The CDC’s Current Hand Washing Promotions are Less than Handy –Devan Darby

The current web-based program sponsored by the Centers for Disease Control and Prevention (CDC) to promote hand-washing in hospital settings, "Hand Hygiene Saves Lives",[1] delivers an inadequate and unrealistic message, both in its design and method of transmission. By failing to consider the psychology of marketing and communication, the culture of the healthcare setting, and the factors of irrationality that underlie human behavior, the “Hand Hygiene Saves Lives” program falls short of being an effective catalyst for health behavior change in the prevention of hospital-acquired infections (HAIs). Borrowing heavily from the Health Belief Model,[2] the CDC’s intervention strategy is less than handy as a behavior change tool and completely inadequate as a source of leadership in the field of hospital infection control.

Background on “Hand Hygiene Saves Lives”

The CDC’s hand washing promotion program, “"Hand Hygiene Saves Lives" is a web-based educational initiative that encourages compliance with the CDC’s 2002 “Hand Hygiene in Healthcare Settings” Guidelines through a patient admission video for recently admitted patients and their loved ones and an online interactive hand hygiene education course for healthcare workers. [1] This website also distributes posters and brochures for hospital infection control personnel to use in hospital settings across the U.S, but those will not be discussed. The five-minute patient admission video, available in podcasts in both English and Spanish, outlines the risks of acquiring common types of hospital-acquired infections, shows proper hand-washing technique, and encourages patients and family members to maintain clean hands to reduce the risk of developing a serious infection.[3] The admission video also attempts to promote self-efficacy not only by empowering patients and their loved ones to wash their hands frequently while in the hospital but also by encouraging patients and their loved ones to take an active role in insisting that their healthcare providers wash their hands before beginning a physical examination. The nurse in the video assures patients to, “feel comfortable asking your healthcare provider to wash their hands.”[3] Two short vignettes depict patients or their loved ones politely insisting that good hand hygiene be practiced.

Like the admissions video, the interactive course for healthcare workers also discusses the scope of the HAI problem and how hand washing is effective at mitigating HAIs. The course even included a one-minute video demonstrating proper hand hygiene. However, the course uses a very different interactive format which forces the course taker to read questions and respond to personal assessment questions. The interactive education course for healthcare workers attempts to promote good hand hygiene by reinforcing the ease of use and effectiveness of alcohol-based hand gels. It encourages healthcare workers, especially physicians, to practice excellent hand hygiene and use of standard procedures not only to improve patient outcomes but to serve as a role model in their work setting.

Critique #1: Marketing and Communications Theories

While both of these web-based initiatives encourage important behaviors, their practical effectiveness is limited by the antiquated design of the messages in the admissions video and the online course. Both of these programs are didactic nature, presenting data and statistics to support their claims. While this is not necessarily a bad tactic, it is probably not very effective because it fails to harness any emotional appeal. According to Marketing Theory, groups of people respond to ideas that resonate with their deep-seated aspirations and desires rather than just the facts.[4] By presenting these important messages in such a cerebral way, the content of these programs are unlikely to become effectively absorbed or widely popular.

The style of the messages themselves further weakened the intervention. The dry, canned delivery of the messages was uninteresting, and the generic background music was outdated. Although the online course for health professionals required user participation, even this approach was static and far from engaging. These qualitative aspects of the video were incongruent with Americans’ expectations of a high-tech, modern healthcare system. The alcohol-based gel or foam hand sanitizer is a relatively new technology which has been clinically proven to be more effective at killing germs while preserving skin integrity,[5] yet the CDC’s programs do not “market” it any differently from traditional soap and water. While the content of these programs was certainly health promoting, the packaging lacked mass appeal, thus reducing the overall uptake and effectiveness of the entire intervention. An apparent lack of concern for the marketing-based, customer-centered approach to message design was absent from these web-based programs, which is ironic because the CDC recently described “health marketing” elsewhere on its website. [6]

