Hygiene Challenges in the Domestic Environment

Overcoming Hygiene Challenges in the Domestic EnvironmentPatricia Borrusso, PhDORISE Research Fellow, Office of Analytics and Outreach U.S. Food and Drug Administration (FDA) Center for Food Safety and Applied Nutrition10 September 2015

+1PhD thesis research (2009-2014)Evaluation of the Domestic Environment as a Reservoir for Foodborne Pathogens: Identification of Consumer Practices Associated with Microbial Contamination in the Home

Current research (2014-Present)Systematic evaluation of consumer food safety interventionsDevelopment of recommendations to improve future efforts

Introduction(Who am I, and What do I know about home hygiene and consumer behavior?)

+2Home Hygiene: Science PerspectivesThere are many sources of microbial contamination in the domestic environment

Contamination may persist and spread due to lack of hygiene

Consumers are the final defense

+3Home Hygiene: Consumer PerspectivesOnly 25% admit to knowing little or nothing at all about germs 92% believe they know enough to keep themselves healthy

Most Consumers Believe they are Familiar with Microbiological ConceptsN=1759 (Source: WK Hallman 2008)+4Home Hygiene: Consumer PerspectivesOnly 25% admit to knowing little or nothing at all about germs 92% believe they know enough to keep themselves healthy

This perception is accurate for some topics, for example: There are always germs on the human bodyHarmful germs are everywherePeople can spread a virus to others even when they have no symptomsWet surfaces typically have more germs than dry surfaces

But, a few misconceptions are still widely held...

Most Consumers Believe they are Familiar with Microbiological ConceptsN=1759 (Source: WK Hallman 2008)+5Home Hygiene: Consumer PerspectivesN=262 (Source: WK Hallman 2008)A Few Misconceptions are Widely Held+6Home Hygiene: Consumer PerspectivesN=262 (Source: WK Hallman 2008)A Few Misconceptions are Widely Held+Not to say this is necessarily a misconception but if people are considering these products equally effective they may use them similarly. One of the issues that may arise with people using ammonia to clean/disinfect surfaces is incorrect use7Home Hygiene: Consumer PerspectivesN=262 (Source: WK Hallman 2008)A Few Misconceptions are Widely Held+People prefer antibacterial soap again not saying this is a misconception but I think the jury is still out on whether these types of soap are actually better 8Home Hygiene: Consumer PerspectivesN=262 (Source: WK Hallman 2008)A Few Misconceptions are Widely Held+9I have no reason to worry about getting sick

Overestimate knowledge and skills necessary to avoid or eliminate health risks

Home Hygiene: Consumer PerspectivesMisconceptionsNegative Attitudes+10Home Hygiene: Consumer PerspectivesN=1759 (Source: WK Hallman 2008)A Few Misconceptions are Widely Held+11I have no reason to worry about getting sick

I only need to clean if I see or smell something unusual

Overestimate knowledge and skills necessary to avoid or eliminate health risks

Visual and olfactory cues = Germs are present

Home Hygiene: Consumer PerspectivesMisconceptionsConsumer Attitudes+12Home Hygiene: Consumer PerspectivesN=275 (Source: WK Hallman 2008)A Few Misconceptions are Widely HeldIn publicAt home+Some people answered 0 for toilet seat at home

13I have no reason to worry about getting sick

I only need to clean if I see or smell something unusual

Im unlikely to get sick because of something I did at home

Overestimate knowledge and skills necessary to avoid or eliminate health risks

Visual and olfactory cues = Germs are present

There are more germs in public places than in the home

Home Hygiene: Consumer PerspectivesMisconceptionsNegative Attitudes+14Home Hygiene: Consumer PerspectivesN=1759 (Source: WK Hallman 2008)A Few Misconceptions are Widely Held+15Home Hygiene: Consumer PerspectivesN=1759 (Source: WK Hallman 2008)A Few Misconceptions are Widely Held

+Can we blame them?16I have no reason to worry about getting sick

I only need to clean if I see or smell something unusual

Im unlikely to get sick because of something I did at home

They are out to get me and theres nothing I can do about it!

