Overcoming Hygiene Challenges in the Domestic Environment

1. Overcoming Hygiene Challenges in the Domestic Environment Patricia Borrusso, PhD ORISE Research Fellow, Office of Analytics and Outreach U.S. Food and Drug Administration (FDA) Center for Food Safety and Applied Nutrition 10 September 2015

2. Introduction (Who am I, and What do I know about home hygiene and consumer behavior?) • PhD 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 interventions • Development of recommendations to improve future efforts

3. Home Hygiene: Science Perspectives • There 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”

4. Home Hygiene: Consumer Perspectives Most Consumers Believe they are Familiar with Microbiological Concepts • Only 25% admit to knowing little or nothingat all about “germs” • 92% believe they know enough to keep themselves healthy N=1759 (Source: WK Hallman 2008)

5. Home Hygiene: Consumer Perspectives Most Consumers Believe they are Familiar with Microbiological Concepts • Only 25% admit to knowing little or nothingat 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 body • Harmful germs are everywhere • People can spread a virus to others even when they have no symptoms • Wet surfaces typically have more germs than dry surfaces But, a few misconceptions are still widely held... N=1759 (Source: WK Hallman 2008)

6. Home Hygiene: Consumer Perspectives A Few Misconceptions are Widely Held N=262 (Source: WK Hallman 2008)

7. Home Hygiene: Consumer Perspectives A Few Misconceptions are Widely Held N=262 (Source: WK Hallman 2008)

8. Home Hygiene: Consumer Perspectives A Few Misconceptions are Widely Held N=262 (Source: WK Hallman 2008)

9. Home Hygiene: Consumer Perspectives A Few Misconceptions are Widely Held N=262 (Source: WK Hallman 2008)

10. Home Hygiene: Consumer Perspectives Misconceptions Negative Attitudes “I have no reason to worry about getting sick” Overestimate knowledge and skills necessary to avoid or eliminate health risks

11. Home Hygiene: Consumer Perspectives A Few Misconceptions are Widely Held N=1759 (Source: WK Hallman 2008)

12. Home Hygiene: Consumer Perspectives Misconceptions Consumer Attitudes “I 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

13. Home Hygiene: Consumer Perspectives A Few Misconceptions are Widely Held N=275 (Source: WK Hallman 2008) In public At home

14. Home Hygiene: Consumer Perspectives Misconceptions Negative Attitudes “I have no reason to worry about getting sick” “I only need to clean if I see or smell something unusual” “I’m 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

15. Home Hygiene: Consumer Perspectives A Few Misconceptions are Widely Held N=1759 (Source: WK Hallman 2008)

16. Home Hygiene: Consumer Perspectives A Few Misconceptions are Widely Held N=1759 (Source: WK Hallman 2008)

17. Home Hygiene: Consumer Perspectives Misconceptions Negative Attitudes “I have no reason to worry about getting sick” “I only need to clean if I see or smell something unusual” “I’m unlikely to get sick because of something I did at home” “They are out to get me and there’s 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

18. Many hygiene risks are present in consumer homes Major discrepancies between consumer perspectives and science perspectives +Quick Recap

19. Consumer Behavior Reduce Contamination on Household Surfaces Recommended Actual • 10-35% 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 less • Use effective cleaning agents • Clean surfaces regularly Data 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)

20. Consumer Behavior Proper Hand Hygiene Recommended Actual • 5-40% use soap and water (although nearly 100% say they do) • <10% for 20 seconds or longer • Most (>50%) do not dry or dry incorrectly • Use soap and clean running water • Wash for 20 seconds • Dry with a clean towel afterward Data 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)

21. Consumer Behavior Proper Hand Hygiene at the Right Times Recommended Actual • Observed: • 5-40% before preparing food • 85% after using the restroom • 20-35% after handling raw meat • Reported: • 80-100% before preparing food, after using the restroom, after handling raw meat • 27-42% 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 hands Data 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)

