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2016/PPFS/002 Agenda Item: 1.5

The Science of Behavior and Infrastructure in Driving Food Safety Culture

Purpose: Information

Submitted by: Kimberly-Clark

Policy Partnership on Food Security MeetingPiura, Peru

23-25 September 2016

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The Science of Behavior & Infrastructure in Driving

Food Safety CulturePhillip Jarpa

Kimberly-Clark ProfessionalSeptember 23, 2016

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Why is this essential?

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K-C Confidential ̂CDC Foodborne Outbreak Tracking and Reporting

* Outbreak is defined as 2 or more cases of a similar illness resulting from eating a common food

Approximately 800 outbreak events in the US without significant change

The CDC estimates that 1 in 6 people in the US suffer a foodborne illness annually

Source: CDC, WHO

Illnesses

Hospitalizations

Deaths

>48M >600M

Leading Organisms:Norovirus

CampylobacterE coli

Shigella

US GLOBAL

128,000

3,000 480,000

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Food workers are a major source of contamination

Meta-analysis of 66 outbreaks that occurred in the US between 1975 and 1998 found that 82% of the outbreaks implicated food workers as the source of contamination and, in 50% of the cases, hands were the source of pathogen transmission.1

Source: (1)Jensen et al. “Quantifying the Effect of Hand Wash Duration, Soap Use, Ground Beef Debris and Drying M ethods on the Removal of Enterobacter aerogenes on Hands.” J of Food Protection, 2015. (2) CDC

According to the CDC ~25-50% of food workers do not wash for the recommended time2.

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Most people do not wash their hands correctly which creates a false sense of hygiene safety

Source: (1)New Zealand Food Safety Authority, Handwashing and Drying Duration Evidence for Efficacy, March 2009.

0

0.5

1

1.5

2

2.5

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Duration of Handwashing vs. Efficacy1

E coli Shigella Serratia marcescens

10 sec 15 sec 30 sec

Mea

n lo

g re

duct

ion

Observational study in New Zealand mean hand washing

duration (1054 subjects) New Zealand Ministry of Health and US FDA recommends 20 sec for hand washing

CDC and APIC recommend 15 sec hand wash

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Hand hygiene compliance is a real risk in food processing.

Source: (1)GeoStrategy Partners Global survey of QA managers in Food Processing facilities. (Nov 2015); (2) Green, L.R. Factors Related to Food Worker Hand Hygiene Practices, Journal Food Protection, 2007.

33-73% of food facilities are out of compliance with proper hand washing procedures2.

38%

22%

21%

10%

9%

Contaminated raw materials

Improperly cleaned production lines (e.g.contaminated equipment/tools)

Poor personal hygiene behaviors byworkers in-shift, during breaks, and after

visiting the washroom

Non-compliance to hygiene protocols inthe hygiene station area

Non-compliance to cross-contaminationprotocols on the production line

Biggest concerns related to contamination risks1

(n=286)

Worker hygiene related risks total 31%

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If the only tool you have is a hammer, you tend to see every problem as a nail

Abraham MaslowPsychologist1908 - 1970

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Science of hygiene and transmission

Behavioral Science

Science of LEAN and 6-Sigma

By blending different scientific disciplines, we have identified relevant strategies to address hand hygiene compliance.

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Behavioral science is an important, cost-effective tool to improve

hand hygiene compliance

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Subconscious processing drives about 95% of actual behaviorFast, reactive, automatic – 11 million bits per second

Conscious processing accounts for about 5% of actual behaviorThoughtful, controlled – 40 bits per second

hippocampusmemory and spatial awareness

amygdalaemotional processing & encoding

basal gangliamotor control & procedural learning

This is what brain science tells us about how we think…

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Daniel KahnemanNobel Laureate & Psychologist

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Study 1: Guatemala Food Processing Plant

Pre-Test Observations:• Not enough time washing hands• Most workers (~100) trying to get through 2 hand hygiene stations in 15 minutes = long lines and

rushing steps• Improper hand hygiene post-toileting• Hand hygiene step perceived as “pre-work” vs. “work”

GOAL: Increase the compliance (time) & efficacy of hand washing & drying, thereby improving clean hands going into the factory floor

Subjects: 220 employees across 3 shifts Test period ~1 month

Phase 1: Baseline (8 days)Phase 2: Behavioral Science Intervention (12 days)Phase 3: No Intervention for (7 days)

Microbial Swab Hands conducted by external micro lab: 1150

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Study 1: Guatemala meat processing facility Hand Stamp Intervention

(We go with pre-set options)

• Introducing a stamp disrupts the default process

(We are influenced by subconscious cues)

• Stamp results in added friction & time spent washing

(Social expectation / norm with stamp appearance)

• Stamp and collateral helps create discuss and shame (if not removed)

(What is visually obvious to us drives our attention)

• Stamp makes visible when hands are clean or not

DEFAULT PRIMING AFFECT SALIENCE

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~63% reduction in “dirty” hands and sustained reduction after intervention ceased

24.70%

9.10%

12%9.30%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Baseline Phase 1 (week 1) Phase 2 (week 2) Phase 3 (week 3)

% “

Dirt

y” H

ands

(>1

000

CFU

)

Source: Final report by Ogilv yChange on Guatemala study, 2015.

