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A field study on watching eyes and hand hygiene compliance in a public restroom



Humans modify their behavior in a socially desirable way when being watched by others. We applied this basic idea to hand hygiene compliance, a behavior that is crucial for preventing germ transmission and successive infections in many settings. Building on the assumption that hand hygiene behavior is socially desirable, we assume that individuals show stronger hand hygiene compliance when being watched. In a field study in a women's public restroom (N = 354), we exposed individuals to a message advising that hand-washing protects against the spread of pathogens. In the experimental condition, stylized human watching eyes were presented above the message. In the control condition, three stars were presented. Analysis revealed a significantly higher percentage of hand hygiene compliance in the watching eyes condition (83.3%) compared to the control condition (71.9%; odds ratio: 1.95, p = .01). The applied value for employers and public institutions is discussed.
A field study on watching eyes and hand hygiene compliance
in a public restroom
Stefan Pfattheicher
Christoph Strauch
Svenja Diefenbacher
Robert Schnuerch
Ulm University
University of Bonn
Stefan Pfattheicher, Ulm University,
Abteilung Sozialpsychologie, 89069 Ulm,
Humans modify their behavior in a socially desirable way when being watched by others. We
applied this basic idea to hand hygiene compliance, a behavior that is crucial for preventing germ
transmission and successive infections in many settings. Building on the assumption that hand
hygiene behavior is socially desirable, we assume that individuals show stronger hand hygiene
compliance when being watched. In a field study in a womens public restroom (N5354), we
exposed individuals to a message advising that hand-washing protects against the spread of patho-
gens. In the experimental condition, stylized human watching eyes were presented above the
message. In the control condition, three stars were presented. Analysis revealed a significantly
higher percentage of hand hygiene compliance in the watching eyes condition (83.3%) compared
to the control condition (71.9%; odds ratio: 1.95, p5.01). The applied value for employers and
public institutions is discussed.
All over the world, hand hygiene
is one of the most important means
to prevent the transmission of pathogens and thereby reduce infec-
tions in professional contexts like the healthcare environment, as well
as in home or community settings (e.g., Aiello & Larson, 2002;
Bloomfield, Aiello, Cookson, OBoyle, & Larson, 2007; Sax et al., 2007;
World Health Organization, 2009). In developing countries, personal
hand hygiene plays a crucial role in the prevention of life-threatening
diseases such as diarrhea and is regarded as one of the most cost-
effective preemptive measures (Bartram & Cairncross, 2010; Borghi,
Guinness, Ouedraogo, & Curtis, 2002; World Health Organization,
2009). In wealthy countries, insufficient personal hand hygiene might
be less life-threatening; nevertheless, it can contribute to elevated
infection rates, particularly in pandemic situations (Aiello & Larson,
2002; Curtis & Cairncross, 2003). In this regard, hand hygiene can save
more than a million people yearly from diarrheal diseases and can
prevent viral infections like influenza (Curtis & Cairncross, 2003;
Moyad & Robinson, 2008).
In addition to home and community settings, adequate hand
hygiene is crucial and even legally regulated in several professional
contexts such as the food processing industries and the healthcare
sector (Allegranzi & Pittet, 2009; Kampf, L
offler, & Gastmeier, 2009;
Medeiros, Cavalli, Salay, & Proença, 2011; Murphy, DiPietro, Kock, &
Lee, 2011; World Health Organization, 2009). In hospitals, hand
hygiene is particularly relevant with respect to patient safety, as it rep-
resents an effective way to prevent hospital-acquired infections among
patients, a most vulnerable group of individuals, including infections
with multi-drug resistant organisms such as MRSA (Allegranzi & Pittet,
2009; Backman, Zoutman, & Marck, 2008; Ducel, Fabry, & Nicolle,
2002; Kampf, L
offler, & Gastmeier, 2009; World Health Organization,
2009). Moreover, childcare centers and schools are receiving special
attention given their double role as institutions that directly and
indirectly interconnect a large number of people and as early-in-life
providers of basic education on hand hygiene (Azor-Martínez et al.,
2014; Meadows & Le Saux, 2004; Wang, Lapinski, Quilliam, Jaykus, &
Fraser, 2017). Overall, hand hygiene is an effective strategy for
preventing diseases and contributes to better health in a vast variety of
contexts (Allegranzi & Pittet, 2009).
In the present contribution, hand hygiene is used to summarize different
hand hygiene procedures, namely washing hands with plain soap and water
as well as hand disinfection using antimicrobial agents such as alcohol hand
rubs (Diefenbacher, Siegel, & Keller, 2016; World Health Organization,
2009). In different settings, different hand hygiene procedures are required
in order to perform optimal hand hygiene (e.g., at home vs. in hospitals).
J Appl Soc Psychol.2018;17. V
C2018 Wiley Periodicals, Inc.
Received: 9 August 2017
Revised: 3 December 2017
Accepted: 11 January 2018
DOI: 10.1111/jasp.12501
All of the above-mentioned hand hygiene-relevant settings differ
in several regards: for example, in the frequency of situations in which
hand hygiene is recommended; in the risk of negative outcomes when
hand hygiene is not performed in those situations; or, in the scope and
severity of the potential negative outcomes. A commonality of these
different settings, however, is the lack of compliance with hand
hygiene recommendations. In private settings, a typical situation rec-
ommended for hand hygiene is after toilet use (Bloomfield et al., 2007;
Nicolle, 2007). Judah and colleagues (2010), for example, report that a
quarter of adult commuters sampled in buses and trains in the
United Kingdom had fecal bacteria on their hands. Other studies
(e.g., Anderson et al., 2008; Cardinale Lagomarsino et al., 2017; Monk-
Turner et al., 2005; Munger & Harris 1989; Nalbone, Lee, Suroviak, &
Lannon, 2005) directly assessed hand hygiene after toilet use in public
restrooms and found largely varying, but frequently suboptimal
compliance rates between 30% and 90% for different populations
(e.g., convenience samples of students or employees at their work
place, male, female, or samples in different regions).
