The Social Aspects of Hand Washing in American Restaurants: An Administrative Approach to Reducing Public and Private Health Care Costs

Abstract

Proper hand sanitation prevents spreading of many types of illness and infection, thereby lowering the quantitative and qualitative costs of public and private health care. Research shows that thinking or knowing someone is watching you wash your hands in a public lavatory appreciably improves the odds of you doing so. Nevertheless, most restaurants place their hand washing facilities inside the bathroom, beyond public view. Reformers from the public and private sectors should work cooperatively to incentivize restaurant owners voluntarily to place their hand washing facilities in public spaces. If this uncompelled approach proves unsuccessful, reformers should seek to impose laws requiring that all public eateries place their bathroom washbasins in conspicuous locations. The discussion closes by suggesting ancillary improvements to test in pursuit of further improving hand washing rates and practices in public spaces.

Keywords

health policy administration social aspects of hand hygiene health care costs administrative change interventions to improve public health hand washing

Why do we behave better in public, when being observed, than in private, when not observed? . . . [M]odifying one’s behavior in public is a highly adaptive response to living in society. We behave differently so that we may be inoffensive or attractive to those around us. We behave differently so that we may conform to social norms. We may also behave differently because we perceive greater self-worth when our public behavior is perceived as positive . . . we may behave differently because we wish to display knowledge or attitudes consistent with higher social standing. Similar themes of attractiveness, social status, and affiliation have been confirmed as important motivators of hand washing with soap, on the basis of formative research in 11 countries. Thus, reactivity to structured observation emphasizes the importance of social expectations for improving individual hand washing behavior.

—Ram et al. (2010, p. 1074)

The Centers for Disease Control and Prevention (CDC; n.d.) states that hand washing is the most effective way to “reduc[e] the spread of infectious diseases” (also see American Society for Microbiology and the American Cleaning Institute, 2010), which, as Sefcik (2010) noted, “are the third-leading cause of death in the United States, and many of the contagions responsible are passed from one person to another by unclean hands” (also see Infectious Diseases Society of America, n.d.). Because bacteria evolve resistance to antibiotics, reducing or eliminating the use of these products through proper hand washing will improve our lives quantitatively—that is, money, time, and lives saved—and qualitatively—that is, reduced pain and suffering (Monk-Turner et al., 2005, p. 629). Based on her review of published studies on the subject, Larson (1988) concluded that hand washing “is recognized as one of the few infection control practices with clearly demonstrated efficacy, and remains the cornerstone of efforts to reduce risk of infection” (p. 28). She ends her commentary by noting, “It was therefore concluded that emphasis on hand washing as a primary infection control measure has not been misplaced and should continue” (Larson, 1988, p. 28). These views about personal hygiene have become so widespread that there is now a Global Hand Washing Day. Governments in 100 countries across five continents participate in this annual event (“Global Handwashing Day,” n.d.).

For maximum benefits, CDC recommends the following hand washing steps: (a) wet both hands thoroughly with water, (b) rigorously rub both hands together for at least 15 to 20 s after having lathered them up past the wrist with soap, and (c) rinse and completely dry both hands (see CDC, 1987, 2013).

Notwithstanding an ever-growing body of evidence showing its benefits, many Americans eschew hand washing. While 96% of us say we always wash our hands after using a public bathroom, a 2010 study reported that only 85% of the people researchers observed in a sampling of public facilities did so (The American Microbiology Society and the American Cleaning Institute, 2010, p. 10). Overall, usage scores in the selected locations ranged from 78% to 93%, with women’s percentages varying between 83% and 98% and men’s 65% and 88% (The American Microbiology Society and the American Cleaning Institute, 2010, p. 6). Other studies have also shown women wash their hands more often than men do after using the bathroom (Edwards et al., 2002; Guinan, McGuckin-Guinan, & Sevareid, 1997; Johnson, Sholcosky, Gabello, Ragni, & Ogonosky, 2003). This same report found that 88% of women and 76% of men said they always wash their hands after changing a child’s diaper (The American Microbiology Society and the American Cleaning Institute, 2010, p. 13). These statistics are important for present purposes because increasingly American restaurants provide bathroom users with baby diaper changing stations.

