to adhere to a physical and nutritional regime if they have others (their team) to report to (13). Raising money will also keep participants accountable to sticking with the event. By asking people to donate to their event, they are much less likely to drop out, and more likely to stay motivated. Involvement in this campaign creates a sense of community where everyone is working together to get healthy and raise awareness for heart disease. The belief that the campaign will lead to a positive outcome will reinforce life-long healthy behavior and participation in heart-disease awareness efforts.
Tailoring the Message
Many women report that they believe they are most at risk for breast cancer, which infers that the Go Red campaign has failed to deliver their message (9). Specifically, African-American women who are most at risk of heart disease have reported not being well informed about heart disease risks (10). The new campaign aims to reach a wider audience, particularly African-American women. Heart disease awareness walk/run/bike events will be held in or within close proximity to major cities, targeting the areas with a high African-American population. Additionally, free local heart disease risk assessments/screenings, heart healthy physical activities and nutritional seminars will be available throughout the year in effort to provide women with the tools to live healthy lifestyles and stay motivated at no cost to them. A 2006 study found that friends and/or relatives were more influential in motivating preventive action in nonwhites than whites (5). This finding is supported by the new campaign’s team participation design, predicting that team members, in particular African-Americans, will help support each other’s efforts towards heart healthy behavior.
All events will be heavily promoted using television, radio, internet, newspapers, magazines, and billboards. Advertisements will include versions specific to Caucasian, African-American, and Hispanic women so that the target audience(s) can personally identify with the message. In a 2003 study, 41% of African-American women reported television as the most common provider of healthcare information (2). Based on this information, a higher concentration of advertisements tailored towards African-American women should be broadcast on television. By simply increasing the frequency, circulation, and tailoring of advertisements to African-American women, the campaign should reach more people and increase awareness of heart disease.
Conclusion
The new public health campaign proposed will promote heart disease awareness through organized physical activity events in all major cities throughout the year, focusing on team participation and fundraising efforts. The new design will be supported by the SNT, concentrating on the relationships that people have with each other and the positive influence of social networks. Tools such as free local heart disease risk assessments, heart healthy physical activities, and nutritional seminars will be made available, empowering women into action. Advertisements tailored to African-American women will reach a larger number of those most at risk of heart disease. The combined effort of all three aspects of the new public health campaign will expand its reach more women at risk and hopefully motivate those women into action. REFERENCES
1. Department of Health and Human Services Centers for Disease Control and Prevention, Women and Heart Disease Fact Sheet. Atlanta, GA: Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, 2009. http://www.cdc.gov/DHDSP/library/fs_women_heart.htm
2. Mosca L, Ferris A, Fabunmi R, Robertson RM. Tracking Women’s Awareness of Heart Disease. Circulation 2004; 109:573-579.
3. American Heart Association. Mission of the American Heart Association. Dallas, TX. http://americanheart.org/presenter.jhtml?identifier=10858
4. American Heart Association. Go Red for women Media Kit 2008 fact sheet. Dallas, TX: American Heart Association Heart Disease and Stroke Statistics – 2008 Update. http://www.goredforwomen.org/media_resources.aspx
5. Mosca L, Mochari H, Christian A, Berra K, Taubert K, Mills T, Burdick KA, Simpson SL. National Study of Women’s Awareness, Preventive Action, and Barriers to Cardiovascular Health. Circulation 2006; 113:525-534.
6. Edberg M. Individual Health Behavior Theories. Essentials of Health Behav Soc and Behav Theory in Pub Health. 2007; 35-38.
7. Rosenstock IM. Historical Origins of the Health Belief Model. Health Education Monographs. 1974; 2:328-335.
8. Salazar MK. Comparison of Four Behavioral Theories. AAOHN Journal. 1991; 39:128-135.
9. Robertson RM. Women and Cardiovascular Disease – The Risks of Misperception and the Need for Action. Circulation 2001; 103:2318-2320.
