7th National Aboriginal and Torres Strait Islander Environmental Health Conference Kalgoorlie, WA

‘No Germs on Me’ Hand Washing Campaign

Page last updated: December 2010

Xavier Schobben & Natasha Clements, Northern Territory Department of Health and Families

Natasha Clements: I would like to start by acknowledging the traditional owners of the land on which we meet. We are here today to talk about the ‘No Germs On Me’ social marketing campaign. So what is all the fuss with hand washing? It’s a question and a skill that we had ingrained in us as children. How many times were we asked “Have you washed your hands?” it was a question that was asked on a daily basis. Every time that we went to the toilet “Have you washed your hands?” Just before you sat down to eat dinner “Have you washed your hands?” So if we all have learned this valuable skill, then why is it that five minutes spent in a public toilet sees so many people leave that bathroom, without touching the tap let alone the soap dispenser. Studies have found that for every five people one person will not wash their hands. Take a look at your neighbour are they that fifth person? Where have their hands had been? Scary proposition!

So despite the proven health benefits of hand washing many people do not practise this habit as often as they should, even after using the toilet. Not washing hands frequently enough can lead to the spread of infections. Inadequate hand hygiene contributes to diseases such as salmonella and hepatitis. Because these diseases are spread by the ingestion of the tiniest faecal material handwashing after using the toilet cannot be over emphasised. Less commonly known is that handwashing spreads respiratory diseases such as the common cold, and flu. And whilst most people will get over the cold the flu can lead too much longer- term effects or problems, particularly for those people of chronic medical conditions.

So today’s presentation will seek to provide you with a whirlwind tour of the handwashing project and the resulting campaign ‘No Germs On Me’. I’ll focus primarily on the marketing aspect of the campaign, the wins, the challenges and most importantly, the outcomes.

We start with Xavier to recapture the origins of the handwashing project before we get on to the campaign and its results.

Xavier Schobben: I have been blessed with having three magnificent project coordinators in Nicola Slavin, Annette Fuller who you met at Cairns and finally Natasha Clements, they have done a sterling job, ably supported by Barbara Klessa, Fiona Smith in Central Australia, Kia Grieves, Ken O’Brien and the treasure trove of EHOs we have across the Territory. I would like to also just like to thank the AMRRIC funding that we received through WGATSIEH though enHealth endorsement and importantly though the auspices of Jenni Paradowski and the Department Health and Ageing. We would like to thank you Jenni for your continued support of WGATSIEH through enHealth, and we obtained funding from Department of Health and Ageing (DOHA) to continue on with this great project .

The handwashing project was developed to assist in addressing the high rates of infectious diseases amongst Aboriginal babies and children in the Northern Territory. Respiratory and intestinal infections impact not only on the health of children in the short term, but may also contribute to chronic disease in adulthood. Infectious diseases such as respiratory and intestinal infections are the leading causes of hospitalisations for Indigenous infants and children aged under five in the Northern Territory with rates many times higher than those in the non-Indigenous population. Research has also indicated that repeated infections during infancy and early childhood can also result in impaired growth, which can lead to long-term health repercussions. Primary barriers such as sanitation and handwashing after feacal contact has been found to be the most effective means of reducing diarrhoeal disease.

The handwashing project was trialled on an Indigenous community in both Central Australia and the top end of the Northern Territory. There was also a designated comparison community in both of these regions. The project commenced on the 9th of February 2006 and was finalised on the 15th of May 2008. The long-term goal of the project was to reduce the person-to-person and environment to person transmission of pathogenic organisms that cause diarrhoea, skin sores and respiratory disease. There were four objectives and these will be reviewed in more detail when we will discuss the outcomes of the project. The project took just over two years from its inception to completion and funding as I have said was provided, thankfully, by the Australian government.

Briefly, the project involved a number of phases; Natasha will talk in more detail about some of these phases throughout the presentation. In a nutshell, the project concept involved undertaking formative research to determine the key barriers and drivers to handwashing, identification of trial communities, the development and testing of creative concepts, the actual launch, and most importantly, the evaluation.