Studies on hand
hygiene practices of food workers reported poor compliance with offi-
cial hand hygiene recommendations during food production in 31% of
catering businesses (Clayton & Griffith, 2004) and 27% in restaurants
(Green et al., 2006). A smaller study reported a compliance rate as low
as 7% during food production in restaurants (Strohbehn, Sneed, Paez,
The best studied hand hygiene context by far is the healthcare sec-
tor, specifically hospitals, where infections that patients might acquire
during their stay are a major concern (Allegranzi & Pittet, 2009; Kampf,
offler, & Gastmeier, 2009; World Health Organization, 2009). None-
theless, compliance with hand hygiene recommendations is still alarm-
ingly low. The mean compliance rate established by a systematic
review of 96 original studies is reported as low as 40% (Erasmus et al.,
As a consequence of the special importance of hand hygiene and
low compliance in the same, it is crucial to identify methods that
enhance hand hygiene compliance (Naikoba & Hayward, 2001). In par-
ticular, research should focus on easily applicable low-cost methods:
Small interventions could represent a low threshold for companies and
institutions. If successful, such interventions could increase health, in
the case of employers, save money due to fewer employee sick days,
decrease infection-related absenteeism in schools, and increase patient
safety in hospitals or other healthcare institutions. In sum, strategies
toward increasing hand hygiene are urgently needed and should be in
the focus of research. The present investigation takes one step in this
direction; specifically, we tested whether a simple cue of being
watched, that is, the presentation of stylized watching eyes, increases
hand hygiene compliance after using a public restroom. In this way, we
tested whether a low-cost method (i.e., the simple presentation of
stylized watching eyes) can improve hand hygiene. This approach might
not only serve applied value for companies, public institution, and
peoples health per se, but also contributes to our basic understanding
about how hand hygiene can be improved. As outlined in detail to
follow, we argue that (subtle) social presence offers this potential.
Watching eyes and socially desirable behavior
There is long-standing, striking evidence that individuals modify their
behavior when other individuals are present (Markus, 1978; Zajonc,
Heingartner, & Herman, 1969). In particular, individuals act in a socially
desirable way when being watched by others (Leary & Kowalski, 1990;
Van Bommel, van Prooijen, Elffers, & van Lange, 2014). It appears that
people not only modify their behavior when other individuals are
present, but also when mere reminders of being observed (i.e., human
watching eyes) are present in the environment (Haley & Fessler, 2005).
In recent years, a growing number of researchers have shown that cues
of being watched reduce socially undesirable behavior such as bicycle
theft (Nettle, Nott, Bateson, & No
e, 2012) or littering (Ernest-Jones,
Nettle, & Bateson, 2011). Similarly, cues of being watched increase
socially desirable behavior such as cooperation (Bateson, Nettle, &
Roberts, 2006) and donations to charity given relatively few other
people were present (Ekstr
om, 2012). Yet we want to point to several
published null effects in the study of cues of being watched
(Northover, Pedersen, Cohen, & Andrews, 2017). We discuss this issue
in detail in the Discussion section.
In the present contribution, we argue that, due to its important
role in the prevention of disease-spreading, hand hygiene reflects a
socially desirable and expected behavior (Aunger et al., 2016). On this
basis, we assume that individuals show stronger hand hygiene
compliance when being watched. In fact, past research shows that an
observer present in a public restroom increases the number of people
who wash their hands after using the restroom (Munger & Harris,
1989). This finding could be replicated in other public restrooms
(Cardinale Lagomarsino et al., 2017; Edwards et al., 2002; Nalbone
et al., 2005) and for hand hygiene compliance in hospitals (Eckmanns,
Bessert, Behnke, Gastmeier, & R
uden, 2006; Maury, Moussa, Lakermi,
Barbut, & Offenstadt, 2006).
Recent studies have explored whether the presentation of watch-
ing eyes can be applied to increase hand hygiene behavior. Beyfus
et al. (2016; see also King et al., 2016) demonstrate increased compli-
ance with hand hygiene recommendations in a hospital when watching
eyes are placed next to an alcohol foam dispenser compared to when
no stimulus is presented. However, there were two notable disadvan-
tages in that study: First, the image not only showed eyes but the eyes
of a recognizable leader at the institution where the study took place.
Second, the eyes pinned above the dispensers could be interpreted as
angry. Therefore, the findings might not reflect the influence of a
simple depiction of watching eyes. Instead, they could be driven by the
participantsfear of being caughtby someone in leadershipviolating
the hand hygiene instruction and/or the apparent aggressiveness of
the eyes. Interestingly, a similar study in the hospital context showed
that angry watching eyes do not significantly increase hand hygiene
A huge portion of variation in reported compliance rates might be caused
by (a) different operationalizations, that is, what specific behavior is consid-
ered in the study (e.g., washing with or without soap; disinfection yes or
no), and (b) the facilities that are considered (i.e., commodes and/or urinals
which can differ in perceived contamination of hands; Berry, Mitteer, &
Fournier, 2015).
behavior (Bolton, Rivas, Prachar, & Jones, 2015). Overall, research is
needed to enhance knowledge on the possible effect of watching eyes
on hand hygiene behavior. In the study reported below, we address
this issue and examined whether (neutral) watching eyes increase hand
hygiene compliance. The study took place in a womenspublic
Procedure and assessments
A field study was set up to assess the impact of watching eyes on
hand-washing compliance after using a public restroom. The study took
place at a central public restroom on a campus at a German university.