22. Consumer Behavior Minimize Cross-Contamination and Microbial Transfer – While Shopping for Food Recommended Actual • 40-80% do not separate raw meat from other foods while shopping or transporting groceries • 50% frequently use reusable grocery bags for non-food items • 3% cleaned bags regularly • Keep raw items separate from other food in your cart or bag • Clean, store and use reusable bags correctly Data from food handling studies (Chambers 2014, Kosa et al. 2015, Li-Cohen and Bruhn 2002, Williams et al. 2011)

23. Consumer Behavior Minimize Cross-Contamination and Microbial Transfer – While Cleaning Recommended Actual • Average 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 Data from food handling studies (Borrusso et al. 2015, Byrd-Bredbenner et al. 2007, Larson and Duarte 2001)

24. Consumer Behavior Minimize Cross-Contamination and Microbial Transfer – While Cleaning Recommended Actual • 17-29% 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 Data from food handling studies (Borrusso et al. 2015, Byrd-Bredbenner et al. 2007, Larson and Duarte 2001)

25. Many 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

26. Many 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 • Communication Breakdown

27. What is Being Done to Fix This? Good News: Countless efforts to improve consumer behavior and home hygiene • Education and Training • National Campaigns • Environmental Interventions (i.e., food product labels) • Innovative Tools and Smart Technology

28. What is Being Done to Fix This? Good News: Countless efforts to improve consumer behavior and home hygiene • Education and Training • National Campaigns • Environmental Interventions (i.e., food product labels) • Innovative Tools and Smart Technology Not-So-Good News: We still don’t know a lot about how to change behavior Despite 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

29. How to Improve Future Efforts? Improve quality of research studies • Many things can go wrong when planning, implementing and evaluating education programs • Difficult to know true intervention effects Good intervention strategy + No message testing = Weak results Good intervention strategy + Unreliable outcome measurement = Weak results Bad intervention strategy + Lack adequate controls = Good results Bad intervention strategy + Non-random sample = Good results (Source: Young et al. 2015)

30. How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs How most programs are developed:

31. Understand barriers How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs What is missing? How most programs are developed:

32. Understand barriers to executing the desired behavior How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs Many internal and external factors impact consumer behavior It’s important to know which one you are trying to change Favorable environment Social norms Access to resources Perceived risk Convenience Desired Behavior Taste preferences (food handling) Remember when necessary Fear of consequences Adequate knowledge No conflict with personal values

33. Understand barriers to executing the desired behavior How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs Desired 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

34. Understand barriers to executing the desired behavior How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs Desired 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 Current strategy does not address barrier  No behavior change

35. Understand barriers to executing the desired behavior How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs Desired 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

36. Understand barriers to executing the desired behavior How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs How to identify barriers? • Look at data • Ex: High SR + low OBS = Adequate knowledge • Ask the target audience!

37. Understand barriers How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs • Address needs of target audience What is missing? How most programs are developed:

38. Address needs of target audience How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs Warning! If your target audience thinks your message • Is boring, • Does not apply to them, • Is delivered by someone who is untrustworthy, • Contains information they already know, • Is difficult to understand, OR • Conflicts with their beliefs, It needs to be revised.

39. Address needs of target audience How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs Must have a complete understanding of audience What 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

40. Address needs of target audience How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs Must have a complete understanding of audience What 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

41. Address needs of target audience How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs Must have a complete understanding of audience What 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

42. Address needs of target audience How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs Must have a complete understanding of audience What 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

43. Address needs of target audience How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs Must have a complete understanding of audience What 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

44. Address needs of target audience How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs Must have a complete understanding of audience What 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

45. Address needs of target audience How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs Must have a complete understanding of audience What 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

46. Address needs of target audience How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs Must have a complete understanding of audience What 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? 16.7% of people or 1 in 6 people Audience can understand the message

47. Address needs of target audience How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs Must have a complete understanding of audience What 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

48. Understand barriers How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs • Address needs of target audience What is missing? How most programs are developed: • Test materials & delivery method with target audience

49. Understand barriers How to Improve Future Efforts? Use a systematic, data-driven approach to design education programs • Address needs of target audience What is missing? How most programs are developed: • Test materials & delivery method with target audience • Revise materials accordingly

50. How to Improve Future Efforts? Provide information about the positive behavior of others • What are others doing? • What do others think I should be doing? 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.