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Natasha Clements: There are several aspects to the handwashing campaign, none of which could taken place without the formative research. It was used to identify the barriers for people not washing their hands routinely with soap and the sorts of things that motivate people to adopt good handwashing practices. Several barriers were identified and I will briefly mention a couple;

  • Handwashing wasn’t considered a social norm, so washing hands was not considered a routine behaviour, and there was no social expectation of each other in terms of washing hands. Soap is not available in homes, so if it’s not available you are certainly not going to use it. Some of the households did talk about using other types of cleaning products such as dishwashing detergent and shampoo.
  • Handwashing was not seen as useful. Many people did not see the link between washing hands, and stopping the spread of germs.
  • Health hardware wasn’t being maintained, so if the tap wasn’t working then you are unable to wash your hands.
  • There was lower self efficacy, people didn’t believe that they have control her of their own situation and the events in their lives.
On the upside, however, there were two key drivers for washing hands with soap:
  • Soap is cheap.
  • People expressed a positive attitude towards washing hands and soap.
Social marketing: so why would you use social marketing? The formative research basically guided the development of the social marketing campaign which included television advertisements, posters and stickers and point-of-sale materials which were all trialled in the intervention communities. The determinants of hygiene behaviour such as handwashing are complex and research indicates that simply teaching people the health benefits of handwashing does not result in substantial behavioural change. Internationally, there is an increasing awareness that in order to change handwashing behaviour on a large scale the principles of industrial marketing need to be applied. So this was the rationale behind choosing social marketing as a means of promoting handwashing to achieving the goals and objectives of this campaign.

The key difference between social marketing and commercial marketing is that the benefits of social marketing benefit individuals and society rather than the market organisation. Promotion of hand washing will have a far greater impact on public health than promoting drinking Coke as a means to ‘winning the girl’ in order to sell the product.

What were the chosen tools? We produced several tools to ensure that the campaign reached the widest audience. In doing so, it also ensured that there was sufficient support material available (i.e. posters, stickers ) to reinforce the commercials. During the course of the presentation, I will show you some of these chosen tools and the advertisements.

There were 8 commercials that were filmed, and they used local talent. The style was a top and tail format, so essentially that meant at the commercial break, a poor handwashing scenario would first come on then at the completion of the commercial break, the same commercial would be shown with a positive reinforcement of handwashing. The commercials screened on Imparja for 6 months, and because we had a bit of extra funding available we did another 6-month block about a year later.

There were 4 posters and stickers developed; A3 posters, three of them each featured one of the critical junctures for washing hands, and the fourth one, tied them messages together. A bar sticker was developed using the five steps to effective handwashing, and then posters and stickers were displayed at key sites on the intervention communities, including the Council office; community stores; health centres and schools.

Point-of-sale materials: These were fantastic, they included a counter top display unit for soap, a large counter sticker featuring the logo and shelf talkers where the soap was displayed in the community stores at the intervention sites. We did have to alter some of those point-of-sale materials due to confusion of the message, i.e. purchasers thought the messages meant the soap was complimentary instead of for sale.

The hip-hop workshop was another tool. A professional hip-hop artist and DJ were contracted to hold the hip-hop workshop with the schoolchildren at the Central Australian intervention community. The artists worked with schoolchildren to develop a hip-hop song incorporating the hygiene message. This footage was then incorporated into a community service announcement and an educational DVD. The health education activities promoted handwashing and germ theory and were conducted throughout the duration of the campaign and beyond. Such activities included; handwashing and hygiene themed literacy and numeracy days, colouring competitions, demonstration of germs on agar plates and games with ‘Gerry the Germ’ - a fibre glass germ where students were able to use glo germ gel and UV light to witness their handwashing effectiveness . Most recently a hygiene activity book was sent across the entire Northern Territory to all schools, which was matched against a Northern Territory curriculum framework as a way of incorporating it into the education program.

The community service announcement was a 30 second announcement that featured the students footage from the hip-hop workshop and an educational DVD was also produced, targeted at lower primary students.

The benefits of social marketing: Social marketing costs a lot of money, but there are a lot of good benefits to it. Marketing traditionally has one main goal and that is profit. Companies such as Coca-Cola, Nike and Holden spend exorbitant amounts of money on marketing due to its proven ability to persuade viewers and listeners to buy their products. On a much smaller scale, the health sector uses the same concept to persuade the public to change their behaviours. How this is achieved and the degree to how it works varies, but in the case of the ‘Did you wash your hands?’ social marketing campaign, a number of secondary benefits were achieved in addition to the goal of improving hand washing practices. ‘Did you wash your hands?’ formed a talking point, ‘should the government be seen to be promoting a health message that isn’t correct English?’ but the slogan was easily remembered. So I guess it worked out quite well. It went on to be well used and well remembered after the completion of the program. By using local talent, the commercials and support material united and engaged communities. There was a certain sense of pride of seeing local people featured in the commercials. Of importance to the Northern Territory Environmental Health Program the campaign raised the program’s profile so all of a sudden we were no longer just inspectors, we were the ‘germ people’. We also had new resources and opportunities available to promote handwashing.