The study was conducted in full accordance with the Ethical Guidelines
of the German Association of Psychologists (DGPs) and the American
Psychological Association (APA). No personal information was
assessed; participants remained completely anonymous and were not
identified in any regard during the study process. Moreover, by the
time the data were acquired in June 2017, it was also not customary at
Ulm University, nor at most other German universities, to seek ethics
approval for simple, noninvasive field studies.
Hand hygiene compliance was defined as washing hands with
soap. Data on whether individuals washed their hands with soap was
collected with a soap dispenser provided by the company Ophardt
Hygiene Technologies, Inc.
The dispenser set timestamps for each
use. In addition, the times individuals entered and left the restroom
were recorded by one hidden (female) observer situated about 15
meters away.
The recorded times of entering and leaving the restroom
and the data from the soap dispenser were matched to determine who
used the dispenser. Whether or not people used soap to wash their
hands served as the binary dependent variable. In addition, we
recorded (a) whether at least one other person was also present during
the time individuals were in the restroom (control group583.3%,
watching eyes 578.8%, n.s.), and (b) the time, in minutes, that individu-
als spent in the restroom (control group M53.46, SE5.09; watching
eyes M53.22, SE5.08, t(352) 51.93, p5.05, Cohensd50.21).
Watching eyes
Two posters were changed every 12 hr, reflecting two conditions (see
Figure 1). In the control condition (n5144), a poster carrying a
message of advice on hand hygiene and a distractor (three stars) was
displayed directly at the sink. The message read Hände verbreiten
Krankheitserreger. Richtig waschen sch
utzt.(Hands spread pathogenic
germs. Hand-washing protects). In the experimental condition
(n5210), the stars were replaced by a pictogram of neutral eyes look-
ing straight ahead, taken from Keller and Pfattheicher (2011; see also
Pfattheicher & Keller, 2015). The message of advice was therefore
present in both conditions, but the presence of the watching eyes
versus stars was varied. Both posters were the size of an ISO 216
paper sheet (210 mm 3297 mm). Posters were changed only when no
individuals were in the restrooms and the procedure took only a few
seconds. We used the pictogram of watching eyes because they were
relatively neutral, that is, more parsimonious regarding the information
that is salient in the situation. Accordingly, possible confounding factors
that may come along with other (eye) manipulations (e.g., attractive-
ness, emotion) can be excluded. The applied eyes were tested
previously in a study by Pfattheicher and Keller (2015). They found
that these eyes reliably increase a sense of being watched.
Using G*Power (Faul, Erdfelder, Buchner, & Lang, 2009), a power anal-
ysis was conducted for a one-tailed z-test for a single binominal regres-
sion coefficient in a logistic regression. Power was set to .80 (Cohen,
1992) and a medium effect (odds ratio 52.15; Rosenthal, 1996) was
assumed which would correspond to an increase of hand hygiene com-
pliance from 65% to 80% caused by watching eyes. We went for a
medium effect to detect an effect that is of relevant size. This power
analysis revealed a required sample size of N5220 to detect a signifi-
cant effect (alpha level of .05) given there actually is an effect. Data
from 354 individuals between June 20 and 27, 2017, could be
collected. Due to the fact that the experimenter was female while a
FIGURE 1 The posters pinned in the restroom: Watching eyes (left) and the three stars (right) with the message about hand washing. The
message (in German) says Hands spread pathogens. Hand washing protects
We could have used a dispenser from another company as well. To be
transparent, we mentioned that the dispenser is from Ophardt Hygiene
Technologies, Inc.
The observer only entered the restroom to change the watching eye pic-
ture (experimental condition) and the three stars (control condition). The
study took place in the main building of the university; there are typically
other people also present outside the restroom walking by or sitting there.
That said, the observer was probably not considered an observerbut as a
person just sitting there.
As reported in detail below, watching eyes increased hand hygiene compli-
ance. Controlling for time spent and whether other people were present
even strengthened the effect of watching eyes on hand hygiene behavior.
regular change of posters in the restrooms was necessary, the study
took place only in the womens restroom. Data of the study are avail-
able on the Open Science Framework (see We
used SPSS Statistics 24 (IBM Corp., Armonk/USA) to run the analyses.
As we had a binary variable (hand hygiene yes/no), we ran logistic
regression analyses. For testing interactions, we used the PROCESS
macro provided by Hayes (2013).
Overall, 76.6% of the individuals used the soap dispenser. Using logistic
regression analysis, whether individuals used the soap dispenser
(1 5yes, 0 5no) was regressed on the experimental condition
(1 5watching eyes condition, 0 5control condition). This analysis
revealed a significant effect of the experimental condition (B5.67,
SE 5.27, p5.01, odds ratio 51.95, Nagelkerke R
5.03, v
Specifically, analysis suggests that individuals used the soap dispenser
more often in the watching eyes condition (83.3%) compared to the
control condition (71.9%).
To provide convergent evidence that social presence increased
hand hygiene compliance (see also Edwards et al., 2002; Munger &
Harris, 1989), we analyzed whether the presence of at least one other
person during the time individuals were in the restroom (1 5yes,
05no) also increased hand hygiene compliance. This was the case
(B5.74, SE 5.29, p5.01, odds ratio 52.10, Nagelkerke R
56.14). Specifically, when at least one person was present, individu-
als used the soap dispenser more often (79.4%) compared to when
they were alone (64.7%). This finding is of high importance as it pro-
vides convergent and independent validity: either subtle social pres-
ence (i.e., watching eyes) or real social presence increased hand
hygiene behavior. This speaks to the validity of the entire study. In
addition, we tested whether the effect of the experimental condition
(i.e., the presence of watching eyes) depended on the presence of other
people in the restroom (see Ernest-Jones et al., 2011; Powell, Roberts,
Nettle, & Fusani, 2012). No significant interaction was found (p5.35).