In addition to flaws in the message design, the CDC’s “Hand Hygiene Saves Lives” intervention also suffered from a stifling choice of communications channels. While the internet is a growing source of news and information, the decision to post these programs solely online limited the scope and reach of the intervention. Nearly 8 million Americans search for health information each day, but those individuals are more likely to be women, college educated, and young.[7] Americans who are less health-oriented and have more restricted access to the Internet will therefore be far less likely to benefit from these materials. If patients and their families are to benefit from these messages at all, they would probably be introduced to them through a hospital program utilizing these resources. This campaign is therefore dependent upon hospital administrators and infection control personnel to disseminate the resources for them, which is largely dependent upon local agendas, budgets, and myriad other social, political, and economic constraints. Lessons from both history and the social sciences (e.g. Communications Theory) teach that successful public health campaigns are based on formative research that provides insight into the message design and channels of communication.[8, 9] It is unlikely that much if any formative research contributed to either the design or dissemination of these CDC hand-washing initiatives. Total dependence upon local personnel without any other means of exposing Americans to this information makes it much easier for these messages to go unheeded.

Critique #2: Anthropology and Cultural Theory

A second criticism of the CDC’s “Hand Hygiene Saves Lives” campaign is its failure to consider the cultural contexts in which poor hand hygiene goes unchecked. The dramatizations in the patient admissions video depicting patients and their loved ones insisting upon impeccable hand hygiene from their visitors and healthcare providers is difficult to replicate in the actual hospital setting. In one dramatization, the patient’s loved one not only asks the doctor to wash her hands before examining, but then when she is rebuffed, insists for a second time that the hand cleansing be performed again in her presence.[3] An anthropological critique of this example would point out a fundamental misunderstanding of the power dynamics inherent in the healthcare culture; in the hospital setting, there exists a “latent tension…between notional, political equality and the need for dependency on care from others”.[10] This asymmetric distribution of expertise between the caregiver and the patient which exists in practice is in direct conflict with the theoretical independence and personal empowerment which the CDC’s hand washing campaign aims to promote. What results is a fundamental disconnect between what is recommended in the videos and what is actually practiced in real life. From an anthropological perspective, this intervention strategy misunderstands this crucial relationship and therefore neglects the culture of the healthcare environment. For a recently admitted patient viewing this video, the CDC’s misrepresentation of the real challenges of reminding an authority figure to maintain proper hand hygiene makes that task even more daunting.

Not only is the difficulty of challenging authority presented unrealistically, the setting in which hand washing behavior is depicted is devoid of the barriers which often inhibit its consistent practice. Healthcare providers juggle multiple competing demands for their time and attention. Insufficient time, inadequate access to sinks, skin irritation, staff attitudes and habits, and lack of personal initiative are all frequently cited barriers to hand hygiene compliance; insufficient staffing and high patient demands can further reduce compliance with hand hygiene protocols.[11] In all of the materials and videos from the “Hand Hygiene Saves Lives” campaign, the CDC assumes that hospital workers have the time and presence of mind to engage in consistent hand washing, which may not be the case. The interactive course outline does little to change either culture or structural problems which reduce personal accountability and initiative to perform hand washing protocols.

One final troubling aspect of the CDC’s culturally incompetent campaign is its overestimation of the abilities of patients and their families to take an active role in preventing nosocomial infections caused by the noncompliance of healthcare workers. In addition to the difficulties of confronting a physician or nurse outlined above, patients recently admitted may be unable to listen to the admissions video, let alone advocate for themselves in the face of cultural mores, because of severe illness or loss of consciousness. Admission to a hospital for an inpatient stay is warranted by severe physical or emotional distress, so receptivity to new concepts and tasks is probably at a minimum. The emotional turmoil accompanying hospitalization puts immense strain on family and friends, making them likewise unreceptive to a didactic educational video. Patients may not always have a loved one present to insist upon hand hygiene as shown in the idyllic world of the video. Since only doctors and nurses are mentioned and portrayed in the admissions video, this program could even be viewed as misguiding patents into thinking that only their doctors and nurses can spread germs. In reality, a far more diverse flow of providers, from physical therapists to nutritionists to patient care assistants, are constantly coming into contact with inpatients.[12] These providers also can potentially spread infection just like doctors and nurses.

