The Effectiveness of Sign Prompts to Increase Hand Washing Behaviors in Restrooms Abstract (summary) This research investigated the effects of descriptive prompts on the hand washing behaviors of restroom patrons. Outcome data were collected from two female and two male restrooms on a university campus. All four restrooms experienced three conditions: (1) baseline (no intervention); (2) posters prompting hand washing were posted; and (3) the display of posters focusing on the transmission and seriousness of influenza ("the flu") along with the previous hand washing prompt. Results suggest that, females wash their hands more often than males. It appeared that the initial prompts increased hand washing for both genders in only one building tested. However, the second treatment (ie, the sign with the flu warning) returned most conditions to near or below baseline. Prompts may be effective for increasing hand washing in specific settings. The type of prompt utilized should be further investigated, as fear-arousing health-related messages may inadvertently decrease the desired behavior. Full Text Headnote This research investigated the effects of descriptive prompts on the hand washing behaviors of restroom patrons. Outcome data were collected from two female and two male restrooms on a university campus. All four restrooms experienced three conditions: (1) baseline (no intervention); (2) posters prompting hand washing were posted; and (3) the display of posters focusing on the transmission and seriousness of influenza ("the flu") along with the previous hand washing prompt. Results suggest that females wash their hands more often than males. It appeared that the initial prompts increased hand washing for both genders in only one building tested. However, the second treatment (i.e., the sign with the flu warning) returned most conditions to near or below baseline. Prompts may be effective for increasing hand washing in specific settings. The type of prompt utilized should be further investigated, as fear-arousing health-related messages may inadvertently decrease the desired behavior. During fall and winter months, influenza or "the flu" is a major topic of concern among many Americans. According to the Center for Disease Control, the flu virus is a serious and contagious disease that is mainly spread when people with the flu cough, sneeze, or talk, and leave droplets of the disease on other people and on various surfaces (CDC, 2013). The flu virus presents with symptoms such as fever, headache, cough, and sore throat; however, the symptoms may progress into vomiting, diarrhea, hospitalization and occasionally death. According to the CDC (2013), during the 2012 - 2013 season, the following types of flu virus have been identified in the United States: Influenza A, Influenza B, and HINT Some people are at higher risk for developing flu-related complications, including women who are pregnant, children, people with asthma, the elderly and infirm, ...

1. The Effectiveness of Sign Prompts to Increase Hand Washing
Behaviors in Restrooms
Abstract (summary)
This research investigated the effects of descriptive prompts on
the hand washing behaviors of restroom patrons. Outcome data
were collected from two female and two male restrooms on a
university campus. All four restrooms experienced three
conditions: (1) baseline (no intervention); (2) posters prompting
hand washing were posted; and (3) the display of posters
focusing on the transmission and seriousness of influenza ("the
flu") along with the previous hand washing prompt. Results
suggest that, females wash their hands more often than males. It
appeared that the initial prompts increased hand washing for
both genders in only one building tested. However, the second
treatment (ie, the sign with the flu warning) returned most
conditions to near or below baseline. Prompts may be effective
for increasing hand washing in specific settings. The type of
prompt utilized should be further investigated, as fear-arousing
health-related messages may inadvertently decrease the desired
behavior.
Full Text
Headnote
This research investigated the effects of descriptive prompts on
the hand washing behaviors of restroom patrons. Outcome data
were collected from two female and two male restrooms on a
university campus. All four restrooms experienced three
conditions: (1) baseline (no intervention); (2) posters prompting
hand washing were posted; and (3) the display of posters
focusing on the transmission and seriousness of influenza ("the
flu") along with the previous hand washing prompt. Results

2. suggest that females wash their hands more often than males. It
appeared that the initial prompts increased hand washing for
both genders in only one building tested. However, the second
treatment (i.e., the sign with the flu warning) returned most
conditions to near or below baseline. Prompts may be effective
for increasing hand washing in specific settings. The type of
prompt utilized should be further investigated, as fear-arousing
health-related messages may inadvertently decrease the desired
behavior.
During fall and winter months, influenza or "the flu" is a major
topic of concern among many Americans. According to the
Center for Disease Control, the flu virus is a serious and
contagious disease that is mainly spread when people with the
flu cough, sneeze, or talk, and leave droplets of the disease on
other people and on various surfaces (CDC, 2013). The flu virus
presents with symptoms such as fever, headache, cough, and
sore throat; however, the symptoms may progress into vomiting,
diarrhea, hospitalization and occasionally death. According to
the CDC (2013), during the 2012 - 2013 season, the following
types of flu virus have been identified in the United States:
Influenza A, Influenza B, and HINT Some people are at higher
risk for developing flu-related complications, including women
who are pregnant, children, people with asthma, the elderly and
infirm, and people suffering from obesity (CDC, 2013).
Additionally, areas with high population densities, such as in
collegiate settings, increase the likelihood of the spread of the
virus. Due to the potential seriousness and pervasiveness of the
illness, reducing the spread of the flu is a significant concern in
the scientific community.
A person may have the flu vims and not exhibit symptoms for
24 hours; thus, lack of immediate symptoms increases the risk
of unknowingly spreading the virus. In addition to the spread of
the flu virus through direct contact with an infected individual,
transmission can also occur when an individual touches a
surface or object infected with the virus droplets and
subsequently touches his/her nose or mouth (CDC, 2013). The