One plausible explanation for why some people do not wash their hands is that pathogens are invisible. In writing about hand washing practices among college students, Botta, Dunker, Fenson-Hood, Maltarich, and McDonald (2008) observed, “the following comment from one student was echoed by most other students in each of the focus groups: ‘I don’t really associate the germs on my hands with getting sick, I just don’t think about the connection’” (p. 376). Above and beyond this out of sight, out of mind view of germs, Munger and Harris (1989) reminded us there are no “explicit sanctions” for failing to wash our hands (p. 733). We rely on voluntary compliance, an honor system.

Unlike motorcycle helmets, it is doubtful any state government will pass a law requiring people to wash their hands after using the bathroom, at least in public lavatories and surely not in private ones. In either case, these decrees would be unenforceable. Americans would not tolerate video cameras or guards in their bathrooms, public or private, to ensure compliance. Instead, those concerned with increasing hand washing rates and practices must rely on noninvasive and more informal means.

Thesis Statement and Discussion Outline

Although hand washing is one of the most effective disease prevention techniques available, a high number of Americans fail to do so after using a restaurant lavatory. This article maps a strategy for establishing a large-scale, pro-hygiene, and pathogen intervention targeting American restaurants. This work uses existing knowledge about hand washing predictors to justify a public health reform project oriented toward increasing personal sanitation practices in communal eateries. The proposed public policy involves a novel but logical environment-behavior intercession that entails important design implications for business, society, and governments. The overall strategy outlined provides a process that includes (a) citing empirical findings about the social mechanisms that most influence hand washing, (b) discussing the best ways to approach governmental and business concerns with the goal of having them adopt the proposed reform, and (c) offering ideas for dealing with follow-up research, best practice, and policy refinements. Although this discussion focuses only on the American scene, the article’s overall thesis is readily adaptable to the unique circumstances of other nations’ respective political and social arrangements, thereby achieving the same beneficial outcomes worldwide. A similar reasoning applies to only focusing on restaurants. With just a little tweaking, the same recommended approaches to publicizing hand washing in communal eateries will achieve equally beneficial results in most if not all other collective settings, such as grocery stores, department stores, and libraries.

Hand Washing in Restaurants

On average, the National Restaurant Association reports that Americans eat a meal or snack at a restaurant 5.8 times per week (Magee, 2009). Research on restaurant and other public lavatories indicates the widespread presence of various disease-carrying agents harmful to humans (Drankiewicz & Dundes, 2003). Given their high traffic, public eateries are ready vectors for spreading pathogens. Regrettably, hand washing alone may prove insufficient for significantly reducing germs on people’s hands after they use a public toilet. Microorganisms are present on assorted bathroom facilities, including soap dispensers, spigot handles, door fixtures, light switches, towel dispenser knobs, and so on (Berry, Fournier, & Porter, 2011). Even if people follow CDC guidelines, they may recontaminate themselves by touching these and other infected surfaces after washing and drying their hands. In response, designers have devised ingenious ways to reduce the number of so-called touch points bathroom users encounter during a visit. Electronic eye activated flushing devices on urinals, toilets, soap dispensers, and faucet handles exemplify these improvements. Theoretically, at least, if you could remove every touch point, including having bathrooms without doors, hand washers would leave the lavatory far less contaminated with pathogens they might later ingest or spread, or both.

Unfortunately, these lavatory redesign efforts can backfire. Berry et al. (2011) proposed that women wash their hands more often than men do because they, females, encounter more touch points while in a public bathroom, with each contact reminding them of possible contamination. Counterintuitively, these researchers found that reducing the number of touch points diminished hand washing rates for both sexes. In other words, lowering the number of risk reminders may lessen bathroom users’ incentives to wash their hands.