While patients and their loved ones certainly have a role to play in upholding proper hand hygiene, it is unrealistic, presumptuous, and dangerous to assume that sick patients and their families can make up the difference. The language of the patient admissions video verges on exculpatory, saying “healthcare providers know to practice hand hygiene, but sometimes they forget.”[3] For the reasons stated above, over-reliance on patients and their families to police hand washing behavior is unlikely to result in decreasing the rates of HAIs.

Critique #3: Fallacious Assumptions of Rational and Intended Behaviors

The final drawback of the “Hand Hygiene Saves Lives” campaign is that its approach is primarily based on the assumption that human behavior is rational, planned, and internally controlled. These assumptions are largely supported through the Health Belief Model which states that the decision to perform a health behavior is based upon an individual’s weighing of the perceived susceptibility to the disease against the perceived severity of the disease and the perceived benefits of the behavior against the perceived barriers to enacting the health behavior.[2] Also enmeshed within the Health Belief Model is the idea that the ability to perform a behavior is dependent upon self-efficacy. [13] The main objective behind the message presented in the patient admissions video of “Hand Hygiene Saves Lives” is to lessen the perceived barriers of hand-washing (e.g. the fear of confronting visitors and healthcare workers about washing their hands), while promoting the perceived benefits, (e.g. healthier hospital stays). Likewise, the Hand Hygiene Interactive Training Course attempts to sway health worker behavior by delivering a highly rational assessment of the risks of nosocomial infection and the benefits of using alcohol-based hand sanitizer. This is accompanied by slides emphasizing the low-time requirement, and therefore low barrier, associated with using these alcohol-based gels, as well as the benefits of alcohol over soap-and-water method for maintaining healthy skin. After completing these programs, the CDC would hope that a logical decision-making process would occur in which the viewers would develop a positive intention, and that this positive intention would in turn, lead to a planned, rational behavioral outcome of better hand hygiene.

There are numerous practical problems with the theoretical basis on which this intervention is based. First, human behavior is frequently not rational or planned. Doctors and nurses already know that hand washing is effective and important for reducing the risk of HAIs. Healthcare personnel typically receive infection control information at some point in their professional training and possess at least a basic knowledge of the merits of hand hygiene.[14] In a study of physician knowledge of best practices, 85% reported already knowing the importance of hand hygiene in preventing nosocomial infection.[15] If behavior change were simply about appealing to healthcare workers’ rationality, then after completing the CDC’s “Hand Hygiene Saves Lives” intervention, all rational doctors and nurses would be fully compliant with the CDC’s hand hygiene guidelines and rates of HAIs cease to be a real problem. Yet, each year in the United States, some 100,000 deaths occur and nearly $6 billion in additional healthcare costs accrue due to HAIs.[16, 17] Perhaps doctors and nurses are not as rational as one would suppose.

A second theoretical fallacy that should be dismissed is the notion that intentions inevitably lead to behavior change. Many physicians have positive intentions to wash their hands more frequently but still do not comply with the CDC’s regulations. The mean compliance rate from numerous observational studies is consistently low. The CDC places this figure at only 40%.[18] In contrast, studies have shown that among healthcare workers, 92% had positive attitudes about hand hygiene after patient contact and 77% reported intentions to adhere to good hand hygiene protocols.[15] These high rates of positive attitudes and intentions suggest that simply aiming to improve intentions is missing the point.

From the perspective of behavioral economist, Dan Ariely, irrationality and inability to enact some of our best intentions are key components of human behavior. Ariely designed and implemented a procrastination experiment in his classroom to show that his students’ actual interests differed from what they thought were their actual interests. Students were divided into three groups. In the first group, students were told to adhere to a rigid schedule for submitting three term papers. In the second group, students were free to set their own deadlines for the papers. The final group also had some free choice but had to select a certain week in which to submit each of the three papers. When all papers were submitted and graded, the “dictatorial” group performed the best while the group with total freedom performed the poorest. [19] Ariely thinks this was no accident. Students in the second and third groups were overwhelmed by choice. Their good (rational) intentions to complete their assignments and submit them on time were overthrown by the strong emotional (irrational) appeal of short-term needs and wants, resulting in procrastination.

