Are we too clean? Restoring public understanding of hygiene is key to behaviour change

1. Are we too clean? Restoring public understanding of hygiene is key to behaviour change Sally F Bloomfield International Scientific Forum on Home Hygiene, London School of Hygiene and Tropical Medicine

2. Preventing infection in homes and everyday life is a vital part of sustaining health • Gut (inc foodborne and norovirus) infections remain at unacceptable levels • Emerging infections – new agents/strains/pandemic threats • Increasing healthcare and at risk groups at home – particularly growing elderly population • Tackling antibiotic resistance - reduce ab prescribing by preventing infection • “Selfcare” strategies - empowering public to take care of own health

3. Barriers to change • Various studies in last few years show • Loss of public confidence in hygiene • how confused we have become about hygiene • how commonly quoted “myths” have fuelled this confusion. • Concern that this is a major barrier to getting people to adopt good hygiene behaviours which needs to be addressed. • 2018 RSPH online poll  of 2000 members of the public

4. Hygiene myths

5. “We need exposure to “germs” to build a strong immune system”? • RSPH pollshowed that 23% agreed (40% disagreed) • How this myth shapes hygiene beliefs depends on how we interpret the words ‘germs’ and ‘strong’. Our immune systems have become weak

6. “We have become too clean for our own good” • Cleanliness is the underlying cause of rising allergies The Old Friends Hypothesis 2003 Q1 Have you heard of The Hygiene Hypothesis, Old Friends Hypothesis, human microbiome

7. RSPH Poll - the underlying cause of reduced exposure to beneficial microbes? Which of the following factors do you believe is preventing children coming into contact with enough good bacteria?

8. What does the public think - what do they say? • I encourage my children not to worry about being dirty, e.g If we are on a picnic I don’t bother to get them to wash their hands because they need plenty of exposure to germs to keep their immune system strong • Its only by contact with dirt and germs that our body builds up our immune system. I remember a TV programme showing that children living on farms with animals had the highest immunity against almost everything because they were exposed from an early age • My daughter is the only one in her class who washes her hands before school lunch - and often the only one not to catch stomach bugs and colds. But many in her class have allergies - so poor hygiene evidently doesn’t guard against allergies.

9. Hygiene misunderstanding

10. Barriers to change • Lack of public understanding of about hygiene • What is hygiene - how it differs from cleanliness • Visibly clean is not necessarily hygienically clean • Confusions about “germs” • Understanding risk

11. Do we understand the difference between hygiene and cleanliness? • IFH Pilot study of 117 people asked – “What do YOU understand by terms clean and hygienic” Q2 Which of these 3 approximates most closely to your understanding Q3 In your language - what term do you use to describe the concept of reducing microbial contamination to a safe level

12. How do you visualise germs? B A Q4 Which of these (A or B) corresponds most closely to your visualization?

13. What are germs? • Yuck!, Uurgh! • Nasty dirty germs • Poo – smelly! • Don’t touch! • Make you sick • disgusting • We are brainwashed as children with Germophobia

14. So - When we reach adulthood and have our own children to protect we ask “Tell me where are the germiest places in my home ?” • Where do germs lurk? • Where are the dirtiest places in my home? • The 5 second rule – is food dropped on the floor (perceived as the dirtiest place in the home) still safe to eat

15. Messages reinforced by media articles So you think your bathroom is clean?Daily Mail – 10th April 2017 “Bathroom is a haven for bacteria, breeding in places you believe are sparkling clean” “Here’s a map to help identify where germs love to lurk and help you to banish the bugs” “I don’t believe all this scaremongering about germs. If it’s as bad as they say – how come I am not sick all the time” Q5 How often do you see media articles/TV/adverts like this ?

16. What do the public think about germs? RSPH poll - To what extent do you think these things are good or harmful to your health? • If we use the word “germs” we must qualify whether we are talking about harmful or beneficial microbes. • After 2 centuries of “germaphobia” changing perceptions is a big challenge

17. Do people’s behaviours correlate with their perception of risk ?

18. Do people’s behaviours correlate with perception of risk ?

19. How important is it to remove germs from the following locations in your home? Most frequently mentioned are those perceived as “dirty”?

20. What methods are available for “hygienic cleaning” • Purpose of hygienic cleaning - to reduce organisms on critical sites/surfaces to acceptable safety target level. • Hygienic cleaning can be achieved by: • Removal c. cleaning products (e.g detergents or soap) & cleaning utensils, and water • Inactivate/kill in situusing products/processes i.e. heat, UV light, disinfectants, hand sanitizers

21. Hand Hygiene – how does it work? Is it A? Hand washing c. soap When I rub my hands with soap it gets rid of the germs – I rinse them to get the soap off my hands Alcohol hand rub When I rub my hands with alcohol it gets rid of the germs. I don’t need to rinse them because the alcohol evaporates Q6 How do you think hand hygiene works ?

22. Hand Hygiene – how does it work? Or is it B? Hand washing c. soap When I rub my hands with soap it loosens the germs –rinsing under running water removes the germs from my hands Alcohol hand rub When I rub my hands with alcohol it kills the germs on my hands

23. In future we are going to have to view our microbial world differentlyThe way forward?

24. The Challenge • How do we develop lifestyles and hygiene regimes which protect us against infection whilst at the same time sustaining exposure to essential beneficial microbes ?

25. The will is there • When polled directly: • 98% acknowledged importance of hygiene in the home. • 50% agreed that poor hygiene contributes to AMR • 74% people believed hygiene reduces pressure on NHS by preventing ill health. • 2019 UK Action Plan on AMR says • “Health & social care providers can only do so much to prevent infections; when it comes to infections in the community (which requires exposure to antimicrobials), the public have a huge part to play” • UK gvt commitment to “selfcare” • – empowering the public to take care of their own health

26. The way is there • Targeted hygiene provides • a simple plausible approach which makes sense to the public • It’s a way to get over the key message: • Hygiene is about breaking the chain of infection • It’s not getting rid of germs that “lurk” in our homes through rigorous cleaning

27. We’re making progress • EU/PHE-funded e-Bug project • (www.e-bug.eu) • Teaching pack for primary and secondary schools (and adults) • Aim – ensure all children in Europe leave school with basic understanding of hygiene and AMR – chain of infection, hand, RT and food hygiene • Translated into 27 European languages

28. The overall objective of SafeConsume is to reduce health burden from foodborne illnesses.5yr EU funded projectwww.safeconsume.eu

29. The importance of hygiene in home and everyday life • We need to remind people (and health agencies) why hygiene in home and everyday life is important • We need to give them clear consistent messages about what hygiene is, how it differs from cleanliness • If we don’t take steps to change public understanding/dispel myths, our best efforts to change hygiene behaviour will not be successful • Promoting hygiene practice on its own is not enough

30. Royal Society for Public Health Policy Paper 2019Too clean or not too clean? The case for targeted hygiene in home and everyday lifehttps://www.rsph.org.uk/our-work/policy/infection-control/too-clean-or-not-too-clean.html.