The Social Aspects of Hand Washing

Social norms rely heavily on the perceived or actual presence of others to sanction noncompliance. For example, people may swear out of frustration when alone but forego doing so in polite company, or they may refrain from cursing because they think someone will hear them, as when young children avoid using profanities fearing their parents are listening, even if, in fact, the mother and father are outside earshot. Norms predispose people toward certain behaviors and away from others in search of social acceptance.

These principles tell us how we are supposed to behave in different situations. They are “Ought Incentives,” in effect, our “Invisible Audience.” Laws back some norms—it is illegal to drive drunk—while other norms rely only on psychological states such as embarrassment, shame, or humiliation for acquiescence.

Although other efforts to increase hand washing compliance levels have had mixed or limited results, several studies report that thinking or knowing someone is watching whether you wash your hands significantly raises the odds you will do so (Armellino et al., 2012; Munger & Harris, 1989; Ram et al., 2010). Foreman (2011) offered an amusingly colorful if somewhat overstated description of the research findings on this point:

If you are curious about the impacts of social situations on whether or not someone washes the poo and tinkle off of their hands in a public restroom, just do a quick google on “hand-washing compliance” and “social psychology.” What you’ll basically find, after clicking on different links and wading through academic abstracts is something you already know, and might never personally admit to: Most people are lazy and germy, and they are likely to skip hand washing if they think no one notices, but will wash if they think you are watching . . .

This is a crucial point because it means the earlier cited observational findings concerning the difference between what people say about their hand washing habits versus what really happens may understate the discrepancy, including the earlier mentioned diaper changing statistic. The act of observing alters the outcome, in this instance, causing more people to wash their hands than would otherwise be so.

A Policy/Administrative Proposal

Those interested in reducing the quantitative and qualitative costs of health care in the United States should seek to reform existing restaurant hand washing arrangements.

One of two methods or a combination thereof should practice-demonstrate that melding different elements of the two systems yields better results. The first method entails encouraging existing restaurants voluntarily to move their hand washing facilities outside their restrooms. The voluntary route to reforming existing lavatory hand washing arrangements involves “nudging,” which means having public- and private-sector interests work together to incentivize restaurant owners to relocate these sanitizing facilities. It is worth noting that Americans have used this same tactic to reduce significantly overall smoking rates. The second technique involves having public- and private-sector interests cooperate to compel restaurant owners under penalty of law to relocate their hand washing facilities to public spaces. The first, or voluntary, method is preferred, however, and only if it fails should reformers require these changes by law.

Finally, the third means of reforming existing practices involves combining the first two options based on what works best in practice. In other words, this pragmatic approach entails combining elements of the two previously discussed means, such as the government requiring restaurants to relocate their hand washing facilities, but still rewarding these actions with an income tax write-off. Because this third policy option mingles elements of the other two, it is not necessary to discuss its possible permutations here, as practice will reveal what components to include in the mix.

The next two sections illustrate, respectively, the major attributes of the voluntary and compulsory approaches to using research findings to improve hand washing rates in American restaurants, thereby reducing the quantitative and qualitative costs of communicable diseases.

The Policy Options

The Voluntary Model: Market-Driven Reforms

The incentive structure of the voluntary mode involves appealing to the self-interest of business owners (profits) and their customers (healthier and longer lives, for example). Thaler and Sunstein’s (2008) Nudge: Improving Decisions About Health, Wealth, and Happiness offers an excellent summary of this free market approach to reform. These authors recommend changing people’s conduct through consumer/citizen education versus the “paternalism” alternative—having government officials obligate the desired actions, tactics Thaler and Sunstein (2008) consider coercive (p. 47). They summarize their philosophy of voluntary policy making this way: “In many cases markets provide self-control services, and government is not needed at all” (Thaler & Sunstein, 2008, p. 48). They insist it is better to employ three social influences to elicit the desired behaviors, including information, peer pressure, and priming. The latter refers to structuring choices to increase the odds of people acting in their self-interest, such as when a surveyor asks respondents whether they intend to floss their teeth, and the question itself increases the percentage of people who later do so.