Next, we (exploratively) examined whether the effect of watching
eyes depended on the time people spent in the restroom. To test this
notion, whether individuals used the soap dispenser was regressed on
the experimental condition (this time contrast coded to allow interpre-
tation of main effects, 10.5 5watching eyes condition, 20.5 5control
condition; cf. Hayes, 2013), the time spent in the restroom (centered to
the mean), as well as their interaction (overall statistics of this model:
Nagelkerke R
5.11, v
525.60, p<.001). Analysis revealed a signifi-
cant main effect of the experimental condition (i.e., the presence of
watching eyes; B5.56, SE 5.28, p5.05, Odds ratio 51.75) and a sig-
nificant main effect of the time spent in the restroom (B5.32, SE5.15,
p5.04, Odds ratio 51.38). The latter main effect indicates that the
probability of hand washing increased the longer individuals stayed in
the restroom. Most importantly, the two main effects were qualified by
a significant interaction (B52.83, SE 5.31, p<.01, Odds ratio 5.43).
The pattern of the interaction is displayed in Figure 2.
Decomposing the interaction (Aiken & West, 1991; Hayes, 2013),
watching eyes increased hand hygiene compliance only when individ-
uals spent a relatively short period (1 SD below the mean; i.e., about 2
min) in the restroom (B51.52, SE 5.41, p<.001, Odds ratio 54.57).
When individuals spent a relatively long period (1 SD above the
mean, i.e., about 4.5 min) in the restroom, watching eyes did not
significantly increase hand hygiene compliance (B52.40, SE 5.50,
p5.42, Odds ratio 5.67). That is to say, individuals already had a rel-
atively high hand hygiene compliance when staying a relatively long
time in the restroom. However, when staying a relatively short time
in the restroom, hand hygiene compliance was lower and could be
significantly increased by watching eyes. These interesting findings
are further discussed below.
The present research deals with a question that is important for
humanshealth: How can we increase hand hygiene compliance? Build-
ing on (a) past research showing that watching eyes increase socially
desirable and expected behavior (e.g., Ekstr
om, 2012; Powell et al.,
2012), and (b) the assumption that hand washing after using the toilet
is socially desirable and expected (Aunger et al., 2016), we have
assumed that the presentation of watching eyes has the potential to
increase hand hygiene compliance. In line with this hypothesis, we
show a significant increase of hand hygiene compliance when watching
eyes were presented in a womens restroom, as compared with a
neutral control condition.
The present work has several implications and contributes to the
existing literature in a meaningful way. First, we extend previous
research on watching eyes and hand hygiene behavior. Beyfus and col-
leagues (2016) as well as Bolton et al. (2015) tested the effect of angry
watching eyes on individualshand hygiene; in addition, Beyfus and col-
leagues (2016) used the eyes of a recognizable leader at the institution
where the study took place. In our study, we eliminated these interfer-
ing third variables by using simple, neutral-looking eyes and were able
to demonstrate their positive effect on hand hygiene compliance. Thus,
FIGURE 2 Probability of using the soap dispenser as a function
of the experimental condition and the time spent in the
we can conclude that the mere presence of watching eyes has the
potential to increase hand hygiene compliance.
Second, amidst recent concerns about reproducibility in psycholog-
ical science (Open Science Collaboration, 2015), replications should be
of particular interest to the field (Brandt et al., 2014). Indeed, with the
present study we conceptually replicate previous research showing
that the (actual) presence of other people increases hand hygiene com-
pliance (Eckmanns et al., 2006; Edwards et al., 2002; Maury et al.,
2006; Munger & Harris, 1989). In combination with the finding that
watching eyes affect hand-washing behavior, the present research pro-
vides convergent evidence that different forms of social presence can
likely increase hand hygiene compliance.
Third, with the present study, we might also show who increases
hand hygiene compliance when being watched. Taking into account
the time individuals spent in the restroom, we document an effect of
watching eyes only when individuals spend a relatively short period in
the restroom. Remarkably, for these individuals, watching eyes had a
big effect in terms of effect size (Rosenthal, 1996). In contrast, when
individuals spent a relatively long period in the restroom, hand hygiene
compliance was already high and could not be further increased by
watching eyes. We speculate that staying for a longer period in the
restroom is accompanied with defecation rather than urination only. In
these instances, individuals might see a greater necessity to wash their
hands with soap. Given this ceiling effect, watching eyes could not
have an additional impact. We further speculate that staying in the
restroom for a shorter period of time is accompanied with urination
only. In these instances, individuals might see less of a need to wash
their hands with soap, leaving room for watching eyes to increase hand
hygiene compliance.
Limitations and outlook
Since the reported data are the result of a field experiment, limitations
are particularly important to mention. First, we acknowledge that we
cannot draw conclusions about why watching eyes have increased
hand hygiene compliance in the present study. That is, we have not
provided evidence for the psychological process in this field study.
Recent research has accumulated evidence that individualsavoidance
(rather than approach) system underlies the effect of social influence in
general and watching eyes in particular (Keller & Pfattheicher, 2011;
Pfattheicher, 2015; Pfattheicher & Keller, 2015; Schnuerch &
Pfattheicher, in press; Steinmetz & Pfattheicher, 2017). That is to say,
individuals typically change behavior when being observed not to gain
a positive reputation and to make a good impression in the eyes of
others (i.e., approach) but typically to avoid the violation of social
expectations, social punishment, and a bad reputation. On this basis,
one can argue that the effect of watching eyes on hand hygiene
compliance might be based on individualsavoidance system, yet we
have no empirical basis for this claim so far.