If this scenario from behavioral economics were applied to hand-washing, the troubling disconnect between the high levels of hand-washing knowledge and the low levels of hand-washing compliance becomes easier to understand. In the stressful environment of the hospital ward, the immediacy of patient needs compiled with other obligations and time commitments hijack the best intentions of doctors and nurses to perform consistent hand hygiene. What results is a dulled sensitivity to the importance of a very important, very rational health behavior. The CDC’s program does little to comprehensively counteract these real forces. Instead, it relies upon the Health Belief Model and insistently repeats the benefits of hand washing and the dangers of hospital-acquired infections in the naive hope of converting good intentions into lower rates of HAIs.

Through the lens of Marketing and Communications Theories, anthropology, and behavioral economics, the problem with hand washing can be understood as a complex issue that requires greater input from the social sciences if it is to affect genuine health behavior change. First, the CDC’s message is disappointingly unentertaining and does not even attempt to elevate the status of hand washing, already an arguably mundane subject, beyond that of a health lecture. Secondly, this intervention strategy fails to realistically consider the culture of the hospital setting and the practical ability of inpatients and their loved ones to police the healthcare workers providing care to them. Finally, the strategy assumes that more consistent hand washing, and subsequently fewer HAIs, can be achieved by improving the already-positive attitudes and intentions of healthcare providers to perform regular hand washing by appealing to their rational senses. All told, the CDC’s program fails to grasp key factors underlying the human psychology, culture, and behavior, and in doing so, fundamentally limits the scope and reach of its intervention. The CDC’s “Hand Hygiene Saves Lives” program lacks the leadership one would expect in this field of hospital infection control. These criticisms from the social sciences provide insight into the flaws of the current behavioral models employed in hospital infection control and should be used to construct more effective campaigns in the future.

1. Hand Hygiene in Healthcare Setting: CDC Infection Control in Healthcare. 2008 [cited 2008 November 11]; Available from: http://www.cdc.gov/handhygiene/.

2. Hochbaum, G. (1958) Public Participation in Medical Screening Programs: A Sociopsychological Study. Public Health Service Publication

3. Patient Admission Video: Hand Hygiene in your Healthcare Facility. 2008 [cited 2008 November 11]; Available from: http://www.cdc.gov/handhygiene/Patient_Admission_Video.html.

4. Siegel, M., Marketing Theory: Alternative Public Health Behavior Models. October 9, 2008, Boston University School of Public Health: Boston, MA.

5. Trick, W. and R. Weinstein, Hand hygiene for intensive care unit personnel: Rub it in. Critical Care Medicine, 2001. 29(5): p. 1083-84.

6. CDC - Health Marketing Basics. June 27, 2006 [cited 2008 November 11]; Available from: http://www.cdc.gov/healthmarketing/basics.htm#healthmarketing.

7. Hughes, S. and C. Dennison, Progress in Prevention: How Can We Help Patients Seek Information on the World Wide Web?: An Opportunity to Improve the "Net Effect". J of Cardiovascular Nursing, July/August 2008. 23(4): p. 324-5.

8. Hicks, J., The strategy behind Florida's "truth" campaign. Tobacco Control, 2001. 10: p. 3-5.

9. Edberg, M. and L. Abroms, Application of Theory: Communication Campaigns, in Essentials of Health Behavior: Social and Behavioral Theory in Public Health, R. Rieglman, Editor. 2007, Jones and Bartlett: Washington DC. p. 117.

10. Atkins, C., The failure of formal rights and equality in the clinic: a critique of bioethics. Ethics & Medicine, 2005. 21(3): p. 139-62.

11. Haas, J.P. and E.L. Larson, Compliance with Hand Hygiene. Amer. J of Nursing, August 2008. 108(8): p. 40-44.

12. Gawande, A., On Washing Hands, in Better: A Surgeon's Notes on Performance. 2007, Metropolitan Books: New York.

13. Edberg, M., Individual Health Behavior Theories, The Health Belief Model, in Essentials of Health Behavior: Social and Behavioral Theory in Public Health, Riegelman, Editor. 2007, Jones and Bartlett: Boston. p. 36-7.