3. latter form of transmission is a particular concern in the
collegiate setting. People who use public facilities should be
wary of the spread of the flu virus as it is possible for the virus
to spread quickly and exponentially (i.e., multiple students in
one infected classroom or bathroom per day). One way that
students, faculty, and other collegiate personnel can help reduce
the spread of the virus and decrease their risk of contracting the
virus is by simply washing their hands (CDC, 2013).
Good hand hygiene practices are taught and encouraged in
health care settings, in child care settings, and in the food
service industry. In 2007, Seigel, Rhinehart, Jackson, Chiarello
and the Healthcare Infection Control Practices Advisory
Committee published guidelines for preventing transmission of
infectious diseases. These guidelines were created specifically
for use within the health care setting and noted that hand
hygiene is the single most important standard precaution to
prevent the spread of disease (Siegel, et al., 2007). Stephens
and Ludwig (2005) examined hand sanitizing behavior of
Certified Registered Nurse Anesthetists in a hospital. Baseline
measurements of hand sanitizing behaviors were collected and
then graphic feedback was presented to the participants.
Participants were then trained on proper hand sanitizing
procedures and graphic feedback on participant hand
sanitization behavior was presented throughout the study. The
results showed an increase in hand sanitizing behavior;
however, the behavior decreased once the intervention ceased
(Stephens & Ludwig, 2005).
Student hand washing behavior in a university setting was
observed by Monk-Turner, et al. (2005). Hand washing behavior
was observed inside the bathroom in full view of the patron at
the restroom sink from either behind a slightly opened stall door
or while the observer was at the sink. Observations revealed
that women washed their hands more often than men and women
used soap more often than men (Monk-Turner, et al., 2005).
Another collegiate study conducted by Edwards, et al. (2002)
found that individuals who know they are being observed are

4. more likely to wash their hands. Both studies noted that the
amount of hand washing is still relatively limited among college
students.
Opportunities to spread infection could be decreased by
increasing the hand washing behavior of college students. Based
on a literature review, Pittet (2000) recommended several ways
to increase hand washing. Those suggestions included
education, observation, feedback, reminders in the workplace,
and promoting individuals' hand hygiene (Pittet, 2000). The
CDC also recommends several ways to reduce the spread of
infection, including washing hands with soap and water and the
use of reminders or prompts in the workplace (CDC, 2002).
The use of prompts to change behavior is well researched and
has generally been found to be effective. For example, using a
multiple baseline across settings design, Clayton and
Blaskewicz (2012) found that visual prompts were highly
effective in reducing urine splatter on the floor of the men's
restrooms and the behavior change persisted four months after
removal of the prompts. Visual prompts have been successfully
employed to persuade restroom patrons to turn off the lights
after use (Sussman & Gifford, 2012). Patrons were eight times
more likely to turn off the lights when visual signage was
present, and large signs appeared to be more effective than
smaller signs. Visual prompting was also employed by
Wiesenthal and Hennessy (2005), who found that visually
prompting motorists to stop increased complete stops and
decreased rolling stops. Mueller, Moore, Tingstrom, and
Doggett (2001) conducted a study on a university campus
utilizing a sign prompt to successfully increase the number of
chairs students would push back under the table at the end of
class. Other applications of visual prompting have not been as
successful. When trying to increase the use of food composting,
Sussman and Gifford (2013) determined that a behavioral model
was necessary to enact change whereas written prompts did not
affect behavior.
Although prompting behavioral changes can be effective in