Overestimate knowledge and skills necessary to avoid or eliminate health risks

Visual and olfactory cues = Germs are present

There are more germs in public places than in the home

Germs have super-human abilities

Home Hygiene: Consumer PerspectivesMisconceptionsNegative Attitudes+17Many hygiene risks are present in consumer homes

Major discrepancies between consumer perspectives and science perspectives

+Quick Recap+1810-35% use natural products (i.e., vinegar, baking soda) to clean at home

4-35% homes observed had no dish soap or sanitizing agents in the kitchen

46% clean their refrigerator 2-3 times per year or lessUse effective cleaning agents

Clean surfaces regularly

Consumer BehaviorData from food handling studies (Borrusso et al. 2015, Byrd-Bredbenner et al. 2007, Kennedy et al. 2005, Li-Cohen and Bruhn 2002, Phang and Bruhn 2011)Reduce Contamination on Household SurfacesRecommendedActual+Some examples..195-40% use soap and water (although nearly 100% say they do)

50%) do not dry or dry incorrectlyRecommendedActualUse soap and clean running water

Wash for 20 seconds

Dry with a clean towel afterwardConsumer BehaviorData from food handling studies (Anderson et al. 2004, Bermudez-Millan et al. 2004, Bruhn 2014, Dharod et al. 2007, Fein et al. 2011, Hoelzl et al 2013, Kennedy et al. 2011, Nesbitt et al. 2009, Parra et al. 2014, Phang and Bruhn 2011)Proper Hand Hygiene+Caveat: data from food handling studies20Observed:5-40% before preparing food85% after using the restroom20-35% after handling raw meat

Reported:80-100% before preparing food, after using the restroom, after handling raw meat27-42% after contact with animals, coughing or sneezing, handling money

Before handling food

After using the restroom; handling raw meat; contact with animals; blowing your nose or sneezing; any other activity that may contaminate handsConsumer BehaviorData from food handling studies (American Cleaning Institute 2010, Anderson et al. 2004, Bermudez-Millan et al. 2004, Bruhn 2014, Dharod et al. 2007, Fein et al. 2011, Hoelzl et al 2013, Kennedy et al. 2011, Nesbitt et al. 2009, Parra et al. 2014, Phang and Bruhn 2011)Proper Hand Hygiene at the Right TimesRecommendedActual+2140-80% do not separate raw meat from other foods while shopping or transporting groceries

50% frequently use reusable grocery bags for non-food items3% cleaned bags regularlyKeep raw items separate from other food in your cart or bag Clean, store and use reusable bags correctly

Consumer BehaviorData from food handling studies (Chambers 2014, Kosa et al. 2015, Li-Cohen and Bruhn 2002, Williams et al. 2011)RecommendedActualMinimize Cross-Contamination and Microbial Transfer While Shopping for Food+22Average lifespan of a dishwashing sponge: 19.5 days (11% > 30 days)

38-60% of homes had sponges that were visibly dirty or stored incorrectly

Sanitize or replace sponges and cleaning cloths regularly

Store sponges and cloths in a dry area

Consumer BehaviorData from food handling studies (Borrusso et al. 2015, Byrd-Bredbenner et al. 2007, Larson and Duarte 2001)RecommendedActualMinimize Cross-Contamination and Microbial Transfer While Cleaning+2317-29% of homes did not have paper towels in the kitchen (cloth towels only)

27% use the same sponge for washing dishes and wiping up spills on the floor (always, usually or sometimes)If possible use disposable paper towels instead of cloth towels

Use separate sponges for clean items and dirty items

Consumer BehaviorData from food handling studies (Borrusso et al. 2015, Byrd-Bredbenner et al. 2007, Larson and Duarte 2001)RecommendedActualMinimize Cross-Contamination and Microbial Transfer While Cleaning+24Many hygiene risks are present in consumer homes

Major discrepancies between consumer perspectives and science perspectives

Consumers fail to take appropriate measures to reduce or eliminate hygiene risks at home+Quick Recap+25Many hygiene risks are present in consumer homes

Major discrepancies between consumer perspectives and science perspectives

Consumers fail to take appropriate measures to reduce or eliminate hygiene risks at home+Quick RecapCommunication Breakdown+26What is Being Done to Fix This?Education and TrainingNational CampaignsEnvironmental Interventions (i.e., food product labels)Innovative Tools and Smart Technology

Good News: Countless efforts to improve consumer behavior and home hygiene+What is Being Done to Fix This?Education and TrainingNational CampaignsEnvironmental Interventions (i.e., food product labels)Innovative Tools and Smart Technology

Good News: Countless efforts to improve consumer behavior and home hygieneDespite an abundance of positive results from intervention studies (publication bias), frequent methodological flaws* limit our ability to infer causal relationships from these data

*Few RCT, lack of adequate controls, weak design and evaluation

Not-So-Good News: We still dont know a lot about how to change behavior+Proof of concept vs. Robust causal inferences