10. Mosca L, Jones WK, King KB, Ouyang P, Redberg RF, Hill MN. Awareness, Perception, and Knowledge of Heart Disease Risk and Prevention Among Women in the United States. Arch Fam Med 2000; 9:506-515.
11. Christian AH, Rosamond W, White AR, Mosca L. Nine-Year Trends and Racial and Ethnic Disparities in Women's Awareness of Heart Disease and Stroke. Journal of Women's Health 2007; 16(1): 68-81.
12. Centers for Disease Control and Prevention. Public Health Action Plan to Prevent Heart Disease and Stroke. Atlanta, GA: Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, 2009. http://www.cdc.gov/DHDSP/library/action_plan/pdfs/action_plan_2of7.pdf
13. Christakis, NA, Fowler JH. The Collective Dynamics of Smoking in a Large Social Network. The New England Journal of Medicine 2008; 358:2249-58.

“Ask Me If I Have Washed My Hands:” A Critique of Patient-Centered Handwashing Campaigns for Health Care Workers – Christine Zachek

The Centers for Disease Control and Prevention estimate that, in American hospitals alone, hospital acquired infections account for 1.7 million infections and 99,000 deaths each year (1). Handwashing has become widely accepted as one of the most important activities in reducing pathogen transmission in health care settings (2). However, compliance with handwashing standards among physicians and hospital staff is unacceptably low, often with rates less than 40% (3). Recent interventions have focused on increasing patient involvement in protecting against hospital-acquired infections. A typical intervention of this type will ask physicians and nurses to wear a button that reads, “Ask me if I have washed my hands” (4) or a sticker that adheres to a patient’s hospital gown that says, “Did you wash your hands?” (5). Some strategies also recommend incorporating an element of patient education, by placing brochures in patient areas around the hospital emphasizing the importance of handwashing in reducing infection transmission (5-7). Evaluations of these campaigns have reported short-term success (8). However, research methods in this area provide unreliable indicators of health care worker behavior because studies are generally limited by small sample size; narrow scope of investigation; and failure to capture a complete range of health care worker activity (9-10). For reasons argued later in this essay, the long-term successes of these campaigns are dubious as they overlook significant social factors that regulate human behavior at the group level.
These campaigns are fundamentally flawed because they fail to account for significant social factors that inhibit patients from challenging their providers and fail to accurately predict the behaviors of doctors and hospital workers. These interventions narrow in scope as they are dedicated to changing behavior at the individual level by relying on patients to prompt health care workers to take action on a one-to-one basis. Creators of these campaigns frame their initiatives in terms of “empowering” patients to take an active role in their own safety and seem to rely on Albert Bandura’s concept of self-efficacy, or a person’s belief in his or her ability to take action, to motivate patients to act (11). A sticker or a button serves to remind and encourage patients to question their doctor or nurses’ hand hygiene habits, supposedly empowering them with self-efficacy (11). However, these interventions do not incorporate any environmental or contextual variables that are present in Bandura’s complete Social Cognitive Theory (12). The educational materials provided by some interventions are aimed at increasing patients’ perceived severity and perceived susceptibility to hospital-acquired infections. This directly follows the Health Belief Model (HBM), which states that individuals will rationally weigh the costs and benefits of an action and choose whether to perform an action based on this calculation (13-14). By increasing the patients’ perceived severity and perceived susceptibility to infections, this increases the perceived benefit of asking a provider if he or she washed his or her hands. So-called “empowering” patients through campaign materials would reduce the patients’ perceived barriers to performing the action under the HBM. The sticker or button serves a cue, or trigger, for the patient to question the provider about handwashing (14).
It is important to note that these interventions target the patients to ultimately change the behavior of another group – health care providers. The patient will not be completing the action that is the desired outcome (i.e. handwashing). The patients’ questioning will provide a cue to action, or an external event that will motivate the nurse or physician to act (12). The health care worker must ultimately complete the action, and as I will argue later, make it a habit in order to be effective in reducing infection transmission. Because the intervention targets and relies on a secondary group to prompt the group of interest, it allows for more potential missteps in the process to achieve the desired outcome.