Rather than forcing people to behave in their self-interest by using the government’s power to inflict punishment, Thaler and Sunstein prefer steering consumer choices. They favor “nudging,” or voluntary manipulation, if you will, versus coercion in pursuit of what they call a “good . . . cause” (Thaler & Sunstein, 2008, p. 71). Elsewhere they justify this method by saying leaders should use research findings “to move people in better directions” (Thaler & Sunstein, 2008, pp. 59-60).

Thaler and Sunstein would be especially supportive of nudging restaurant owners to relocate their hand washing facilities to make them more visible given the delayed onset of most communicable health problems; there is no immediate positive feedback for making the right choice. As these authors explain, “people may most need a good nudge for choices that have delayed effects; those that are difficult, infrequent, and offer poor feedback; and those for which the relation between choice and experience is ambiguous” (Thaler & Sunstein, 2008, p. 76-77).

In practice, nudging restaurant owners to relocate their washbasins would involve a series of steps. Although it is impossible to identify every potential nudging method in this space, a few examples will show how this approach could work. In turn, these examples should prompt others to think of still more ways to entice restaurant owners to relocate their hand washing facilities.

First, reformers should pursue as wide an audience as possible for existing research findings. They should seek interviews with a broad array of print and broadcast journalists, including, whenever possible, appearing on television or radio talk shows.

Many larger cities circulate alternative newspapers and these can be valuable outlets for dispersing new ideas. By definition, editors of unconventional publications are open to reporting cutting-edge considerations, particularly health-related items.

These publicity efforts should involve enlisting public health directors and other leading government officials. These individuals would cite empirical findings when explaining their support for the proposed voluntary alterations, as happened in 1964 when the U.S. Surgeon General and his colleagues announced their findings about the harmful effects of smoking. Their press conference received widespread coverage and remains a landmark in public health consciousness-raising.

Second, restaurants that relocate their hand washing facilities could publicize their commitment to improving public health, much as how vehicle manufactures tout their safety features to safeguard riders from crashes, injuries, and death. Restaurants can proclaim this accomplishment on their menus, in media advertisements, and in interviews with TV and radio reporters, who are sure to present stories about these innovations, especially when the first few eateries make the change, while the idea is novel.

Restaurant owners can emphasize how they pay close attention to the latest scientific findings in pursuit of their customers’ best interests. Disseminating this information will pressure other restaurant owners to follow suit in search of greater profits.

Third, to reinforce this last point, reformers should encourage individual health departments to publicize which restaurants have made the recommended changes, as now happens in some political jurisdictions when eating places consistently receive high marks for sanitation. Besides distributing this information to the media, health departments should include it on their websites. The legitimacy flowing from this government endorsement will further pressure other restaurant owners to make the desired alterations.

Health departments should also grant a Certificate of Recognition (CR) to complying restaurants. Winning eateries will receive two different CRs. One will be larger, say 10″ by 12″, and framed before distribution. Eateries can hang these by their cash registers or in another conspicuous location. The other award will be a small decal, say 5″ by 6″, these businesses can place on or near their front door, again as a reminder to customers of the owners’ commitment to good public health habits. Thaler and Sunstein (2008) mentioned how Los Angeles County began distributing sanitation quality grade cards that owners were required to display on the windows of their restaurants (citing Jin & Leslie, 2003, p. 190). This policy led to more restaurants achieving higher health inspection scores, greater consumer awareness of restaurant hygiene, and fewer admissions to hospitals for food-borne illnesses. A similar approach should work for relocating washbasins, although given the profit motive, there should be no need to require displaying these notices.

Finally, Thaler and Sunstein (2008) argued that government “might offer some useful nudges” to achieve a desired policy end (p. 105). Given the profit motive, reformers should lobby the U.S. Congress to grant restaurants a full income tax write-off for charges associated with relocating their hand washing facilities plus a small “incentive deduction” for making the desired adaptations. For example, if it costs a certain restaurant owner US$2,000 to make this change, that enterprise’s federal income tax obligations would decline by this amount plus another US$200 to cover the costs of arranging to have the existing washbasins relocated. Thus, if owners Sally and Sam would otherwise owe US$3,000 in income taxes at the end of the calendar year, their bill would fall to US$800 after claiming the deductions. These are theoretical instances, but the point is to establish workable thresholds to elicit the desired behaviors. When making their case to Congress, reformers should emphasize how the recommended tax law change will reduce the nation’s spiraling health care costs, thereby easily offsetting the proposed tax expenditure, if not paying for itself many times over. (See next section for helpful hints about lobbying legislators and chief executives to revise existing tax legislation, among other incentive changes.)