14. Curry, V. and M. Cole, Applying Social and Behavioral Theory as a Template in Containing and Confining VRE. Crit Care News, 2001. 24(2): p. 13-19.

15. Pittet, D., et al., Hand Hygiene among Physicians: Performance, Beliefs, and Perceptions. Annals of Internal Medicine, 2004. 141: p. 1-8.

16. Yokoe, D. and D. Classen, Improving Patient Safety Through Infection Control: A New Healthcare Imperative. Infection Control and Hospital Epidemiology, 2008. 29(1): p. S3-S11.

17. WHO Guidelines on Hand Hygiene in HealthCare (Advanced Draft): A Summary, in Clean Hands are Safer Hands, D. Pittet, Editor. 2005, WHO: Geneva.

18. Boyce, J.M. and D. Pittet, Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. 2002, Centers for Disease Control and Prevention.

19. Ariely, D., Predictably Irrational: The Hidden Forces That Shape Our Decisions. 2008, New York: Harper Collins.

In Search of a Hands-Down Better Approach to Preventing Hospital Acquired Infections –Devan Darby

Given the theoretical shortcomings and practical ineffectiveness of traditional hand-washing interventions posited by the Centers for Disease Control and Prevention (CDC), a new and better approach is needed to tackle the problem of hospital-acquired infections (HAIs). This new and improved approach will have three notable attributes that differentiate it from more traditional efforts. First, it will reconsider the premise of traditional public health interventions that human behavior is planned, logical, and rational. Secondly, the new approach presents a comprehensive message that addresses HAIs in a realistic way given the context of the modern hospital environment. Finally, the new strategy will incorporate insights and lessons from the social sciences, namely communications and marketing theories, to boost uptake of and participation in the intervention. Because the culture and personnel composition of each hospital is slightly different, a successful intervention may not look the same in all hospital environments. The approach outlined here will be less of a one-size-fits-all solution and more of a framework around which hospitals may formulate their own tailored strategies.

The Framework:

The basic framework of this new intervention will be premised on the idea that in order for any intervention to be successful, it must consider the populations in which it will be operating. Before implementing any infection control intervention, formative research should take place to identify the cultural values particular to the place in which that intervention will be implemented. Additionally, comprehensive approaches which are based on multiple levels of behavioral interventions are more likely to succeed than interventions targeted solely at individual-level factors.[1] This new interventional framework will be a multifaceted solution which employs a positive deviance approach to empower personnel working in the hospital to improve patient outcomes through habitual infection control behaviors. Specific aspects of the new framework are outlined in each of the three sections below:

Attribute #1: Rethinking Rationality

The new hand-washing framework will abandon the premise of traditional hand-washing promotions sponsored by the CDC[2] which fail to consider the factors of irrationality that underlie human behavior. By and large, health care workers are informed and committed to the prevention of HAIs in their patients. As professionals in the healthcare field, most healthcare personnel are health-oriented people who possess a foundation in the merits of infection control.[3] In a study of physician knowledge of best practices, 85% reported already knowing the importance of hand hygiene in preventing nosocomial infection.[4] If high rates of nosocomial infection persist despite educational campaigns, doctors and nurses must not be as rational as one would suppose, despite their scientific training and fabled appreciation for data. This new framework will rethink hand-washing not as a conscious act but as a knee-jerk habit which must be instilled in every person who cares for a patient. Habit formation begins in medical, nursing, physician assistant, and other health professional schools; training programs must be enlisted to help inculcate the next generation of providers with the hand-washing instinct. By reinforcing hand washing as a habitual process, the necessity for rationality – indeed, for thinking at all – is eliminated.