Second, in the present study, the advice to wash ones hands was
present in both experimental conditions. Thus, we cannot conclude
whether watching eyes per se increase hand hygiene compliance, or
whether basic advice sets a precondition for watching eyes to operate.
We assume that the message of advice smoothes the way for watching
eyes to increase hand hygiene compliance. With information about the
necessity of hand washing being activated, watching eyes might create
the social expectation that hand washing should be done, leading to
actual hand-washing behavior. Without information about the neces-
sity of hand washing being activated, there is no information available
that can be transformed into social expectations, affecting behavior.
Future investigations could thus add a condition during which only
watching eyes are present to assess the impact of the advice alone and
to enable an estimation of possible interactions.
Also in light of recent meta-analyses and publications showing
weak evidence of a main effect of watching eyes on prosocial behavior
(e.g., Northover et al., 2017; Sparks & Barclay, 2013), it is relevant for
future research to examine preconditions for watching eyes to affect
human behavior (see also Northover et al., 2017; Pfattheicher & Keller,
2015). In the theoretical part of this contribution, we have argued that
watching eyes increase socially desirable behavior. In this regard, we
speculate that hand hygiene is strongly socially desirable; thus, as
shown in the present contribution, watching eyes can increase this
behavior. In contrast, transferring money to an anonymous stranger
could be considered less socially desirable; the lower degree of social
desirability might explain the found null effects with this dependent
variable (Northover et al., 2017). Building on these considerations, a
promising approach for future research would be to manipulate the
degree of social desirability that is inherent in the investigated behavior
and to test whether watching eyes increase prosocial behavior
especially when it is socially desirable.
Third, we want to acknowledge that the study assessed data from
females only and took place at a public restroom on a university cam-
pus. Thus, our conclusions apply to this specific group and this specific
context. The question whether the effect found in the present study is
also found in different places and populations can only be answered in
future research. Given that hand hygiene behavior is likely socially
desirable in different places and populations, we expect that watching
eyes increase hand hygiene behavior in different contexts as well. In
this regard, it seems particularly promising to test the effect of
watching eyes in companies and public institutions. In fact, watching
eyes reflect a low-cost method with the potential to increase hand
hygiene compliance, which in turn might reduce germ transmission; as
such, the application of watching eyes could increase health, save
money for employers due to fewer sick days for employees, decrease
infection-related absenteeism in schools, and increase patient safety in
hospitals or other healthcare institutions. This, however, needs to be
tested in future research.
To conclude, the present contribution shows the potential of
watching eyes to increase hand hygiene compliance. As such, the pres-
ent work opens a new avenue of research for studying hand hygiene
By showing that watching eyes can increase hand hygiene behavior we do
not claim that norms are irrelevant (they are indeed highly relevant); we
merely argue that there are different routes to increasing hand hygiene
behavior that do not exclude each other. One way is though norms (and
safety climate and safety culture) and another is through simple nudges like
watching eyes.
compliance while emphasizing that individualsbehavior can be influ-
enced by simple social nudges.
Stefan Pfattheicher
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How to cite this article: Pfattheicher S, Strauch C, Diefenbacher
S, Schnuerch R. A field study on watching eyes and hand
hygiene compliance in a public restroom. J Appl Soc Psychol.
... In terms of image testing, previous work has shown that messages based on principles of social norms, disgust, knowledge/reminders, monitoring and feedback can be successful in raising HH compliance levels. Translated into designs by researchers, the following approaches have been shown to be successful: text asking whether the person next to you is washing their hands (Judah et al. 2009), images of eyes (Pfattheicher et al. 2018), images of a 'faeces sandwich' (Porzig-Drummond et al. 2009;Rutter et al. 2022), images of germs on a hand (Dubner and Levitt 2006) and statements of fact -'Water doesn't kill germs. Soap does' (Judah et al. 2009). ...
... For example, just the presence of a pair of eyes is enough to make people feel more observed [47], making them wash more their hands [48] or litter less [49]. In the case of dishonesty, studies show that people seem to refrain from dishonesty when they are being monitored, for example when they know that someone is going to check their answers (e.g., [6,50], see [51] Study 3). ...
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Cheating has been extensively studied in Psychology and Economics, showing a variety of factors that can increase or decrease this behavior. Considering future human–robot interactions, where robots are being thought to be integrated in a variety of contexts, it is important to test which characteristics robots can have to prevent people from cheating. In this study (N = 123), we investigated whether people will cheat if an autonomous robot showed situationally aware behaviors towards the participant’s performance (i.e., intervened when they cheated). Our results showed that being in the presence of an aware robot is better at decreasing cheating behavior than being alone, and that there are no differences in cheating behavior between a non-aware robot or being alone. This study brings implications for the development of autonomous robots in roles where cheating might happen.
... (2) Humans modify their behavior in a socially desirable way when being watched by others (Pfattheicher et al., 2018) (Priming). ...
To assess the effectiveness of promoting hand hygiene by nudges, the control experiment was conducted during the COVID-19 pandemic in Japan. Hand sanitizers were placed at entrances of health centers A (nudge group) and B (non-nudges/reference group). The users of each group were approximately 40 daily. In the nudge group, during week 1, the conventional notice was displayed. From weeks 2 to 4, sequential nudges based on the framework “MINDSPACE” were implemented: drawing an arrow on the floor towards a hand sanitizer, posting altruism messages, and providing trends in hand sanitizer usage. From weeks 5 to 8, no additional interventions were implemented. Until week 4, usage in the nudge group increased steeply. Although the gap narrowed after week 5, usage in the nudge group (1.7 times of week 1 usage) was higher than that in the reference group (1.4 times of week 1 usage) at week 8. The nudges cost 0.9 USD and were prepared within 3 hours. The series of nudges can be implemented with low cost and minimal efforts, and the effect may last until week 8; these nudges will meet practitioners’ needs during the COVID-19 pandemic.