While these campaigns purport the well-intentioned goal of increasing patient involvement in their care, a “self-defense” strategy to patient safety is questionable at best (15). These campaigns wrongly put the onus on the patients to ensure their own safety “in an environment over which they have no control” (15, p. 2065). These types of interventions fail to consider crucial group-level variables such as power dynamics; fear of damaging the physician-patient relationship; and lack of habitual action that severely limits the effectiveness of the intervention. These factors make it difficult for patients to follow the advice on the buttons and voice their concerns regarding their providers’ hand washing behavior in the first place, and even if this is accomplished, these interventions do not provide a good long-term strategy to make handwashing behavior a more regular occurrence in hospital settings.
Power Imbalance
Lessons from other public health and social science domains teach us that power differentials between individuals can have a substantial impact on individual behavior. This is evident in condom negotiations where gender-based power differentials in traditional societies lead to lower contraceptive use (16). In these instances, women fear that a husband’s disapproval of contraceptives will lead to loss of affection or divorce (17). In the hospital setting, the provider is in a position of power as patients generally do not possess extensive knowledge of medical sciences. This makes patients ‘abjectly dependent’ on their physicians for information and for treatment (18). Furthermore, patients enter into the hospital when they are sick, scared, and vulnerable. In a fragile mental and physical state, patients may not be able to assert their rights effectively or have the “presence of mind” to ask questions regarding handwashing (4, p.1). In this situation, patients are naturally reluctant to raise any issues that may be viewed as confrontational, such as asking hospital workers if they have washed their hands (4, 20). These interventions fail to consider the ramifications of power differentials in the hospital room, or falsely assume that a button or a sticker will be sufficient to override these imbalances.
The interventions also neglect to account emotional factors, such as the fear experienced by patients in a hospital facility. As mentioned in the contraceptive example, fear is a common emotion associated with power imbalance (17). Here, patients may feel they will not receive adequate treatment if they question their caregivers’ authority or ability to keep them free of infection (4). A study by Judith Lorber, which will be revisited later, found that most patients resented the passivity and submissiveness that characterize a patient’s perceived role in the rigid hospital structure. However, most hospitalized patients felt that this was the proper way to act, and that if they did not “keep Quiet,” their care would suffer as a result (21, p.214). George Annas and Joseph Healey echo, “Because a sick person’s first concern is to regain health, he is willing to give up rights that otherwise would be vigorously asserted” (22, p. 245). Ignoring larger, psychosocial factors that drive human behavior, as these interventions have done, is a significant error.
This power differential is amplified with particular populations such as the elderly, non-English speakers, and patients lacking health insurance. Elderly patients tend to be more passive with doctors as medical paternalism, or the notion that the “doctor knows best” and makes decisions for the patients, is more common among older generations (4, 19, p. 113). Aside from the obvious technical issues that non-English speakers would have reading the buttons and verbalizing a response, disadvantaged populations experience an even greater power differential with their physicians or other hospital staff. A patient lacking health insurance may think a physician is “doing them a favor” by treating their ailments under such circumstances, therefore, would not want to raise any issues that might jeopardize their treatment. Jodie Kliman recounts her personal experience waiting in an emergency room, and demanding an intervention from the hospital staff when her husband’s condition became increasingly severe. Reflecting on this experience, she questions whether she would be a widow today had she been of a different class or racial group and less willing or unable to assert herself in the hospital setting (23). She writes, “Many forms of privilege and power, or lack thereof, contribute to our interactions and beliefs… They permeate what we say, what and whom it silences, what we notice or overlook. They operate for those with privilege, and those without” (23, p. 43). These underlying forces were undoubted not considered in this intervention and leave it substantially lacking, particularly with respect to vulnerable populations.