28How to Improve Future Efforts?Improve quality of research studiesMany things can go wrong when planning, implementing and evaluating education programs

Difficult to know true intervention effects Good intervention strategy + No message testing = Weak resultsGood intervention strategy + Unreliable outcome measurement = Weak results

Bad intervention strategy + Lack adequate controls = Good resultsBad intervention strategy + Non-random sample = Good results(Source: Young et al. 2015)+Recent paper showed significantly better results from studies that included thorough formative research29How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsHow most programs are developed:+How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsHow most programs are developed:What is missing?Understand barriers+How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsUnderstand barriers to executing the desired behaviorMany internal and external factors impact consumer behavior

Its important to know which one you are trying to change Desired BehaviorAdequate knowledgeSocial normsAccess to resourcesPerceived riskFear of consequencesConvenienceRemember when necessaryTaste preferences (food handling)No conflict with personal valuesFavorable environment+Cannot just assume barrier is lack of knowledge32How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsDesired behavior: Scrub firm produce (potatoes, melon) under running water

Barrier: People with decreased physicalability (such as older adults) cannot hold heavy produce long enough to scrub thoroughly

Current education strategy: Show and tell consumers how to execute behavior

Understand barriers to executing the desired behavior+How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsDesired behavior: Scrub firm produce (potatoes, melon) under running water

Barrier: People with decreased physicalability (such as older adults) cannot hold heavy produce long enough to scrub thoroughly

Current education strategy: Show and tell consumers how to execute behavior

Understand barriers to executing the desired behaviorCurrent strategy does not address barrier No behavior change+How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsDesired behavior: Scrub firm produce (potatoes, melon) under running water

Barrier: People with decreased physicalability (such as older adults) cannot hold heavy produce long enough to scrub thoroughly

Improved education strategy: Advise consumers with decreased physical ability to seek help from family members or purchase smaller, more manageable produce items

Understand barriers to executing the desired behavior+How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsHow to identify barriers?

Look at dataEx: High SR + low OBS = Adequate knowledge

Ask the target audience!

Understand barriers to executing the desired behavior+How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsHow most programs are developed:What is missing?Understand barriersAddress needs of target audience+How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsAddress needs of target audienceWarning! If your target audience thinks your messageIs boring, Does not apply to them,Is delivered by someone who is untrustworthy,Contains information they already know,Is difficult to understand, ORConflicts with their beliefs,It needs to be revised.+How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsAddress needs of target audienceMust have a complete understanding of audienceWhat do they want to know?How do they communicate with each other? (sense of humor, language style)

Audience notices, pays attention to and remembers the message+Add pictures: humor, disgust39How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsAddress needs of target audienceMust have a complete understanding of audienceWhat do they want to know?How do they communicate with each other? (sense of humor, language style)

Audience notices, pays attention to and remembers the message

+Add pictures: humor, disgust40How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsAddress needs of target audienceMust have a complete understanding of audienceWhat do they want to know?How do they communicate with each other? (sense of humor, language style)What are their values?What are they concerned about?

Audience believes message is personally relevant and important+Add pictures: appeal to emotions41How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsAddress needs of target audienceMust have a complete understanding of audienceWhat do they want to know?How do they communicate with each other? (sense of humor, language style)What are their values?What are they concerned about?

Audience believes message is personally relevant and important

+Add pictures: appeal to emotions42How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsAddress needs of target audienceMust have a complete understanding of audienceWhat do they want to know?How do they communicate with each other? (sense of humor, language style)What are their values?What are they concerned about?What do they do for fun?Who do they trust?Where do they look for information?

Audience is exposed to and believes the message+Add pictures Sources and settings for delivery43How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsAddress needs of target audienceMust have a complete understanding of audienceWhat do they want to know?How do they communicate with each other? (sense of humor, language style)What are their values?What are they concerned about?What do they do for fun?Who do they trust?Where do they look for information?

Audience is exposed to and believes the message

+Add pictures Sources and settings for delivery44How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsAddress needs of target audienceMust have a complete understanding of audienceWhat do they want to know?How do they communicate with each other? (sense of humor, language style)What are their values?What are they concerned about?What do they do for fun?Who do they trust?Where do they look for information?Literacy/Numeracy?

Audience can understand the message+This is especially true for numeric probability45How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsAddress needs of target audienceMust have a complete understanding of audienceWhat do they want to know?How do they communicate with each other? (sense of humor, language style)What are their values?What are they concerned about?What do they do for fun?Who do they trust?Where do they look for information?Literacy/Numeracy?