... psychological triggers to bring about a huge change in solving social and personal problems (Matsumura et al., 2015) E.g., painting a pair of watchful eyes at the washing area significantly increased the hand hygiene behavior in public restroom (Pfattheicher et al., 2018). ...
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Close to 0.3 million children under the age of five (U5) die every year in India just due to infectious diarrhea. These children are mostly from socio-economically vulnerable communities. Drinking water that is contaminated with fecal pathogens and living in poor sanitation and hygiene (WASH) conditions are the main causes of diarrhea. Primordial preventive measures including sustained access to microbially safe drinking water, proper use of toilets, and handwashing with soap can prevent these meaningless deaths. Technological and other interventions by the public and private sectors to tackle the WASH challenge have achieved commendable success in improving the WASH situation in India over the last decade. Yet, half of India’s population still does not have access to safely managed drinking water, and around the same number continues to defecate in the open. Improvement in the health outcomes including reduction in diarrheal deaths among U5 children has not been dramatic either. This article presents a snapshot of the status of drinking water quality and the prevalence of diarrhea among U5 children in India. The appropriateness of some of the commonly used drinking water disinfection technologies for the vulnerable population has been assessed. While providing clean water through concerted public and private interventions, the critical role of communities has been emphasized. Fresh design thinking is seen as necessary to ensure the sustainability of efforts. Providing access to safe drinking water and a WASH environment to the masses in India are no doubt complex, with multi-sectoral challenges. But, without securing these there can be no sustainable development. Public Health systems that are not built on the foundations of primordial prevention will continue to remain fragile.
... In previous pandemics, the uptake of these NPIs has been an uphill battle for the public health sector (Gilles et al., 2011;Mitchell et al., 2011;Steelfisher et al., 2012). In general, people routinely fail to follow handwashing recommendations (Pfattheicher et al., 2018). During the 2009 swine flu pandemic, people who believed that they were in the "low risk" category for infection were less likely to engage in handwashing (Gilles et al., 2011). ...
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COVID-19 has had a profound negative effect on many aspects of human life. While pharmacological solutions are being developed and implemented, the onus of mitigating the impact of the virus falls, in part, on individual citizens and their adherence to public health guidelines. However, promoting adherence to these guidelines has proven challenging. There is a pressing need to understand the factors that influence people’s adherence to these guidelines in order to improve public compliance. To this end, the current study investigated whether people’s perceptions of others’ adherence predict their own adherence. We also investigated whether any influence of perceived social norms was mediated by perceptions of the moral wrongness of non-adherence, anticipated shame for non-adherence, or perceptions of disease severity. One hundred fifty-two Australians participated in our study between June 6, 2020 and August 21, 2020. Findings from this preliminary investigation suggest that (1) people match their behavior to perceived social norms, and (2) this is driven, at least in part, by people using others’ behavior as a cue to the severity of disease threat. Such findings provide insight into the proximate and ultimate bases of norm-following behavior, and shed preliminary light on public health-related behavior in the context of a pandemic. Although further research is needed, the results of this study—which suggest that people use others’ behavior as a cue to how serious the pandemic is and as a guide for their own behavior—could have important implications for public health organizations, social movements, and political leaders and the role they play in the fight against epidemics and pandemics.
... Another plausible explanation is a social function of pupil size changes, as the eyes are a most important channel for communication. For example, we demonstrated how a recommendation to wash one's hands after visiting the toilet was associated with 83.3 % of students washing their hands with soap compared with 71.9 % of students when it was accompanied by a depiction of two watching eyes instead of three stars as a control (Pfattheicher, Strauch, Diefenbacher, & Schnuerch, 2018). Given this important role of the eyes, it is hardly surprising that also arousal-linked changes in pupil dilation have been suggested to serve a communicative and social purpose: Kret, Fischer, and De Dreu (2015) report that participants generally trusted (virtual) partners with dilating pupils more than (virtual) partners with constricting pupils during an economic game. ...
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Pupils constantly change size, not only due to shifts in fixation position or changes in illuminance, but also due to changes in arousal, as elicited by a broad number of cognitive processes. In this thesis, I present pupillometric research into the effects of a process that may be considered central for human information processing: the selection of stimuli. Related literature on perceptual decision-making and visual search suggests stronger pupil dilations for targets than distractors. And indeed, in previous works, we found pupils to dilate when fixating a to be selected target in gaze-based human-computer interaction. Yet, observed effects might be attributed to exogenous factors affecting pupil dilation, such as changes in illuminance, or endogenous factors, such as varying stimulus valence. In this cumulative thesis I present results of a systematic investigation into selection using pupil dilation. Four of my original research works are completed with investigations and analyses that are reported in this thesis for the first time. In two initial experiments, pupil dilation was found to be indicative of the repeated selection of letters. Stronger pupil dilations to targets than to distractors were robust to a number of exogenous factors affecting pupil dilation simultaneously, such as abrupt changes in illuminance. Extending the view to endogenous factors on pupil dilation, we found stronger pupillary responses when reading the own name compared to other names of low self-relevance, especially under inhibition. Taking an intermediate role between exogenously and endogenously triggered processes, differential stimulus probabilities (oddball effect) might explain a substantial part of differences in effect sizes reported for selection across existing research. Investigating the interplay of selection and stimulus probability, selection consistently let pupils dilate more for targets than distractors, whereas stimulus probability alone had no main effect on pupil dilation. However, there was an interaction: Pupils dilated more when targets were rare compared to being equiprobable or frequent. Previous investigations propose that task-relevance might be the decisive precondition for effects to emerge. Narrowing down this factor, results demonstrate that stimuli must not only be task-relevant for effects to unfold, but also goal-relevant to the beholder. Integrating these findings, I present a framework for effects of selection based on pupil data: Stimuli are classified as either goal-relevant or not. In a subsequent step that is lagged to the initial classification, only goal-relevant stimuli are further evaluated regarding their relative importance or value. Results of an additional experiment, during which the consequence to errors in the paradigm was systematically varied, provide some tentative first support for this notion. The synopsis of the here described results suggests that selection can be assumed to be an integral part of key concepts in cognitive psychology, such as visual search, emotion, and phenomena such as the oddball effect. Considering possible application scenarios in human-computer interaction, a ROC analysis shows that pupils indeed revealed which perceptually equal stimuli are selected and which are rejected above chance. Still, such classification performances are - as of today - too low to allow pupil-based intent recognition alone, suggesting that other predictors would have to be integrated as well. However, selection has to be considered as central to how we as humans process information. The systematic analysis of pupil dilation therefore proves to be a useful method for not only investigating cognition and perception for basic research, but also for applications.