The Physician-Patient Relationship
Based on the information presented in the previous section, the patient-centered handwashing initiative is likely to remain ineffective as patients are in a weaker position in the power hierarchy of a hospital setting and are therefore unlikely to assert themselves. This section will argue that the “ask me if I have washed my hands” intervention is not only ineffective, but has a negative effect on patient outcomes. The intervention fails to consider the broader aspects concerning the nature of the physician-patient relationship, the emotions involved, and the consequences of damaging it. While this paper uses the term, physician-patient relationship, this dynamic can also be applied to other types of providers and caregivers in the hospital setting.
Although the physician-patient relationship has deep historical roots, legal doctrines have outlined the duties of a physician that arise from the fiduciary (trust) nature of the relationship and presence of information asymmetries (18-19). The physician-patient relationship is more than a business-like transaction or simple exchange of information; it involves trust and compassion to make the patient feel comfortable relaying sensitive information to the physician and engaging in a meaningful discussion regarding treatment options (19). The handwashing intervention damages the physician-patient relationship by creating an atmosphere of confrontation, instead of one based on trust and mutual respect. When these qualities are not present, physicians are unable to obtain truthful and complete information from their patients, and patient care suffers as a consequence. Questioning a physician as to whether he or she washed his or her hands creates a combative relationship from the minute the physician enters the room. This interaction instills emotions of resentment and distrust that damage the physician-patient relationship. The failure of the intervention to consider the importance of the integrity of this relationship and the various emotions involved is a serious oversight.
Furthermore, physician education and training can lead to physicians being resistant to patients questioning their authority. Dr. Bruce Siegel comments that many physicians are taught to “think of themselves as little gods,” and would view a challenge to their handwashing habits from their patients as an affront to their authority and professional ability (4, p. 2). Many physicians might not even wear the buttons if they call these deeply engrained values into question. Physicians could also perceive their patients’ questioning as a threat to their personal or professional freedoms. The theory of psychological reactance states that any message that attempts to change behavior could be perceived as a threat to freedom. The mind reacts to preserve freedom by ignoring the request or performing more of the undesired behavior (24). Applied to this context, physicians might experience psychological reactance to a patient challenge (i.e. asking if the physician washed his or her hands) and refuse to take the suggested action. Anecdotal evidence indicates that physicians wash their hands when asked around 60% of the time, but do so quickly and begrudgingly (4, 8). This limits the quality of handwashing behavior (increasing the potential for pathogen transmission) and could possibly reduce the providers’ inclination to wash their hands in the future if they perceive this campaign as a threat to their freedom. The campaign’s failure to consider psychological reactance, and its potential effects on the quality of handwashing at the patient bedside and future consequences for physician behavior could lead to an increase in hospital infection rates.
As previously mentioned, this intervention does not take into account the emotion of fear experienced by most patients that they will not receive adequate care if they question the behavior of their doctors or nurses. A study by Judith Lorber may substantiate these fears, as it documents the possible consequences for patients who go against established hospital norms. Patients who were viewed by staff as cooperative, stoic, and uncomplaining were labeled “good patients.” Those patients who complained when staff felt it was medically unwarranted, were less submissive and, “did not subscribe to the norm of unquestioning obedience” were labeled “problem patients” (21, p. 217). The study found that patients labeled “problem patients” were more likely to be tranquilized or discharged early (21). The hang hygiene interventions could establish, and even encourage, more patients to become “problem patients” in the eyes of the staff. This damages the cooperative relationship between patients and caregivers, potentially leading to a decline in patient health status.
Habit Formation
The patient-centered handwashing intervention is further limited in its failure to establish staff handwashing behavior as a habitual activity. Evidence from psychology and behavioral science indicates that habitual actions govern a substantial part of daily life. Up to 47% of a person’s activities are conducted every day, usually in the same location (25). This consistency establishes what social scientists call habits or, “behavioral dispositions to repeat well-practiced actions given recurring circumstances” (26, p. 918). Much of our behavior (including handwashing) is regulated by habit, rather than by thoughtful consideration (27). Professional marketers and consumer psychologists know this concept well, and for years have sought manufacture habits by integrating consumer products into daily behavior (28). Advertising techniques use subtle habitual cues to tie products to a behavior. For example, Proctor and Gamble created an advertising campaign for Febreze that tied using the perfume to cleaning a room, something their target audience did daily, and sales soared (29).