An important component of transforming infection control behaviors into Pavlovian instinct is constant reinforcement. Recent studies have shown that compliance is significantly improved when health care workers either receive constant reminders or perceive that they were being observed or evaluated.[4, 5] Culturally competent reminder mechanisms such as voice-reminder systems have been tested with great success in some places[5] and should be implemented wherever possible. Reinforcement of excellent compliance can also be improved through system-level changes that improve the ease of compliance. The most frequently cited reasons for noncompliance with hand-washing protocols are lack of time, the grueling demands of work, and dry or chapped hands.[6] Placement of alcohol-based hand sanitizer dispensers in convenient places around the wards and in patient rooms as well as the provision of conveniently bundled infection control materials (i.e. gown, glove, and eye-shield packs) are system-level improvements which may help boost infection control compliance. Reengineering the hospital setting in this way would reduce the amount of thinking that compliance with hand washing protocols require. By making adherence mindless, the new framework sidesteps the major assumptions that healthcare worker behavior is rational and that their intentions lead to behavior change, thus making achievement of 100% compliance more tenable.

Attribute #2: Cultural Competency

The second major component of the new framework will entail a critical look at the cultural context in which infection control does or does not take place. In a departure from the strategy adopted by the CDC’s “Hand Hygiene Saves Lives” intervention, the new framework will not depend on reinforcement by patients and loved ones because such a dependency fails to consider the strong cultural aversion to challenging medical authority in a healthcare setting.* Given the historical context of paternalism in the medical profession compounded by the emotional turmoil which accompany hospitalization,[7, 8] patients and their loved ones generally lack the sense of duty or empowerment which is required by the traditional intervention strategies that depend on them for enforcement. Instead, the new framework will communicate infection control as an institutional priority to both patients and providers by fostering problem-solving and feedback at the small-group level. This new approach will also play to and encourage already strong qualities in healthcare workers: internal locus of control, deductive problem solving, and teamwork. The small group sessions will simultaneously allow for both formative research and candid, productive discussions in which positive deviants, individuals who already display excellent adherence to infection control protocols, can lead a shift in cultural norms.

The new framework will aim to introduce interventions which are culturally acceptable by encouraging and incorporating input from healthcare workers and community members who have a stake in lowering rates of HAIs. Several hospital systems have had success through implementing positive deviance approaches in which strong performers are engaged to help change cultural norms. In one highly culturally competent and successful approach taken by the University of Pittsburgh Medical Center Veteran’s Affairs (VA) Hospital, interactive small group brainstorming sessions were used to identify positive deviants and attach importance to hospital-worker ideas and suggestions.[9] This bottom-up strategy was remarkably different from the top-down, dictatorial strategy in which hospital protocols were mandated from above. Instead, nosocomial infection was posed as a community problem with a community solution. Cultural attitudes amongst hospital staff, who were now empowered to suggest numerous excellent improvements to the hospital’s current infection control system, began to change. Soon, drug-resistant bacterial infection rates at the VA Hospital became negligible.[10]

This new approach represents a major advance over traditional approaches because it is informed by the social sciences, namely anthropology, sociology, and psychology. Even more, this approach inspires creativity and personal accountability as it plays to the strengths of healthcare workers and gives them a renewed sense of duty and personal accountability. By incorporating knowledge of the specific culture, social interactions, and incentives particular to healthcare workers, this new bottom-up approach is able to motivate and catalyze positive change in ways that standard approaches have not.

Attribute #3: Marketing

The final component of the new framework will be a rejuvenated advertizing campaign that communicates the benefits of hand hygiene in powerful ways to both patients and healthcare workers. For starters, hand hygiene marketing must cease to be an act of tedium. Hand washing must be elevated beyond the humdrum, mundane public health intervention to an affirmation of one’s participation in cutting-edge medical science. Progress in the development of more effective and more nourishing hand sanitizers for use in hospital settings has been remarkably underplayed by traditional infection control campaigns. The alcohol-based gel or foam hand sanitizer is a relatively new technology which has been clinically proven to be more effective at killing germs while preserving skin integrity better than soap and water.[11] Most recently, a new ethanol-based hand sanitizer was developed which has been shown to kill some enteroviruses [12] – a tremendous breakthrough. This information is one of the best-kept secrets in hospital infection control. Given the high regard for medical technologies in the medical profession and in the public at large, this marketing tactic incorporated in the new framework would undoubtedly boost hand-washing compliance.