The only exception to beginning with the voluntary approach would be requiring that henceforth all newly constructed restaurants place their washbasins in prominent locations. This new criterion would become part of each jurisdiction’s normal building code and would save public money by avoiding federal government payments (through tax breaks) for retrofitting these just-built structures. This would also prevent some restaurant owners from intentionally failing to publicize their hand washing facilities in new buildings to give their contractors additional work later (at government expense).

Ironically, requiring this reform would serve as another voluntary incentive for existing businesses to adopt the proposed architectural plan. By informing their clientele about the rationale for this design in these just-constructed restaurants, owners would be educating their customers about proper health habits as well as encouraging them to frequent this and other eating establishments sporting healthier hand washing arrangements. Obviously, these latter choices come at the expense of eateries with traditional bathroom layouts. A similar situation occurred when smoking bans encouraged more restaurant customers to appreciate for the first time the rewards of dining in fresh air. Before the ban, most patrons simply assumed that going home wearing now smoke-laced clothing and having irritated eyes and noses were just another cost of dining out. In sum, by requiring that newly constructed restaurants place their hand washing facilities in public spaces, government officials will prompt customers immediately to think differently about a potential health benefit they, the patrons, likely would have otherwise overlooked.

The Compulsory Model: Uniting Business, Health Policy, and Politics

Despite their preference for nudging, Thaler and Sunstein (2008) acknowledged that sometimes governments must compel certain actions when voluntary efforts fail to achieve an acceptable level of adherence (pp. 80, 93, 155, 253). Prohibitions on smoking in public/private buildings and laws requiring drivers and passengers to wear seat belts exemplify such legally compelled behaviors. If it becomes apparent that nudging leads too few restaurants to move their hand washing facilities to public spaces, only then should reformers lobby legislators to change their respective state laws to compel these businesses to relocate their hand washing amenities. For now, this discussion about appealing to government will focus on the 50 U.S. states individually, which could accommodate localized needs and concerns. If this state-by-state strategy fails to achieve sufficient results, only then should reformers redirect their efforts toward convincing the U.S. Congress to require these architectural changes.

Although it is impossible to review here all the Do’s and Don’ts of convincing public officials to alter existing health policies, and most are familiar to the readership of this journal, still a few major practical concerns are worth noting. First, it is imperative to schedule meetings with legislators, governors, and public health department directors to inform them of the impending benefits of the intended legislation, for example, cutting health care costs, lowering the number of school and workdays lost due to preventable illnesses, reducing death rates, and so forth. Government officials must understand and convey to citizens the significant rewards associated with changing existing conditions. Assuming efforts to legislate changes were undertaken at state and local levels, it is especially important that advocates schedule meetings with both majority and minority party leaders, and chairs of the various legislative or council committees likely to handle these bills. These representatives have deep institutional knowledge about their respective chambers, and thus wield considerable influence over the lawmaking process.

Second, it is crucial to abide by certain rules of political etiquette when interacting with state officials. Adhering to these informal standards of conduct will greatly increase the odds of gaining their favor. Most legislators, chief executives, and public health department directors have busy schedules, so conciseness and attention to detail are mandatory for success. This means spending ample time becoming familiar with important facts, including in the case of legislators knowing their individual committee assignments, party affiliations, years of continuous service (seniority), individual voting records on public health issues, and the demographics of each district’s constituents.