... Some recent research considers how the physical environment can be modified to signal handwashing behavior (as a behavioral impulse) 37 . Like painting with footprints as a guide to toilets and handwashing facilities 38 placing eye pictures above handwashing facilities 39 and putting toys in soap 40 are proven to improve a person's handwashing behavior. ...
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This cross-sectional study was conducted in North Bogor's district to find out the relationship of facilities, knowledge, and counseling to the level of behavior of the handwashing of elementary school students. This research is a quantitative study, accompanied by observations of the availability of handwashing facilities in schools. Data characteristics, facilities, counseling, behavior, and knowledge of students were collected using a questionnaire. Three hundred fifty-five students (51.8% were male) registered in this study. The average age of students is 10 years (73.0%). The availability of facilities such as hand washing facilities (100%), toilets (100%), clean water (97.7%), running water (82.0%), and soap (91.3%) in schools is quite complete. The behavior of students using soap when washing their hands (76.1%), after defecating small (88.7%), and after handling animals (82.0%). Students’ knowledge about correct hand washing (73.8%), the exact duration of handwashing (22.8%). In the logistic regression analysis, gender, age, and counseling were not significantly related to student behavior. However, facilities (P=0.011) and knowledge (P=0.037) are related to students’ handwashing behavior. Observation found that the availability of washbasket facilities in five schools was in good condition and functioning normally and the standard operational procedures for handwashing in schools, but placed in a location that is not visible to students. In short, students’ handwashing behavior is still lacking, especially among students who are in schools with inadequate facilities and have less knowledge about handwashing.
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Introduction. Behaviour change is key to the public health measures that have been issued in many countries worldwide to contain COVID-19. Public health measures will only take preventive effect if people adhere to them. Interventions taking health psychology approaches may promote adherence to public health measures. However, evidence from randomised controlled behaviour change trials is scarce during an ongoing pandemic. We aim to use the example of hand washing with soap to optimise and test a digital, theory-based and evidence-based behaviour change intervention to prevent the spread of COVID-19. Methods and analysis. This protocol describes the multiphase optimisation strategy for the preparation, optimisation and evaluation of a theory-based and evidence-based intervention delivered via app. The app aims to promote correct hand hygiene at key times in the adult general population. The study will be conducted in German-speaking Switzerland. The preparation phase has identified relevant behavioural determinants of hand hygiene during a pandemic from health behaviour theories and formative research with focus groups (n=8). The optimisation phase will identify the most effective and acceptable combination and sequence of three intervention modules in a parallel randomised trial (n=387) with analysis of variance (ANOVA) and regression analysis. Additionally, thematic analysis of qualitative interview data (n=15) will be used to gain insights on the feasibility, usability and satisfaction of the intervention. The evaluation phase will test the optimised intervention against an active control group in a randomised controlled trial (n=205), analysing pre-post differences and 6-month follow-up effects with ANOVA and regression analysis. Ethics and dissemination. The trial was approved by the Cantonal Ethics Commission Bern of the Swiss Association of Research Ethics Committees (protocol ID: 2021-00164). Final results will be presented in peer-reviewed journals and at conferences. Trial registration number NCT04830761.
Zusammenfassung Aufgrund der kontinuierlichen Ausweitung von Datenerhebungsbefugnissen für Sicherheitsbehörden wird ein häufig als »Chilling« bezeichneter Effekt befürchtet. Demnach führt die Sorge über ein mögliches Überwachtwerden dazu, dass freiheitliche Grundrechte nicht mehr ausgeübt werden. In der Rechtswissenschaft ist die Existenz eines Chilling-Effekts bzw. das Ausmaß seiner Auswirkungen auf Verhaltensänderungen jedoch umstritten. Der vorliegende Artikel gibt einen Überblick über die empirische Evidenz zum Chilling-Effekt. Hinzugezogen werden im ersten Teil Befunde aus verschiedenen Paradigmen und Traditionen, die den Chilling-Effekt nicht explizit untersuchen, jedoch Hinweise auf die dahinterstehenden Mechanismen geben (Asch-Paradigma, Watching Eyes-Paradigma, Befunde aus der Forschung zur Wirkung von Sicherheitskameras im öffentlichen Raum). Einschränkungen in der Übertragbarkeit der Ergebnisse werden jeweils diskutiert. Im zweiten Teil werden Untersuchungen skizziert, die den Chilling-Effekt direkt in Online-Kontexten untersuchen, wobei die methodischen Probleme der verschiedenen Ansätze diskutiert werden. Wir beleuchten abschließend die empirische Evidenz zu Argumenten, die häufig als Gegenbeweise zur Existenz von Chilling-Effekten angeführt werden. Wir kommen zu dem Ergebnis, dass es sich verdichtende Hinweise auf die Existenz eines Chilling-Effekts aufgrund von Datenerhebungsbefugnissen gibt, jedoch weitere empirische Forschung notwendig ist.