Secondly, the marketing campaign will advertise hand-washing in a way that is meaningful and that harnesses deep emotions for healthcare workers. Healthcare workers are generally united by their humanistic interests in the welfare of patients and by their professional interests in garnering respect from patients and colleagues for doing a good job.[13] Hand washing can easily be shaped into an act of social consciousness and professionalism: good doctors and nurses care about their patients’ well-being and take the time to disinfect their hands. Framed in this way, hand washing ceases to be viewed as a mundane act, protocol, or mere checklist but instead as an expression of caring and humanistic values. Marketing theory informs this discussion, reminding us that people respond to ideas that resonate with their deep-seated aspirations and desires rather than just the facts.[14] By reframing hand washing in this new way, the act itself may come to take on a far richer, more nuanced, and more attractive meaning.

This new, multidimensional, multifaceted framework draws upon the social sciences and does not make the same mistakes as the currently implemented hand hygiene interventions. Because it understands that hand hygiene is not always rationally planned behavior, the new framework accommodates the need for both theoretical and structural changes in the way that hand hygiene interventions are conceptualized, allocated, and engineered in the hospital setting. By considering the cultural context and psychological motivators underlying healthcare worker behavior, the new framework provides a foundation for culturally appropriate, community-derived solutions. Finally, borrowing from communications and marketing theories, the advertizing campaign revitalizes the tired image of infection control, elevating it to a more socially and personally compelling behavior. The new hand hygiene framework is pliable and adaptable to various community settings and incorporates insight from the social sciences to rectify flaws of the current behavioral models employed in hospital infection control.

1. Pittet, D., Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach. Emerging Infectious Diseases, 2001. 7.2: p. 234.

2. Hand Hygiene in Healthcare Setting: CDC Infection Control in Healthcare. 2008 [cited 2008 November 11]; Available from: http://www.cdc.gov/handhygiene/.

3. Curry, V. and M. Cole, Applying Social and Behavioral Theory as a Template in Containing and Confining VRE. Crit Care News, 2001. 24(2): p. 13-19.

4. Pittet, D., et al., Hand Hygiene among Physicians: Performance, Beliefs, and Perceptions. Annals of Internal Medicine, 2004. 141: p. 1-8.

5. McGuckin, M., et al., The effect of random voice hand hygiene messages delivered by medical, nursing, and infection control staff on hand hygiene compliance in intensive care. American Journal of Infection Control, 2006. 34(10): p. 673-5.

6. Haas, J.P. and E.L. Larson, Compliance with Hand Hygiene. Amer. J of Nursing, August 2008. 108(8): p. 40-44.

7. Atkins, C., The failure of formal rights and equality in the clinic: a critique of bioethics. Ethics & Medicine, 2005. 21(3): p. 139-62.

8. Goodyear-Smith, F. and S. Buetow, Power Issues in the Doctor-Patient Relationship. Health Care Analysis, 2001. 9: p. 449-462.

9. Gawande, A., Better: A Surgeon's Notes on Performance. 2007, Metropolitan Books: New York. p. 26.

10. Gawande, A., Better: A Surgeon's Notes on Performance. 2007, Metropolitan Books: New York. p. 26-27.

11. Trick, W. and R. Weinstein, Hand hygiene for intensive care unit personnel: Rub it in. Critical Care Medicine, 2001. 29(5): p. 1083-84.

12. Macinga, D.R., et al., Improved Inactivation of Nonenveloped Enteric Viruses and Their Surrogates by a Novel Alcohol-Based Hand Sanitizer. Applied and Environmental Microbiology, 2008. 74(16): p. 5047.

13. Sheldon, A., Managing Doctors. 2002: Beard Books. 292.

14. Siegel, M., Marketing Theory: Alternative Public Health Behavior Models. October 9, 2008, Boston University School of Public Health: Boston, MA.

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* It should be acknowledged that all individuals who come into contact with patients have a role to play in preventing HAIs