5. many settings, it can also lead to behaviors inconsistent with
the prompt due to psychological reactance. There are many
factors that can affect compliance with visual prompts.
Repeated or mere exposure tends to increase the favorability to
the exposed message; however, this favorability can decrease if
there is excessive exposure (Miller, 1976). Moderate exposure
has been found to be more effective in attitude change than
excessive exposure. Excessive exposure can cause a boomerang
effect; however, the boomerang effect can be countered by a
period of non-exposure (Miller, 1976). With regard to health-
related messages, the magnitude of the request affects
behavioral changes; messages requesting greater magnitudes of
change are less likely to yield change than lower magnitude
messages (Rains & Turner, 2007). Rains and Turner (2007)
theorized that smaller requests resulted in less psychological
reactance and were not viewed as an imposition by the message
receiver. Health-related messages are also more likely to be
attended to and perceived as more important when the message
uses concrete language as opposed to abstract language (Miller,
Lane, Deatrick, Young, & Potts, 2007). Other factors affect
psychological reactance; increasing similarity between message
giver and receiver decreases reactance and leads to greater
compliance (Silvia, 2005).
Psychological reactance and factors that increase reactance are
important to consider when designing health-related visual
prompts. The use of implicit persuasive messages is more
effective than explicit persuasive messages in adolescent anti-
smoking campaigns (Grandpre, Alvaro, Burgoon, Miller, &
Hall, 2003). Grandpre et al. attributed the greater effectiveness
of implicit messages to lower levels of psychological reactance.
Changes in drinking behaviors among college students have also
been targeted using messages containing normative statistical
messages. Students were found to move in all directions from
the message (i.e., no change, change toward message, or away
from message). Those students whose attitudes moved away
from the normative message demonstrated behavioral changes

6. by engaging in less healthy drinking behaviors than the other
groups, whereas students who moved toward the message
engaged in healthier drinking behaviors (Campo & Cameron,
2006).
Across a variety of behavioral settings, previous research
supports the notion that prompting is successful at changing
behavior. The purpose of the current study was to use
descriptive prompting procedures to increase hand washing
behavior among patrons in the lavatories on a university
campus. Since observation of patrons' hand washing behavior in
the restrooms was not possible, an outcome-based measure of
hand washing was recorded (i.e., soap usage). This study
attempted to extend previous research by evaluating the effects
of prompts on hand washing in a public setting. Soap usage was
monitored in both men's and women's restrooms. In each
setting, repeated baseline measures were taken followed by a
simple hand washing prompt (i.e., first treatment condition). A
second treatment condition followed and incorporated
information regarding the spread of influenza in addition to the
previous hand washing prompt. Based on previous research, it
was expected that women would use more soap than men.
Additionally, it was hypothesized that the use of sign prompts
in both treatment conditions would lead to significant increases
in hand washing over baseline as assessed through soap usage.
It is important to note that the current study did not directly
observe hand washing behavior because of Institutional Review
Board for the Protection of Human Subjects (IRB) restrictions.
METHOD
Participants and Setting
Participants were male and female college students, faculty,
auxiliary staff, and visitors on a university campus. The settings
were male and female restrooms in two similar buildings,
education and business. The two buildings are mirror images of
one another and are physically identical. Each male restroom
contains four urinals, three toilet stalls, and three soap
dispensers, while each female restroom contains six toilet stalls

7. and four soap dispensers.
Materials
Hand washing prompts. Laminated 8.5 x llinch posters were
used to prompt patrons to wash their hands in two different
experimental treatments. One poster was a simple instructional
guide for hand washing. The poster described to patrons how to
thoroughly wash their hands, including a step-by-step process in
an easy-to-read format (i.e., a bulleted list of steps). The second
poster included information on how to decrease the likelihood
of contracting the flu virus, the importance of good hand
hygiene in the prevention of disease transmission, as well as
how to wash their hands.
Measurement of restroom traffic. The Electronic Pedestrian
Counter- IRD1 (EPC-IRD1) is a microprocessor that uses an
infrared beam to sense and record pedestrian traffic. One EPC-
IRD1 unit was installed either on the door frame or on the door
itself for each restroom. The EPC-IRDl's counter buzzer was
disarmed and a security code feature was enabled to prevent
tampering by non-research personnel. Thus, if an individual
entered one of the monitored restrooms, the corresponding EPC-
IRD would record that a patron entered the restroom.
Daily hand soap usage. Premeasured industrial hand soap was
ordered for the experiment. The soap was in prepackaged bags;
when dispensed a foam-based soap was produced. At the start of
the experiment, all soap dispensers were replaced with the
testing soap, which did not differ from the usual hand soap
available. Hand soap measurements were taken five days a week
at the same time each day. Data collectors entered the restroom
and measured the amount of soap used by pouring the soap into
standard 1000 ml plastic liquid measuring cups. After the soap
was measured, the soap was then poured back into the soap
dispenser. The amount of soap usage for each day was
calculated by subtracting each day's amount of soap from the
previous day's amount. In addition, restroom traffic was also
measured to ensure that any effects found were not due to
differences in number of patrons at each of the four testing