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Social psychology has demonstrated that people behave differently in social attention, compared to when alone. First and foremost, being in social attention affects people's performance and their interpersonal behavior by increasing arousal and reputational concerns, respectively. However, newer work demonstrates more fundamental intra-psychological effects of social attention. As mere reminders of social attention can activate reputational concerns, people's thoughts and behavior are affected by such reminders even when people's reputation is not at stake. These findings provide a deeper look at more intra-personal effects of social attention. As a result, recent research focuses on how social attention fundamentally influences people's subjective perceptions and experiences. In this review, we provide an overview of the far-reaching effects of social attention, identify relevant moderators and mediators, discuss socio-motivational and cognitive processes underlying these effects, and highlight avenues for future research.
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Humans, just as many other animals, regulate their behavior in terms of approaching stimuli associated with pleasure and avoiding stimuli linked to harm. A person’s current and chronic motivational direction—that is, approach versus avoidance orientation—is reliably reflected in the asymmetry of frontal cortical low-frequency oscillations. Using resting electroencephalography (EEG), we show that frontal asymmetry is predictive of the tendency to yield to social influence: Stronger right- than left-side frontolateral activation during a resting-state session prior to the experiment was robustly associated with a stronger inclination to adopt a peer group’s judgments during perceptual decision-making (Study 1). We posit that this reflects the role of a person’s chronic avoidance orientation in socially adjusted behavior. This claim was strongly supported by additional survey investigations (Studies 2a, 2b, 2c), all of which consistently revealed that trait avoidance was positively linked to the susceptibility to social influence. The present contribution thus stresses the relevance of chronic avoidance orientation in social conformity, refining (yet not contradicting) the longstanding view that socially influenced behavior is motivated by approach-related goals. Moreover, our findings valuably underscore and extend our knowledge on the association between frontal cortical asymmetry and a variety of psychological variables. (197 words)
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A substantial proportion of the total infectious disease burden world-wide is due to person-to-person spread of pathogens within households. A questionnaire-based survey on the determinants of hand-washing with soap and cleaning of household surfaces was conducted in at least 1000 households in each of twelve countries across the world (N = 12,239). A structural equation model of hygiene behaviour and its consequences derived from theory was then estimated on this dataset for both behaviours, using a maximum likelihood procedure. The analysis showed that the frequency of handwashing with soap is significantly related to how automatically it is performed, and whether or not someone is busy, or tired. Surface cleaning was strongly linked to possessing a cleaning routine, the perception that one is living in a dirty environment and that others are doing the behaviour, whether one has a strong sense of contamination, as well as a felt need to keep one's surroundings tidy. Being concerned with good manners is also linked to the performance of both behaviours. This study is the first to identify the role of manners, orderliness and routine on hygiene behaviours globally. Such findings should prove helpful in designing programs to improve domestic hygiene practices.
Background: Hand-hygiene interventions are widely used in schools but their effect on reducing absenteeism is not well known. Methods: The aim of our literature review was to determine whether implementation of a hand-hygiene intervention reduced infectious disease-associated absenteeism in elementary schools. The eligible studies (N = 19), published between 1996 and 2014, were summarized and the methodologic quality of each was assessed. Results: Our review indicated evidence is available to show hand-hygiene interventions had an effect on reducing acute gastrointestinal illness-associated absenteeism but inadequate evidence is available to show an effect on respiratory illness-associated absenteeism. Conclusions: The methodologic quality assessment of eligible studies revealed common design flaws, such as lack of randomization, blinding, and attrition, which must be addressed in future studies to strengthen the evidence base on the effect of hand-hygiene interventions on school absenteeism.
We provide experimental evidence on the effect of peer pressure on individual behavior. Specifically, we study the effect of being exposed to an observer in a public restroom on handwashing and urinal flushing behavior. Our estimates show that being exposed to an observer increases the probability of handwashing by 13 percentage points and the probability of urinal flushing by 15 percentage points. Given that handwashing and urinal flushing have social benefits that exceed individual benefits, our findings provide support for peer pressure as an additional way of addressing the social suboptimality arising from externalities. (JEL C91, C93)
Many studies have seemingly demonstrated that anonymous individuals who are shown artificial cues of being watched behave as if they are being watched by real people. However, several studies have failed to replicate this surveillance cue effect. In light of these mixed results, we conducted two meta-analyses investigating the effect of artificial observation cues on generosity. Overall, our meta-analyses found no evidence to support the claim that artificial surveillance cues increase generosity, either by increasing how generous individuals are, or by increasing the probability that individuals will show any generosity at all. Therefore, surveillance cue effects should be interpreted cautiously.
Background: To encourage handwashing, we analyzed the effect that a passive visual stimulus in the form of a picture of a set of eyes had on self-directed hand hygiene among health care staff. Methods: This was a prospective, single-blind study using a repeated measure design. Four dispensers of alcohol foam located in positions identified as #1, #2, #3, and #4 were used to deliver a single uniform volume of alcohol foam in an automated fashion. Pictures of eyes were placed on dispensers #1 and #3 but not dispensers #2 and #4 for 1 time period. The visual stimulus was rotated with each study time period. At the end of each study period, the volumes dispensed were examined to determine if the visual stimulus had a statistically significant influence on the volume dispensed. Results: There were a total of 6 time periods. The average volume dispensed in stations with eyes was 279 cc versus that in the stations without eyes, which was 246 cc, and this was a statistically significant difference (P = .009). Conclusion: The correct visual stimuli may enhance compliance with hand hygiene in health care settings.