HANDWASHING BEHAVIOR OF WOMEN IN PUBLIC RESTROOMS Richard Wittenburg, President and Chief Executive Officer of the American Association of World Health addresses a very important issue: “Hand washing, which traditionally was the first line of defense in preventing the spread of disease, has been neglected and must be embraced vigorously by families, schools, and health care professionals.” Similar to brushing one’s teeth in the morning, basic hand washing is a habitual behavior that should be done several times a day to maintain personal hygiene and good health. Munger and Harris (1989) suggest that it is a social norm in our society. Cooks are expected to wash their hands before preparing or eating food, doctors before seeing a patient, and everyone after using the restroom. However, research has found that many people seem to simply run water over their hands without using soap and many fail to wash their hands at all after leaving the restroom. Because washing your hands without soap does not kill germs in an effective manner and not washing your hands at all leaves bacteria on your hands, this might lead one to believe that people wash their hands not because of hygiene or health but simply as a force of habit. In this way, hand washing in public restrooms is related to aspects of social psychology or the scientific study of the way in which people’s thoughts, feelings, and behaviors are influenced by the real or imagined presence of other people (Aronson, 2001). Because others are often present in public restrooms, Wicklund’s theory of objective self-awareness may be applied. This is created through the presence of others who are presumed by the person to be attending to him (1973). Many people assume that because an individual is present they are attending to them, like the spotlight effect or that everyone is in a sense watching them. Objective self-awareness involves conformity. In public, people often change their attitudes, beliefs or behaviors so that they conform to and are similar to those people who are present in the same situation (Aronson, 2001). For example, a person might see that everyone forms a line when all bathroom stalls are full when entering a public restroom to wait their turn. Thus they will follow the norm of standing in a line because of objective self-awareness by modeling others’ behavior. In the American Society for Microbiology (ASM) survey, Hyde found that over 9 out of 10 men and women surveyed over the phone said that they wash their hands every time after using a public restroom though the results of observational studies show the numbers are much lower and closer to 6 out of 10 (2000). This is most probably due to social desirability. The person on the phone did not want the interviewer on the other end of the line to think that he or she was an unhygienic person but those observed in the bathroom may have been unaware of the researcher observing them. In an article run in The New York Times, Dewan (2000) reported that in an observational study, hand washing is down significantly, dropping 60 percent to 49 percent alone in New York’s Grand Central station between 1996 and 2000. Only 43 percent of men washed their hands a slightly higher 54 percent of women washed their hands. This study correlates with another study done in a hospital where female physicians were found to be 30 percent more likely to wash their hands than their male coworkers (AORN, 2002). Because of the apparent widespread problem of hand washing apathy, many people have organized campaigns to promote it. AMS has launched a Clean Hands Campaign to combat the problem and “remind Americans that ‘Mom was right’”—wash your hands (2000). Other studies have tried informational video instruction of proper hand washing techniques to increase awareness and subjects’ likelihood of washing their hands. In a study involving the effects of modeling behavior on hand washing for female students enrolled in a physical therapy program Riolo (1997) found that after watching videotapes of proper hand washing technique, the females subsequently had higher rates of proper hand washing behavior than those in the control group. This would lead one to believe that if awareness is heightened, hand washing may rise. Kimberly-Clark Corporation’s Hand washing Campaign believes just that and is attempting to raise awareness. The campaign produces free posters, how-to-signs, static cling signs for use on mirrors, a button, and stickers that read “Please Remember to Wash Your Hands” and “If you Haven’t Used Soap, You Haven’t Washed Your Hands” (Family Practice, 2002). Another advertising campaign “endorse[s] the ‘Four Principles of Hand Awareness:’ . . . wash your hands when they are dirty and before eating; to not cough into hands; to not sneeze into hands;” and “above all, do not put your fingers into your eyes, nose, or mouth” (Modern Physicians, 2002). Hand washing is something that one should do several times a day but unfortunately many people fail to do so. This causes widespread bacteria and infectious diseases that may be easily prevented with a little soap and warm water. The effect of people not washing their hands not only causes diseases but also immunity to antibiotics. This is because when people get diseases such as diarrhea, colds, and flu viruses because of improper or lack of hand washing and they are then prescribed to antibiotics that they can eventually become immune to. This problem is more far reaching than the diseases themselves. In a study most comparable to this study, Munger and Harris (1989) tested the effects of an observer on hand washing behavior and measured the difference between the absence of an observer versus the presence of an observer. Their results showed a significant difference between women who believed they were being observed and those who did not. Only 11 of 28 subjects washed their hands after using the toilet facilities when they believed they were alone and unattended in the bathroom. When a second person was present 24 of 31 women washed their hands after using the toilet facilities. This is consistent with other studies done. This is also consistent with Wicklund’s theory of objective self-awareness and theories of social influence. The manner in which they performed the study however is questionable and does not seem to follow guidelines of the Institutional Review Board (IRB). In one level of their independent variable, the researchers were in an inconspicuous area of the bathroom listening for running water without the subjects knowing they were present. This would be considered an invasion of privacy because there is an expectation of privacy in bathrooms, even public restrooms. Similar to Munger and Harris’ study, the researchers in this study expected social influence to play a key role in their experiment. The researchers manipulated the environment by either washing their hands, making eye contact with the subjects, and eliciting conversation in one level or talking on a cell phone and avoiding eye contact and avoiding conversation in the second level. This is unlike Munger and Harris because the researchers never made themselves absent from the sink area of the bathroom. In this study, it was hypothesized that women would be more likely to wash their hands in the presence of another woman (the investigator) washing her hands than those subjects in the presence of another woman (the investigator) when she appeared to be having a cell phone conversation, avoiding eye contact, and avoiding conversation.