Once this information is digested, reformers should ready a succinct (10-15 min) summary of facts, a synopsis of the bill including its major benefits, and a few convincing visuals (charts and graphs). They should also develop a one-page handout summarizing the issue, the proposed solution, and its foremost advantages. Before speaking to these public officials, reformers should hold rehearsals with one or more participants playing tough questioner(s). After meeting with these legislators, chief executives, and public health department directors, speakers should leave several copies of the one-page handout behind as ready reminders of the facts and rationale behind the recommended policy change.

Third, once these presentations are completed, reformers should schedule meetings with a few lobbyists, especially those who commonly advocate for health issues. Such persons can be particularly helpful in understanding the intricacies of policy making, including the relevant rules and personalities of the different public officials likely to be involved. Although they will not offer highly sensitive information, most lobbyists, especially those with long experience, can provide markedly useful insights, notably when it comes to identifying legislators who might sponsor or support a hand washing bill. Depending on their field of expertise, some lobbyists can offer valuable counsel about working with public health department directors and their staffs, as well as point out potential opponents to the proposed hand washing bill. Lobbyists have slow periods and this is when they usually have time for informational interviews. In most instances, it is best to hold these meetings immediately after finalizing the hand washing presentation materials. By definition, this is when it is possible to ask the most informed questions, thereby saving everyone’s time. Knowledge gained from these sessions can then be used, if necessary, to alter the presentation strategy and tactics before meeting with legislators, chief executives, and public health department directors.

Fourth, reformers will likely testify for the proposed bill should a committee formally consider it. Many of the same informal standards as those just mentioned regarding private meetings with legislators, chief executives, public health directors, and lobbyists apply here as well; conciseness, punctuality, a clear presentation with handouts and visuals, and an understanding of the importance of composure when responding to the inevitable tough questioner(s) are at a premium. The best way to appreciate the ambiance of these sessions is to attend several committee hearings beforehand as observers, no matter the topic, although if the bill in question concerns public health, all the better. In general, one important character difference between committee hearings and individual meetings with legislators, public health department heads, chief executives, and lobbyists is that speakers normally have more time to present their case and respond to inquiries. Moreover, these individual meetings can help in detecting which public officials might serve as advocates for the bill during legislative hearings, or before for that matter.

Finally, there are many online references tendering sound advice about interacting with government officials, either in their offices (“How to Lobby Effectively,” n.d.) or before them in committee hearings (Frank, 2011). Still Wildavsky’s (1979) highly readable The Politics of the Budgetary Process remains one of the best commentaries on the subject. This text translates subtleties into common sense. It is a must-read for everyone given the author’s talent for pointing out practicalities that experience alone usually teaches the hard way. Among his many gems of wisdom are (a) “There is no substitute for knowing what you are talking about” (p. 87) because this lowers the odds of “being surprised” (p. 85) by unanswered questions that will inevitably undermine the speakers’ credibility, (b) “[t]he plant” (p. 86), which involves supplying friendly legislators with inquiries that help the speaker’s case, and (c) “[p]lay[ing] it straight” (p. 76), meaning never underestimating the knowledge, sophistication, and fact-finding abilities of public officials and their staffs.

This is only a small sampling of Wildavsky’s (1979) many valuable insights, but it should serve as a word to the wise, whether for newcomers to the process or its veterans (as a reminder). Wildavsky’s implied message is that it takes enormous effort to make a presentation look effortless.

Recommended Legal Technicalities

The law establishing this new hand washing policy should contain certain particulars to ensure its success. These suggested standards apply to both the voluntary and compulsory approaches. For the former, it means unless owners abide by these criteria, they cannot qualify for an income tax deduction. For the latter, it means unless restaurant owners meet all these standards, they must close until they do, as happens now when health department inspectors shutter certain eateries until they abide by their respective jurisdiction’s sanitary requirements.

First, the law must require that restaurant owners place lavatory washbasins in the most visible settings possible right outside the bathrooms, such as the lobby where customers congregate while waiting for a booth or table. Designated public officials will confirm restaurants meet this benchmark. A proximity requirement will prevent users from having to walk long distances, thereby risking their avoiding hand washing by disappearing into the crowd or simply moving out of sight.