Audience can understand the message

16.7% of peopleor1 in 6 people+For example, should express numeric probabilty with both a visual and words46How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsAddress needs of target audienceMust have a complete understanding of audienceWhat do they want to know?How do they communicate with each other? (sense of humor, language style)What are their values?What are they concerned about?What do they do for fun?Who do they trust?Where do they look for information?Literacy/Numeracy?

Ethnographic research

+Add pictures47How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsHow most programs are developed:What is missing?Understand barriersTest materials & delivery method with target audienceAddress needs of target audience+How to Improve Future Efforts?Use a systematic, data-driven approach to design education programsHow most programs are developed:What is missing?Understand barriersTest materials & delivery method with target audienceRevise materials accordinglyAddress needs of target audience+How to Improve Future Efforts?What are others doing?What do others think I should be doing?Provide information about the positive behavior of others

4 out of 5 college students wash their hands EVERY time they use the bathroom.4 out of 5 college students wash their hands EVERY time they use the bathroom.+When asked about hygiene, most subjects said cleaning was prompted by what other people thought of their own actions [36]. Insert link to USDA commercial

Example: Making friends/family sick due to inadequate hand washing)

50How to Improve Future Efforts? Perceived severity of consequences Perceived susceptibility at home Frequency

Help consumers think about hygiene the same way we (health professionals and scientists) do+How to Improve Future Efforts? Perceived severity of consequences

Help consumers think about hygiene the same way we (health professionals and scientists) do

LGMA Training Video Features Foodborne Illness Victims+Emotional appear fear, guilt52How to Improve Future Efforts? Perceived severity of consequences

Help consumers think about hygiene the same way we (health professionals and scientists) do

(Source: USDA)+Another emotion that can be used.. Embarassment

When asked about hygiene, most subjects said cleaning was prompted by what other people thought of their own actions [36]. Insert link to USDA commercial

Example: Making friends/family sick due to inadequate hand washing)

53How to Improve Future Efforts? Perceived severity of consequences Perceived susceptibility at home

Help consumers think about hygiene the same way we (health professionals and scientists) do

+More pictures dont vomit off the boat, sneeze cross contamination

Make connection with earlier slide people associate visual cues with the need to clean. Need to make invisible cues more visible.54How to Improve Future Efforts? Perceived severity of consequences Perceived susceptibility at home FrequencyHelp consumers think about hygiene the same way we (health professionals and scientists) do

+Key PointsConsumers do not think about hygiene risks the same way we (health professionals and scientists) do

Behavior is predictable, not random (therefore can be changed if you understand influencing factors)

Need to make recommended behaviors seem important, easy, and more obvious to consumers

+Final Thoughts It isnt Rocket ScienceA few years ago, a reporter from National Public Radio wondered about the phrase it isnt rocket science as a comparator used to describe something that wasnt very difficult.

In an effort to find out how difficult rocket science actually is, the reporter interviewed an aeronautical engineer.

Source: WK Hallman 2008+ Final Thoughts It isnt Rocket Science The engineer explained that while rocket science could indeed be complicated, the calculations necessary are based on formulas derived from well-known principles of physics.

It isnt brain surgery, he replied.

So, the reporter interviewed a neurosurgeon to find out how difficult surgery on the brain really is.

Source: WK Hallman 2008+ Final Thoughts It isnt Rocket Science The surgeon responded that brain surgery obviously required good eye-hand coordination, and an excellent understanding of the anatomy of the brain.

However, with some variations, the anatomical structures of the brain are pretty much the same from person to person.

Source: WK Hallman 2008+ Final Thoughts It isnt Rocket Science Its not like its psychology the neuro-surgeon replied, Since every human is different, there are few things more difficult than trying to change peoples behavior.

Source: WK Hallman 2008

+ Final Thoughts It isnt Rocket Science Its not like its psychology the neuro-surgeon replied, Since every human is different, there are few things more difficult than trying to change peoples behavior.

Source: WK Hallman 2008

Thats microbial risk communication.

It isnt rocket science. It isnt brain surgery. Its harder. Get started.

+ Thank You!

AcknowledgementsCFSAN Project advisorsSharmi Das and Amy Lando Interviewees, Reviewers & ContributorsHoward Seltzer, Marjorie Davidson, Louise Dickerson, Christine Prue, Maria Malagon, Shelley Feist, Alan Levy, Shauna Henley, Ben Chapman, Ellen Evans, and Christopher Waldrop+Questions?

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