There were eighty subjects in this experimental study. All participants were women over the age of eighteen. Subjects were all of college age (18-24) with the exception of four women. All participants were observed regardless of age, class, or race and represented race/ ethnicity equally to the best of the investigator’s knowledge. Convenience sampling was used. There was no recruitment necessary because it was an observational study. Participants were excluded if the principal investigators knew them on a personal level (i.e. family member, friend, roommate, sorority sister) or if the bathroom was overcrowded and all sinks were being used.
The materials used in our study included paper towels, soap, running water, and a clean and sanitary sink for participants to wash their hands. Cell phones were used to manipulate the study in one level of the independent variable. The investigator pretended to be talking on her cell phone and acted as if she was not paying attention to the participant being observed. A notepad and pen were also used to record observations in a notebook coding the variables of washing or not washing their hands, using soap or not using soap, duration of hand washing, and time of day. The researchers marked on a notepad which dependent variables were relevant to the subject after she exited the restroom.
DESIGN AND PROCEDURE
The design used was experimental. The investigators manipulated the environment, a public women’s restroom at Friar Tuck’s, an uptown bar in New Orleans, Louisiana. The independent variable had two levels. In the first level of the independent variable the investigator talked on her cell phone, avoided eye contact and conversation with the subject as she exited the bathroom stall. In the second level of the independent variable, the investigator washed her hands, made eye contact with the subject, and engaged conversation by saying “hello” and “how are you?” as the subject exited the bathroom stall. The primary dependent variable that was recorded was whether the subject washed her hands or not. The secondary variables were the time of night, whether the subject used soap or not, and the duration of hand washing time. The investigators stood at the sink area in the bathroom and observed only those women who entered the restroom alone. The control in this was the availability of at least one open sink, soap, paper towels, and water. Participants were kept confidential and remained anonymous. No informed consent or debriefing was given because the investigators believed there to be no potential harm or threat to participants. In addition, informed consent may have manipulated the participants’ actions if they attempted to conform to social norms and were conscious that they were in a study.
RESULTS As proposed in our hypothesis, a significant correlation (r = .287 , p < .01) was found in a subjects’ likelihood to wash their hands and the level of the independent variable. Overall only 40% of women washed their hands. Of those who did wash their hands, they were more likely to do it earlier in the night, and of those who used soap, all washed their hands for longer than 8 seconds. A correlation was utilized to compare the effect of the means of the two levels of the independent variable on the dependent variables: hand washing, washing duration, use of soap, and time of night. While the researcher washed her hands the subjects were more likely to wash their hands (M = .56 , SD = .50). While the researchers talked on their cell phones the subjects were less likely to wash their hands (M = .27 , SD = .45). This data supported the researchers’ hypothesis. A significant negative correlation was found between subjects’ likelihood to wash their hands and the time of night (r = -.436 , p < .01). Subjects were less likely to wash their hands later at night between the hours of 11 p.m., and 1 a.m. and more likely to wash their hands between the hours of 9 p.m. and 11 p.m. When doing a correlation with only those subjects who washed their hands, no significant correlations were found except between the use of soap and duration of hand washing at ( r = .899 , p< .01). The researchers believe this is because those who used soap while washing their hands would need to wash their hands longer while those who merely rinsed their hands washed for only a short amount of time.