However, there are always risks with every campaign. The risks associated with social marketing;
  • Be aware of the unintended messages. You don’t want the local talent to be tarnished as a ‘germ boy’ .
  • Beware of getting caught up in the fun of the creation. I had a ball with this, but remember you are trying to promote a message. You’re not there to just have a huge amount of fun.
  • It is easy to get carried away with the storyline and the development of other ideas such as competitions and educational activities such as Gerry. The risk is that you miss the point of the message and you may find it difficult to maintain control of that message.
  • Remember marketing companies are paid to make money off you and their creativity. That is why they are paid big dollars. It doesn’t matter to companies if the messages they create isn’t the message you are trying to sell.
  • Other risks include control of resources on completion of campaign. Whilst the fact that the resources and message are being used is a positive, it is important that it is used appropriately. For example, posters lose their effectiveness if they are tacked up on a wall of other posters with no further promotion undertaken.
  • Social marketing tends to have quite narrow demographics, even large corporations can only target sub-populations such as teenagers, or males, or 20-somethings.
  • A major downside to SM is the cost. It can be very prohibitive especially for small organisations. However, the lessons learnt from this campaign can be applied on a smaller scale for an effective campaign to be undertaken at the local level.
So did the campaign achieve its objectives and ultimately its goal? In terms of whether objective one of the project was met it is difficult to say definitively. In the Top End intervention community there was an increase in the self-reported rate of handwashing after going to the toilet and after changing babies’ nappies however there was no change in the number of respondents who reported washing hands before touching food.

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In the Central Australian intervention community there was an increase in the self reported rate of handwashing after going to the toilet and before touching food. There was however no change in the number of respondents who reported washing hands after changing babies’ nappies.

In relation to Objective Two, Central Australia reported an increased awareness about the importance of washing hands after the three key junctures. In the Top End there was an increase in awareness of the benefits of washing hands after going to the toilet and before changing babies’ nappies but not before touching food.

Objective Three, unfortunately was difficult to measure as the questions used to assess attitudinal change did not turn out to be overly useful. It was felt that respondents did not fully understand the scale that was used. However, almost all of the respondents to both the pre and post handwashing questionnaires expressed a positive attitude to handwashing.

Objective Four was not met. Whilst the original project proposal did include a focus on the safe disposal of faecal matter it was later determined that this was beyond the scope of the project.

The decision to advertise the market research and development of creative materials as a single tender unfortunately restricted the number of submissions received. It would have been better to have advertised each of the contracts separately.

Contracting a marketing research company to undertake the formative research was not as effective as hoped. Conducting the research ourselves and redirecting the funds towards employing a second project officer, one for the top end and one for the central Australia would have been more effective. It was difficult for a single project officer to fully engage with both communities, which unfortunately meant that not as many community based strategies were developed and implemented as originally planned.

Ideally the social marketing campaign should have run for longer than 6 months. Given that routine handwashing with soap is not considered a social norm by the target population, intensive, long term exposure to the handwashing message is needed to engender sustainable behavioural change.

Throughout this presentation, I have provided you with an overview of this campaign, its key successes, lessons learnt and some tricks to be wary of when undertaking a similar styled campaign. To recap, the key success would have to have been the mass media campaign. The concept, campaign and resources have been well received in the NT and beyond. We have received enquiries from around Australia and internationally and are aware of the resources being used in Laos and Cambodia.

Since its formal conclusion, ‘No Germs on Me’ has been extended to the mainstream audience across the NT including the development of more TV commercials, a radio commercial, a school film clip competition and the use of social network sites to further promote the message. Posters were distributed in shopping centres, on tabletops in food courts, in cinemas and other high usage areas including the toilets at Darwin airport.

The school film clip competition was won by Milikapiti School on the Tiwi islands and I would like to finish today’s presentation with a snippet of their entry.

For more information

More information can be accessed on from the NT Department of Heath and Families website (http://www.health.nt.gov.au/Environmental_Health).
Ph:1800 095 646 Email: envirohealth@nt.gov.au