The “ask me if I have washed my hands” campaign fails to consider the influence of ritual and habit over frequent behaviors. While doctors and nurses are presumably aware of the importance of handwashing in reducing disease transmission, the high frequency of handwashing behavior leads to a reduced consideration for the reasons for performing the behavior (3). Therefore, subtle cues and regular associations should be established in healthcare facilities to foster habit-formation. The patient-centered campaigns exclusively rely on an overt external cue, i.e. the patient prompt, for the behavior to take place. The sporadic nature of patient questioning fails to establish consistency in the hospital worker’s routine, thereby weakening the habitual nature of the action and likelihood that the action will take place on a regular basis (30).
The campaign is further limited because this interaction takes place at the individual-level, with one-on-one discussions between providers and patients. A more effective strategy, such as the one mentioned in the previous paragraph, would seek to change the behavior of healthcare providers as a group. One potential mechanism by which this might be accomplished would be to create salient associations in the minds of physicians to wash their hands every time they enter a patient’s room. The current campaign makes no attempt to establish linkages between a habitual cue and the provider’s handwashing behavior. These linkages proved to be a useful and successful tool in consumer product advertising, a strategy that is readily adaptable to public health interventions like handwashing (29).
Summary of Limitations
While the incorporation of patients and their families into medical decision-making is a noble purpose, the “ask me if I have washed my hands” strategy is misguided as it puts the responsibility for patient safety on the patients themselves. The patients’ control over the situation is limited, and the campaign does not produce an effective long-term strategy for improvements in hospital infection control. The campaigns fail to consider the inherent power imbalances that occur between patients and their caregivers that contribute to a patient’s reluctance to question hand hygiene habits. The interventions also foster a confrontational physician-patient relationship that can be counterproductive to providing patients with quality care. Since the interventions rely on patients to prompt their providers to wash their hands, providers do not create or maintain habitual handwashing behavior. Simply put: (1) it is unlikely that patients will question their providers in the first place; (2) if they do raise the issue, it may carry negative health consequences; and (3) this is not a viable strategy to produce lasting change.
The failure of these campaigns to consider the larger, group-level variables like power differentials, the importance of provider relationships, and habit formation are their downfall. Their narrow scope and individual focus have limited their effectiveness, and potentially caused declines in quality of care, to the detriment of patient safety in hospital settings.
Reintroducing a Role for Health Care Providers in Handwashing Campaigns
Patient-centered handwashing campaigns for health care workers present a faulty approach to reducing pathogen transmission in healthcare facilities. These interventions are not likely to achieve lasting effects on handwashing rates because they ignore significant social factors that influence both patient and provider behavior. The limitations of these campaigns include a failure to consider the power imbalance between patients and healthcare workers; the importance of preserving the physician-patient relationship; and the necessity of habit formation in handwashing behavior. Recognizing these limitations, this paper will propose a more comprehensive alternative to patient-centered handwashing interventions that addresses these three flaws and establishes long-term habit formation by changing behavior at the group-level.
Counter-Proposal: A Brief Outline
A patient-centered campaign to promote hospital handwashing relies on an ineffective power dynamic to change behavior and damages the physician-patient relationship. To address these two limitations, the frame of the intervention will shift to focus on changing the behavior of providers instead of patients.
Secondly, the patient-centered interventions rely on patients to prompt physician or nurse handwashing. This fails to establish handwashing as a habitual behavior, which is crucial for the long-term effectiveness of a campaign (26, 28). This counter-proposal introduces a three-pronged approach to creating a handwashing habit among providers. First, the intervention changes the hospital environment to make handwashing easier and more accessible. Second, advertising messages are developed to foster associations and cue providers to engage in handwashing activity. Third, the intervention encourages a change in institutional culture by working with top-level officials to make handwashing a priority for the facility. In developing and executing the provider-centered intervention, the reasons healthcare workers commonly cite for not washing their hands are taken into account. These include being too busy, forgetfulness, and skin irritation (31). Peer norms are also considered as they are significant predictors of handwashing behavior (27).