To ensure the desired health policy objective is clear, the law should state that these sanitary facilities cannot be situated inside any of the restaurants’ bathrooms away from public view. This will prevent eating establishments from providing separate lavatories for owners, managers, employees, or anyone else; there can only be one women’s, one men’s, or one unisex bathroom available for everyone, employees and otherwise. If the restaurant is large and requires more than one bathroom, the same proviso pertains: There cannot be separate lavatories for owners, managers, employees, or anyone else.

Finally, a preamble to the law should stipulate its overall intent is to make hand washing after using a restroom in a public eatery as visible an event as possible. The only caveat to this obligation is allowing restaurant employees to have separate washbasins for all their other hand washing needs, in accordance with existing government regulations. This preamble statement will allow public officials further to amend the law if experience reveals that subsequent unforeseen problems prevent achieving the reformers’ intended health goals.

Nuances and Permutations: When Policy Becomes Practice

As happens with every newly enacted public health policy, the proposed reform will inevitably trigger other research possibilities, with each study seeking more ways to improve hand washing rates and practices in a public setting. Although it is impossible to review—or anticipate for that matter—every empirical opportunity, the following paragraphs propose six potential projects of interest. Ideally, these suggestions will cause researchers to imagine still other questions worthy of concern.

First, Johnson et al. (2003) reported that certain in-bathroom education efforts improve hand washing rates (p. 805). They found that placing “visual prompts” such as “Please Wash Hands” signs in lavatories significantly increased compliance rates among female but not male college students. Later, Botta et al. (2008) reported that ordinary fears commonly included in hand washing education campaigns, such as the risk of spreading illness-causing pathogens, had no effect on the attitudes of college students they studied. However, these students agreed the thought of having feces or urine on their hands was repulsive. In response, the researchers tested whether prompts emphasizing “the ‘gross’ factor” placed in some dormitory bathrooms but not others (the control group) increased compliance rates (p. 373). The authors specified these signs contained “attention-grabbing graphics and photographs,” which were changed periodically to prevent “message-fatigue” (Botta et al., 2008, p. 377). The results showed this campaign significantly improved rates of hand washing among both male and female students in dormitories with signs.

These mixed findings on the effects of in-bathroom signage and message content evince the need for more study of which notices, visual and otherwise, might significantly raise both hand washing rates and adherence to CDC standards for both sexes. By definition, if improving notification formats leads to better compliance rates among bathroom users, the signs will have the secondary benefit of raising health consciousness among restaurant patrons and employees in their role as audience members, thereby further pressuring lavatory goers to meet sanitary expectations.

Second, researchers should test whether certain incentives, such as lighted timers connected to soap dispensers, significantly increase adherence to the recommended 15 to 20 s threshold for hand washing duration. The just mentioned in-bathroom signs would include information encouraging people toward this goal. Knowing onlookers are probably aware of the informational content of these educational reminders will act as another incentive for correct hand washing.Third, proper hand drying helps prevent the spread of pathogens. Researchers have tested different hand drying methods with nuanced results. Snelling, Saville, Stevens, and Beggs (2011) compared various wall mounted hot air blow dryers and found some outperformed their competitors under certain conditions but not others. Outcomes differed, for instance, based on how long users exposed their hands to the airflow as well as whether they rubbed their hands together or held them still during the process, with the latter practice achieving better results. Similar to Gould’s (1994) findings, Blackmore (1989) and Snelling et al. (2011) showed paper towels are a highly effective hand drying method. Last, other studies demonstrated hand dryers can cause pathogens to become airborne, thereby making germs inhalable (Berry et al., 2011; Blackmore, 1989).

Investigators should continue testing different hand drying methods in a public setting, including the consequences of improvements in blow dryers (see “The Fastest, Most Hygienic Hand Dryer,” n.d.). Whatever method proves most effective, placing these facilities in public places will increase proper hand drying, versus, say, people wiping their hands on their clothing.