DISCUSSION The results of the study supported the researchers’ hypothesis. The researchers hypothesized that the subjects in the second condition of the independent variable (i.e. the investigator washed her hands, made eye contact, and engaged in conversation) would be more likely to wash their hands than those subjects who were in the first condition of the independent variable (i.e. the investigator talked on her cell phone, avoided eye contact, and did not engage conversation). This study’s results are comparable to past research. The study’s results with 60% not washing their hands compares to the observational study published in The New York Times, (Dewan, 2002) in which 51% of New Yorkers did not wash their hands in Grand Central Station. This study highlighted the fact that in two observational studies, hand washing was down in 2000 from 1996. In 2002, our study shows significant results with hand washing behavior even lower with only 40% washing their hands. If apathy continues at this rate it would seem that soon no one would be washing his or her hands in public restrooms. However, our study was conducted in a bar restroom which has many dissimilarities from the public restrooms at Grand Central Station and intoxication is probably of no or minor significance there. Additionally, this study’s results are comparable to Munger and Harris’ (1989) results in their study in that they are both consistent with Wicklund’s theory of objective self-awareness. Those subjects who felt the investigators were attending to them were far more likely to wash than those who did not believe the investigators were attending to them. Like Munger and Harris our mean for washing for those who had the independent variable of researchers washing their hands and engaging conversation was higher than in the condition where the researcher was not washing her hands. However, unlike Munger and Harris, the researchers were constantly present. In one level of the independent variable they attended more to the subject than the second when they talked on the cell phone but they were never absent from the sink area of the bathroom. Another factor that plays into this study is modeling behavior. Those subjects who washed their hands only because the researcher was washing her hands were doing so because they believed it to be the “correct” behavior or social norm. The researchers believe that some of the girls were simply modeling our behavior of washing or not washing their hands because of the social desirability. Limitations Though we found significance for our hypotheses there were still some problems that may have had an effect on our validity. For one, our sample size was relatively small and almost entirely college age women from the observer’s observation. One unfortunate limitation was not having males in the study. This could have been easily reversed had we had a male investigator (AORN, 2002). This way we could have compared it to past research that shows higher percentages of women washing and lower percentages of men washing. One uncontrolled extraneous variable was the level of alcohol consumed by the subject. The researchers expected this to be an extraneous variable because their study was at a bar. The researchers believed that this affected the validity of the study, because the results show a significant negative correlation between time of night and whether or not women washed their hands. The researchers believe from observation that this was due to higher levels of intoxication during the latter hours of the night. As subjects grew drunk perhaps they became more apathetic about hand washing with lower social awareness and thus lower compliance to social norms. This could be eliminated in future studies by conducting the study in a non-bar study, for example, in the library as Munger and Harris did. A second extraneous variable that was not expected by the researchers was the effect of wearing Greek sorority letters. Because freshman women cannot go through formal sorority recruitment until the fall, many feel they are in the spotlight of sorority women when they are seen out at a party or a bar for example, Friar Tuck’s. We found that when we wore our sorority jerseys and t-shirts, on one occasion, many women’s self-awareness was higher than that of majority of women we observed in the bathroom. In our Greek letters we were automatically distinguished as upperclassmen. The researchers believed that women washed their hands regardless of whether we did or not and saw that their mean was higher than those of the entire sample. We believed that some were freshmen women and that they were trying to make a positive impression on us. However, one cannot assume that they were not going to wash their hands anyway after exiting the bathroom. One problem the researchers encountered was a third person entering the restroom. This affected our data significantly because ideally we wanted equal numbers of each subgroup but were unable to do so because data had to be thrown out at a relatively high rate.Implications The practical implications of this study could be that if hand washing behavior were this infrequent across all levels of the population regardless of age, race, class, or gender then infectious diseases will rise. Colds and flu viruses will be more prevalent along with diarrhea and other intestinal tract infections. Again, this is a problem because when doctors prescribe antibiotics for these illnesses, people eventually become immune to them. Drug research may not be able to keep up with the new strands of viruses caused by their immunity to prescription antibiotics. The theoretical implications of this study could be that it will increase objective self-awareness causing more people to wash their hands. Wicklund’s theory of objective self-awareness was evident in our study because those subjects who saw the researchers washing their hands were much more likely to conform to the social norm of washing their hands than those in the condition where the researcher was not washing her hands. Those subjects in the condition where the researcher was washing her hands conformed at a higher rate by modeling the researchers’ behavior. This could be due to social desirability. Improvements could include more subjects. The numbers in our study were relatively low. A future study might look at a larger sample size. Another improvement in the study could be location. Because it was a bar, there was a factor of intoxication. This would not be significant in most other public restrooms. In addition, future research should seek a bathroom with more sinks and bathroom stalls.
REFERENCESHandwashing rates higher among females. (2002) Association of Rehabilitative Nurses Journal,75, 863.
Aronson, E., Wilson, T.D., & Akert, R.M. (2001). Social Psychology (4th ed.) New York, NY: Addison Wesley Longman, Inc.
Dewan, S.K. (2000) Washing up is down, study shows. The New York Times. Sept. 19, 2000 Section B; 3; column 1.
Duvall, S. & Wicklund, R.A. (1972) A theory of objective self-awareness. New York: Academic Press.
Hyde, B. (2000, September 18) America’s dirty little secret—our hands. American Society for Microbiology Survey. Retrieved October 8, 2002 from http://www.washup.org Washed Up. (2002). Modern Physicians. 6, 9.
King, C.(2000) Improved rates of compliance with hand antisepsis guidelines: a three-phase observational study. Association of Rehabilitative Nurses Journal. 74, 555.
Munger, K. & Harris, S.J. (1989) Effects of an observer on handwashing in a public restroom. Perceptual and Motor Skills. 69, 733-4.
Riolo, L. (1997). Effects of modeling errors on the acquisition and retention of sterile hand washing task. Perceptual and Motor Skills.84, 19-26.