The Three-Pronged Approach
1) Changing the Hospital Environment

In order to make handwashing more convenient, alcohol-based sanitizers are placed in strategic locations in or outside patient rooms. To identify a suitable location for the dispenser, focus groups or observational research will be conducted to determine the activities most providers complete before entering a patient room. For example, hospitals usually keep a chart of patient information outside of the patient’s room. If providers routinely review this information before interacting with a patient, dispensers could be placed on the container that holds the chart as a reminder to sanitize hands. This would cue providers to use the sanitizer and incorporate it into their patient care routine. Multiple locations or distribution methods for hand sanitizer would be tested to determine which is the most effective. These could include dispensers at the patient bedside or individual-sized bottles given to doctors and nurses to keep in their pockets.
2) Advertising Campaign
Prong two of the intervention is the development of campaign messages linking handwashing behavior to habitual actions. First, focus groups will be conducted among different segments of hospital staff to better understand what motivates handwashing behavior and to determine what their core values might be (since protecting patients may not be the primary motivator for handwashing). For example, one series of questions could assess whether caregivers wash their hands because they are afraid of getting an illness from their patients. If this is the case, the advertising message could integrate the patient chart as the environmental cue and ask, “Picking up a chart? Don’t pick up an infection. Be sure to wash your hands before greeting your patients.” The focus groups would also investigate cues hospital workers associate with handwashing. If eating is a common cue, the advertising message could be constructed around cuing food and might read, “Would you eat with those hands? Wash up.” An example of appealing to a core value would be to appeal to a physician’s sense of authority with the message “Take charge of handwashing” in the campaign materials.
To assess the most effective campaign medium, the intervention team would probe the focus groups on ways they gather and receive information. Focus groups could be asked to identify which magazines, medical or nursing journals, and newspapers they read. Providers could also be asked if they would watch a video clip emailed to the hospital listserv, or if posters placed in the staff lounges would be readily noticed.
3) Organizational Change
For handwashing campaigns to produce lasting change, they must have active involvement and commitment from high-level administration (32). Therefore, senior staff will initiate a “culture of handwashing and patient safety” where everyone is working towards that shared objective (33-34). As a preliminary step, a letter from the CEO or medical director to all employees, volunteers, and physicians would state the leaders’ commitment to handwashing and to the proposed intervention (32). The institution’s name and logo can also appear on campaign materials to show support (31). In addition, top administrators would meet with the chiefs of each medical department, vice president of nursing, or other senior staff to enlist their support in implementing the first two prongs of the intervention. The goal is to ensure that each department has input on the implementation of the intervention, and can modify particular elements if they feel their staff would not respond well to a certain piece. Senior staff would then communicate the details of the intervention to their specific department during staff meetings or in communications materials. This should include information regarding the placement of hand sanitizers, their effectiveness, and ability to reduce skin irritation (35). These leaders would also engage in role modeling of handwashing behaviors. Role modeling would include demonstrating important values and expectations through their own actions and behaviors, as well as acknowledging and encouraging exemplary behavior in others (32).
Feedback and formal recognition are important elements of top-level involvement in the handwashing intervention to establish an institutional culture of handwashing (35-37). Monitoring of the progress of the intervention can be conducted by placing sensors on sanitizer and soap dispensers that count the number of ‘pumps’ taken; measuring the amount of soap and sanitizer used over a given time; or through observation of personnel (37). Recognition can come in the form of public praise at staff meetings or through posting compliance statistics for each unit in staff lounges, for example. Administrators should avoid using monetary rewards because this may take away from the intrinsic reward that one gets from protecting patients or from a “job well done” (36, 38).