Fourth, even those who follow all CDC guidelines may still not wash their hands thoroughly. If they hold their hands under ultraviolet lighting, they can see places they missed because the remaining microbes appear as bright spots (Cowen, 2011; Widmer, 2000). Researchers should test whether placing ultraviolet lighting devices in the washbasin area further improves hand washing practices; if the evidence shows users that these bathroom goers need to wash their hands again (and this time more thoroughly), a significant number might do so.

Fifth, hand sanitizing gels are growing in popularity. Studies reveal these antimicrobial agents are convenient to use and are formidable germ fighters. Vessey, Sherwood, Warner, and Clark (2007), for example, examined the efficacy of hand sanitizers and deemed them an “appropriate alternative to hand washing” (p. 368; also see Widmer, 2000, for other citations showing hand sanitizers are more antimicrobial than traditional hand washing). Their study determined these products are more convenient to use than soap and water because they do not require hand drying and need less time to dispense and apply, thereby addressing the problem of people not washing their hands for as long as CDC recommends. The time savings associated with gels are noteworthy. In a study of hospital nurses, Voss and Widmer (1997) reported that proper use of these products required a small fraction of the time needed for satisfactory hand washing with soap and water (also see Widmer, 1994). Expediency and efficiency are important considerations for busy restaurant employees and customers on a tight schedule. When offered for use, CDC recommends decontaminating sanitizers containing 60% to 90% ethanol versus isopropanol-based cleansers (Hermes, 2015). Researchers should investigate whether having these products available increases hand washing rates.

Even if studies show more people prefer gels, soap and water should not be abandoned, as some individuals might refuse to use alcohol-based products for religious reasons (Luby, Kadir, & Sharker, 2010). In these instances, if future research confirms items such as Vicks First Defense Protective Hand Foam, which contains organic acids instead of alcohol, are effective sanitizers, these products should be available along with ethanol gels, and soap and water. Likewise, even if certain sanitizing agents prove more convenient and effective than others, some people may still prefer a less efficacious approach out of habit. Thus, unless all hand washers prove willing to abandon a less potent method, reformers should provide as many antimicrobial alternatives as practical. Investigators will make these determinations based on monitoring how and whether adding each new cleansing agent improves hand sanitation rates and practices. Whatever the given options, publicizing the event will increase the number of hand washers, thereby reducing health care costs.

Last, the present discussion only focuses on making hand washing conspicuous in restaurants. Future studies should examine whether moving washbasins into public spaces in other venues such as grocery stores increases hand washing. Results from these projects should in turn prove helpful in improving hand washing rates in eateries and other locations; inevitably, there will be a symbiosis among the different findings about what happens when facilities for hand washing are located in plain sight.

Conclusion

Prevention is the cheapest form of health care. Max Planck (1936), the Nobel Prize winning physicist, said,

An important scientific innovation rarely makes its way by gradually winning over and converting its opponents . . . What does happen is that its opponents gradually die out and that the growing generation is familiarized with the idea from the beginning . . . (p. 97)

Planck likely underestimated how quickly establishment figures, at least in the biological and physical sciences, accept novel thinking (Diamond, 1980). Perhaps his comment better describes how public health policy opinions evolve, a sphere wherein politics probably plays a far bigger role than in the harder sciences, where a paradigm shift generally requires a change of mind versus altering long-standing practices via persuasion or statute. Still, the present proposal, deeply grounded as it is in research findings, deserves immediate consideration. The potential quantitative and qualitative rewards are too important to postpone or forego, especially given present-day concerns about America’s ever-rising health care costs. An ounce of prevention.

Footnotes

Acknowledgements

Thanks to Professor Thomas D. Berry, Christopher Newport University, for his insights and suggestions in relation to an early version of this article. Of course, he bears no responsibility for any shortcomings associated with the final product.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biography

Kenneth Oldfield is emeritus professor of public administration at the University of Illinois-Springfield. His research interests are wide ranging, going from how structural changes in the environment might affect public health outcomes, to using class based affirmative action to increase the number of students, faculty, and administrators of poor and working class origins on university campuses, to how the human genome project will profoundly affect public budgeting and finance priorities.

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