St amp usage stopped

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Significant reduction in “dirty” hands with night shift and stickiness after intervention ceased

20.00% 20.83%

40.63%

7.22%12.22% 12.50%

6.67%13.33% 10.00%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

Shift A Shift B Shift C

Percentage of workers in morning, afternoon and night shift returning a 'dirty hands' result

(Total Plate Count exceeding 1000UPC safe limit)

Phase 1 Phase 2 Phase 3

Source: Final report by Ogilv yChange on Guatemala study, 2015.

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Study 2: Peru Dry Snack Food Processing Plant - Compliance Observations

Pre-Test Observations:• Not enough time washing hands (~5-8 sec)• Long lines cause people to rush (non-compliant) hygiene steps (queuing psychology)• Workers drying wet hands on uniform• Workers bypassing long lines

GOAL: Increase the compliance (time) & efficacy of hand washing & drying, thereby improving clean hands going into the factory floor

Subjects: ~250 employees across 2 shifts Test period ~1 month

Phase 1: Baseline (1 days)Phase 2: Behavioral Science Intervention – with “expert” on site (14 days)Phase 3: Behavioral Science Intervention – with no “expert” on site (ran by employees) (7

days)Microbial Swab Hands conducted by external micro lab

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Before the results, we need to establish thresholds…

Very Clean (<10 CFU/Hand)Acceptably Clean

(10 - 1000 CFU/Hand)

Actual count on image: 460 CFU/Hand

Dirty (1000 < CFU/Hand)

Actual count on images: 14000 and 24000 CFU/Hand

Lowest possible limit of detectionUnacceptable, requires immediate attention*

*Source: Swift Microbiological Labs for the Food Processing Industry

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Study 2: Peru snack food processing facility (Using the hand stamp)

Source: Peru study conducted by SGS on behalf of Kimberly-Clark Corp, June 2016.

1st day of Hand Stampby external lab

55%

10% 3%

33%

80%

14%

12% 10%

83%

Sample I (June 16th) Sample II (June 24th) Sample III (July 1st)

TOTAL

Dirty (1000<) Accetpably Clean (10 - 1000) Very Clean (<10)

AddedCollateral

WorkersStamping themselves

(no one else on site)

95% reductionof “dirty hands”

~600% increaseof “clean hands”

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Drying Methods Affect Cross-Contamination Risk

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Queuing psychology teaches us that people will not wait unless the perceived benefit > perceived cost (social pressure of others waiting).

We observed…Long lines waiting for air dryers caused many people to “finish drying” on their uniforms or skip washing altogether

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QA managers see several of the top contamination risks related to hand drying

33%

26%

23%

19%

Employees drying hands ontheir aprons/uniforms

Wet surfaces around the handwashing sink

A manual trigger on a soapdispenser that all employees

must push in order to get soap

Standing in a line with wethands waiting to reach

dryer/towels

Percent of first place rankings (n=277)

Employees [new or ot herwise] overlook rules, forget things—it’s just human nat ure. And t hey love t o bypass t he hand washing st ation. —QA Manager, WTI

Employees [new or ot herwise] overlook rules, forget things—it’s just human nat ure. And t hey love t o bypass t he hand washing st ation. —QA Manager, WTI

Source: (1)GeoStrategy Partners Global survey of QA managers in Food Processing facilities for Kimberly-Clark Corp (Nov 2015)

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Bacteria are transported through moisture and the drying method is proven to impact cross-contamination.

Wet hands pick up and transfer up to 1,000 times the number of bacteria as dry hands and provide the moisture and warmth that bacteria

need to grow1

100%

26%

4%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Fully Wet

20 sec

45 sec

Transference of Microorganisms from Hands after Drying with Hot Air Dryer1

Average drying time observational study17 sec for men / 13 sec for women

Source: (1) New Zealand Food Safety Authority, Handwashing and Drying Duration Evidence for Efficacy, March 2009.

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So the drying method is critical to hand hygiene. Hand towels provide FRICTIONAL REMOVAL of microorganisms while air dryers DISPERSE SHARED

microorganisms onto hands.