Shifting the Frame to Address Power Imbalance and the Physician-Patient Relationship
The patient-centered handwashing intervention is fundamentally flawed because it fails to recognize the power differential between patients and physicians and fear of damaging the physician-patient relationship. Specifically, patients are reluctant to question their providers, especially in ways that might be viewed as confrontational, due to their lack of power and fear their care will suffer (4). Therefore, a handwashing intervention that relies on this questioning is unlikely to succeed as it overlooks significant psychosocial factors that impact behavior. Furthermore, creating a confrontational physician-patient relationship can have a negative effect on patient outcomes because it diminishes the trust and mutual respect required to provide quality care (19). A better alternative is to target the group that will complete the desired outcome, i.e. the providers. Providers have more control over their handwashing behaviors in the hospital setting and are not constrained by these psychosocial factors to the same extent that patients are (15).
The alternative intervention employs Framing Theory to address the above limitations, and sends a message to hospital administrators to shift the frame of handwashing campaigns from a patient-centered approach to one aimed at changing the behavior of providers. Framing Theory relies on redefining the conceptual structure of thinking surrounding a particular issue (39). Therefore, instead using the language of patient “empowerment,” the provider-centered intervention recognizes the inherent power differentials and the likelihood that a button or sticker stating, “Ask me if I have washed my hands,” will not overcome these. The new approach acknowledges that providers possess an unequal amount of knowledge and power, and have more control over their handwashing behaviors than their patients do. Instead of ignoring power differentials, as the patient-centered intervention does, the three-pronged intervention works within the existing hospital power structure to promote change in handwashing behavior. The advertising piece of the intervention directly appeals to the providers’ power and authority with the message, “Take charge of handwashing.” Furthermore, the intervention institutes a top-down approach to initiating the campaign and communicating its objectives (32, 36). It enlists the support of institutional leaders who ‘buy-in’ to the intervention and promote a trickle-down pattern of behavior change (32). In this way, the campaign also minimizes psychological reactance by encouraging department chiefs to role model appropriate handwashing behaviors. While some providers might still experience reactance, it is reduced by making the deliverer of the message more similar to the receiver (i.e. someone from their own department) (40). Furthermore, by reframing the intervention to target the providers directly, damage to the physician-patient relationship does not occur. Patients are not involved in questioning the handwashing behavior of their providers, and consequently a trusting and respectful physician-patient relationship remains intact.
Habit Formation
Evidence presented previously showed the importance of habitual behaviors in daily life (25, 28). A fundamental flaw of the patient-centered intervention is that it relies on the patient’s sporadic questioning to prompt the physician to act and does not create a handwashing habit. Furthermore, the provider-centered strategy changes the behavior at the group-level, as opposed to acting through one-on-one interactions between patients and hospital staff. The implication of a group-level approach is that it will produce a very powerful intervention by changing the behavior of large numbers of people at once.
Each prong of the three-prong intervention works to establish handwashing as a habitual behavior. First, drawing from the environmental component of Social Cognitive Theory (SCT), the intervention institutes physical changes throughout the hospital to cue the habit-forming behavior. According to SCT, the external environment can play a substantial role in shaping behavior (12). Psychological research adds that environmental modifications can significantly impact habitual behavior because they alter cues that trigger performing that behavior (26, 41). By modifying the physical environment of the hospital, this intervention acts on all people that work within the structure to change behavior at the group-level.
The goal of this prong is to make handwashing more convenient and accessible to the staff, thereby increasing the likelihood that they will incorporate handwashing into their routine. Placing alcohol-based hand sanitizers throughout the hospital accomplishes this objective because they act faster, are more effective, and less irritating than traditional handwashing (31, 42). This addresses the major handwashing concerns of the target group, which include busyness, forgetfulness, and skin irritation (31). Because hand sanitizers are quicker and more convenient than finding a sink, providers can regularly use them, even during periods of heavy workload. Placing sanitizers in strategic locations also cues the provider to use them during a routine activity, such as reading a patient chart, so forgetfulness is less likely. Furthermore, alcohol-based sanitizers are very effective, and the Centers for Disease Control and Prevention along with many European countries recommend using them in between patient contact for hands that are not visibly soiled (42-43).
