Christopher Walmsley, MA, BCBA, is a doctoral student in Western Michigan University’s Behavior Analysis program in the Psychology department. He received his Master’s in the same program, and Bachelor’s degree in Psychology at the University of New Hampshire.
Along with the promotion of health behaviors (and decreasing unhealthy ones), he is interested in behavioral gerontology. Specifically, in how we can apply behavioral techniques to the problems commonly observed in older adult populations suffering from dementia, such as the decline of language abilities. He recently published a paper titled: ‘Fostering Hand Washing before Lunch by Students Attending a Special Needs Young Adult Program’ in the journal Research in Developmental Disabilities.
Background of the study
Before this study came about, I was doing practicum work at the school where we ended up recruiting participants and running this project. I was part of a group of graduate students who acted as behavioral consultants in this setting. As we spent more time working there, we began to notice a common issue during the transition from class to lunch: hardly any of the students were washing their hands before they ate. After SARS, H1N1, and other flu scares, we felt this was a good opportunity to make an impact.
Over the course of a school year, absenteeism due to illness can be a problem. Students lose out on opportunities to learn, and program sequencing is disrupted when teachers are out on sick leave. Some portion of this absenteeism could be avoided if students consistently engaged in good hand hygiene.
Measuring hand washing can be tricky. Simply following folks around creates reactivity, and video feeds in the bathrooms are illegal. So, before we sent them off to lunch we had the participants apply a lotion that would glow blue under a black light. After lunch, we would rate how much of the glowing lotion was left on their hands. This served as a pretty decent way to see how well they washed their hands, if at all.
We found that the participants only began to wash their hands both consistently and thoroughly (that is, washing all areas of their hands) after the lotto system was in place, and they received descriptive feedback on their hand washing performance by showing what areas of their hands still had glowing lotion. Importantly, when we stopped the lottery game and feedback, many of the participants continued to wash their hands. Merely teaching them the skill of good hand hygiene through verbal instruction and by modeling the critical steps was not enough to maintain their behavior; making a game of it got them to keep doing it.
I always see signs plastered in every school stating how important it is to wash your hands. I have to wonder just how effective those signs are in actually prompting people to do it. We know about the issue – even hospitals struggle to maintain hand hygiene compliance – but people wash their hands so infrequently despite best intentions. Layered on top of that barrier is the fact that the participants at the school we worked at were cognitively impaired.
By first teaching the correct sequence of steps as recommended by the CDC, which includes washing every part of your hands for at least 15 seconds, we didn’t see great improvements. This suggests that an educational piece alone is not enough, at least for this population of students. Making a lottery game out of washing hands – where tickets were given for good hand washing as indicated by the remaining amount of glow lotion on their hands after lunch – established strong motivation for these individuals to engage in the behavior.
At the end of each week, one of the students’ names was pulled from a basket. They then earned a preferred item. More than just mere education is needed. Instead of scaring kids to wash their hands for fear of germs, it should be made fun.
To more confidently say that our hand washing treatment package is effective, more research is needed with a larger group of participants. If treatment effects are similar, this helps to confirm our findings. Another way is to see if participants would wash their hands in other settings, such as before family meals at home. Such findings would show that the intervention provides more “bang for your buck”, because the new skill would occur in situations other than at school.