Source: (1)Redway et al, “A comparative study of three different hand drying methods: paper towels, warm air dryer, jet air dryer.” European Tissue Symposium, 2008; (2) Jensen et al. “Quantifying the Effect of Hand Wash Duration, Soap Use, Ground Beef Debris and Drying Methods on the Removal of Enterobacter aerogenes on Hands.” J of Food Protection, 2015.

195

42

-76

254

15

-77-100

-50

0

50

100

150

200

250

300

Warm Air Dryer Jet Air Dryer Paper Towel

% Change in Microorganisms on Hands After Drying1

Finger Pads Palms

“Paper towels appear to offer an measurably significant benefit (0.5 log CFU greater reduction) when used after hand washing. Using paper towels to dry hands resulted in 1.9 +/-0.9 log CFU per wash reduction in E. aerogenes, which is significantly greater than air drying.”2

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With a designated 10 sec dry, there was a 3.3X increase in clean hands with towels in our Peru in-situ study using new Jet Air Dryers.

Source: Peru study conducted by SGS on behalf of Kimberly-Clark Corp, June 2016.

14% 6%

79%75%

7%19%

AIR DRYER PAPER TOWEL

Dirty (1000<) Acceptibly Clean (10 - 1000) Very Clean (<10)

2.5x greaterodds of

DirtyHands**

3.3x greaterodds ofCleanHands*

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There seems to be a relationship between the type of drying method and self-declared contamination events

Total (N=301)

Paper towel (N=151)

Air dryer (N=143)

Within the past year 28% 19% 38%

Within the past 2 years 43% 30% 56%

Within the past 5 years 55% 41% 71%

Never 34% 50% 15%

When was the last time you had an event at the plant related to contamination or possible contamination?

Source: (1)GeoStrategy Partners Global survey of QA managers in Food Processing facilities for Kimberly-Clark Corp (Nov 2015)

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The Science of Behavior & Infrastructure in Driving

Food Safety CulturePhillip Jarpa

Kimberly-Clark ProfessionalSeptember 23, 2016

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Conclusions for APEC

• Foodborne illness has a significant impact on health; and food safety incidents have significant impacts on trade and economic growth

• Proper hand hygiene is critical in preventing food safety incidents and should be an integral component of food safety system strengthening efforts

• As part of U.S. efforts to see that food safety measures are developed in a science-based manner, APEC economies should take into account lessons from behavioral science as essential to driving an improvement in hand hygiene compliance

• The 2009 WHO Guidelines on Hand Hygiene in Health Care Settings provides a good basis for hand hygiene in food safety settings

• The hand drying method has a significant impact on hygiene

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APPENDIX

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Approach: Use behavioral science to drive an improvement in hand hygiene compliance

1. Trigger a New Habit by making the right thing to do the easy thing to do

Behavior = Motivation x Ability x Trigger

Source: BJ Fogg, Stanford University.

• Cultural norms• Queuing for drying/washing• Existing training programs (what not why)• Skin disorders / contact dermatitis• Time hand washing is “unpaid”

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2. Tap into our innate human motives driven by heuristics

Approach: Use behavioral science to drive an improvement in hand hygiene compliance

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People have different attitudes, perceptions and cultural beliefs that drive their behavior

Unconcerned 14%

Casual Co-Ex isters 12%

Practical Protectors 8%

Relaxed M anagers

20%

Trad Cleaners 13%

Safe Seekers 11%

Proud Exterminators 8%

Fearful Fanatics 8%

Constantly conflicted 8%

Higher concern about impact of chemicals

Lower concern about impact of chemicals

Higher fear of germs

Lower fear of germs

Gen Pop Unconcerned Fearful Fanatics

I don’t understand why people are so worried about germs

43% 67% 9%

Careful food preparation is the best thing you can do to prevent illness

82% 69% 94%

I don’t like to seem too fussy about germs

62% 77% 19%

Daily cleans kitchen sink / bathroom sink

63% / 30%

-15% +20% / 35%

Hand washing per day 8.63 5.67 11.85

Source: Global Germ Segmentation study, Kimberly-Clark, 2013 (N>15,000).

Germ Concern

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QUANTITATIVE303 surveys

11 countries

30

18

19

78

41

UK

DE

THAILAND

3635

Chile

10108

Colombia

Peru

GeoStrategy Partners Research

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Hand hygiene compliance is a real risk in food processing.

Source: GeoStrategy Partners Global survey of QA managers in Food Processing facilities; U.S. Bureau of Labor Statistic

FACILITIES VS RECALLS – USA

53

150

9

58

0

40

80

120

160

26,000

28,000

30,000

32,000

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

# Establishments Total Food Recalls Undeclared Allergen Recalls

40% Food Processing of companies have experience a contamination event in the last two years, with Worker’s Behavior as the #1

referenced cause for these events.

World’s #1 cause of Food recalls

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Source: Swift Microbiological Labs for the Food Processing Industry