The second prong directly attempts to establish a habit through an advertising campaign. In constructing these messages, the intervention relies heavily on techniques pioneered by the advertising industry, which tie subtle cues to a habitual action with the hope of integrating the product into daily routine (28, 29). Another component of Advertising Theory appeals to deeply held core values and ties them to a product or behavior (29). The intervention team conducts focus groups with the idea of searching for these deeper emotional triggers that motivate behavior. Linking these to handwashing in an advertisement creates salient associations in the minds of the providers that cue them to integrate handwashing into their regular patient care routine (29). For example, one of the proposed campaign messages reads, “Picking up the chart? Don’t pick up an infection. Be sure to wash your hands before greeting your patients.” This cues the habitual action of reading a patient chart and appeals to the nurse or physician’s desire to protect themselves from infection. Appealing to universal or commonly-held core values enables the campaign to affect and change the behavior of many people at once (29, 44-45).
The third, and arguably most important, way this intervention establishes handwashing as a habit among providers is by changing the institutional culture of the hospital to foster handwashing behavior. In creating these large-scale, institutional changes, the culture shifts to make handwashing behaviors become habitual for the hospital as a whole (32-33). Since peer norms are an important predictor of handwashing behavior, establishing a culture where all staff members consider handwashing to be the norm is an effective tool for creating a habit (3, 27). This idea relies on Social Norms Theory, which defines norms as the dominant attitudes, expectations, and behaviors that characterize a group (46). Norms regulate the behavior of groups whose members have a desire to conform to group expectations, and will adopt behaviors to fall in line with the group (46). Through communications and active support for culture change from top management, medical and nursing staff, frequent handwashing becomes the social norm. Senior staff members also act as role models and create a norm of handwashing behavior for their particular unit, and staff seeking to conform to the norm will follow suit (3). This element of behavioral modeling is also recognized by Social Cognitive Theory, which states that individuals observe the behavior of others and the consequences of that behavior for what Bandura termed “vicarious learning” (12). They will engage in or mimic behavior with positive consequences and avoid behaviors with negative outcomes (12). Hence, the feedback and recognition mechanisms are important for all staff members as a form of positive reinforcement to encourage continued handwashing behavior (12, 36-37).
Enlisting senior staff to assist with the intervention also moves towards the goal of establishing an institutional culture of habitual handwashing behavior. This method of selecting senior leaders to relay intervention communications to staff models Social Networking Theory (SNT). Under the SNT, the nature of relationships between individuals is a significant influence on belief and behavior (12). The intervention uses these existing relationships, and identifies a leader in each network to target and spread the intervention to the rest of the group (here, their department) (12). This is essential to the sustainability of the intervention as senior staff would customize the intervention to the particular norms of each department. Therefore, each department would feel involved in and committed to the success of the intervention (31, 34, 36).
Conclusion
In addition to addressing the major flaws of the patient-centered campaigns, this new intervention is stronger and more robust due to its multifaceted approach. Research has shown that single frameworks to address hand hygiene have consistently failed, and multidimensional approaches are needed to achieve lasting change (31, 35, 47). The three-pronged approach produces a stronger intervention than the one-dimensional patient-centered campaigns because it incorporates several aspects to promote habit formation (31).
The power of the three-pronged campaign rests on its ability to change behavior at the group-level, instead of on an individual basis, as the patient-centered intervention does. Understanding the mechanisms by which entire groups adopt behavior change, and incorporating these into an intervention allows it to change the behavior of many providers at once. The provider-centered intervention also takes significant social variables into account. In doing so, it addresses the limitations of the previous campaign and produces a vastly stronger intervention. It shifts the frame from patients to providers to reduce the reliance on an ineffective power dynamic and eliminate the potential damage to the physician-patient relationship. It also develops a three-pronged method to habit formation, providing a long-term strategy for handwashing behavior change among healthcare providers.
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