8. sites. Thus, after measuring the soap, data collectors then
recorded the amount of restroom traffic by reading the number
displayed on the people counter and dividing that number by
two (the EPC-IRD1 is a unidirectional counter). The data
collectors then reset the traffic counter to zero for the next day's
traffic count. The amount of hand washing was measured by
calculating the per person soap usage in each restroom per day.
The amount of per person soap usage in each restroom was
derived by dividing the amount of soap used by the number of
entries into that restroom.
Experimental Design and Procedure
An ABB' multiple baseline across settings design was used,
where A is baseline, B is prompt alone poster, and B' is health-
related information plus prompt poster. Thus, the experiment
occurred in three phases. Multiple measures were taken
throughout each condition at all sites.
Baseline. The purpose of this condition was to establish the
level of hand washing prior to the intervention. During this
condition, participants used the restrooms without the
prompting interventions. The EPC-IRD1 was installed prior to
baseline so restroom traffic could be recorded during this phase.
In addition, the soap levels in each dispenser were recorded
daily.
Prompt alone. Following baseline, posters consisting of hand
washing instructions were posted in each bathroom. The posters
were positioned in various areas in the restroom to help ensure
patrons would read them (i.e., on the inside of the restroom
doors, on the inside of the restroom stall doors, above the
urinals, and near the sinks). Data were collected as described
above.
Health-related information and prompt. During this phase, the
hand washing posters were removed and the posters warning of
the transmission of the flu virus and the importance of hand
washing were then posted in the same locations as the previous
posters. Data collection procedures were the same as those
described above.

9. RESULTS
A second research assistant also scored 67% of all observation
sessions (i.e., hand soap usage) to assess inter-observer
agreement and ensure the soap was measured consistently across
settings and conditions. Point-by-point agreement was
calculated by taking the number of agreements and dividing by
the number of agreements plus disagreements and then
multiplying by 100. Inter-observer agreement averaged 93%,
indicating high levels of agreement between raters and
consistent measurements throughout the trials.
Soap usage per person for the education women's restroom was
1.41 ml (SD = .43) during baseline, 1.95 ml (SI) = 1.62) during
the prompt alone phase, and 1.23 ml (SD = .68) during the
prompt and information phase, respectively. Thus, in the
women's room in the education building, soap usage
significantly increased during the first treatment following
baseline, but then fell below baseline on the second treatment
(i.e., warning of influenza transmission). Soap usage per person
for the business women's restroom during baseline was 1.13 ml
(SD = .64) during baseline, 1.15 ml (SD = 1.01) during the
prompt alone phase, and .94 ml (SD = .59) during the prompt
and information phase, respectively. Interestingly, in the
business building, women's soap usage did not change
significantly from baseline to first treatment, but decreased
slightly on the second treatment. Additionally, overall women
in the business building appeared to use less soap than women
in the education building.
Soap usage per person for the education men's restroom during
baseline was .37ml (SD = .23), .51 ml (SD = .58) during the
prompt alone phase, and .37 ml (SD = .37) during the prompt
and information phase, respectively. Although the amount of
soap used by males in the education building appeared to
increase during the first treatment (i.e., proper hand washing)
the difference was not significant. Soap usage returned to
baseline values on the second treatment. Soap usage per person
for the business men's restroom was .63 ml (SD = .47) during

10. baseline, .61 ml (SD = .56) during the prompt alone phase, and
.40 ml (SD = .32) during the prompt and information phase,
respectively. Thus, men using the restroom in the business
building followed a different behavior pattern than the
education building; there was no increase from baseline to the
first treatment and then a marginal drop in usage on the second
treatment. It is interesting to note that at baseline men in the
business building used significantly more soap than those in the
education building.
A 2 x 2 x 3 analysis of variance (ANOVA) was conducted to
examine the effects of gender, location (building: education and
business), and prompting condition (baseline, hand washing
prompt, and influenza informational prompt) on the average
amount of soap used per day by restroom patrons. A significant
main effect was found for gender, F( 1, 208) = 52.71, p < .001,
eta2 = .20, where women (M = 1.33, SD = 1.04) were found to
use significantly more soap than men (M = .50, SD = .47).
There was no main effect for location of the testing site (the
education building and the business building), F( 1, 208) = 2.13,
p = .15, eta2 = .01. The overall hand soap usage in the
education building (M = 1.00, SD = 1.07) did not differ
significantly from average overall hand soap usage in the
business building (M = .84, SD = .71). The lack of a significant
building effect was qualified by a significant interaction
between Gender x Location, F( 1, 208) = 6.79, p = .01, eta2 =
.03. Using 95% confidence intervals, it was determined that
women in the education building used significantly more soap
overall than women in the business building; there were no
significant differences between men by building type.
A significant main effect was found for prompting condition,
F(2, 208) = 6.79, p = .01, eta2 = .03. A post hoc LSD analysis
revealed that overall baseline (M =.88, SD = .61) did not differ
from the first prompting condition (M =1.05, SD = 1.17);
however, there was a significant decline in average hand soap
usage during the second treatment condition (i.e., influenza
warnings; M =.75, SD = .64), with the second treatment not

11. differing from baseline. There were no statistically significant
findings for the remaining interactions: Gender x Condition,
F(2, 208) = .67, p = .51, eta2 = .01; Location x Condition, F(2,
208) = .90, p = .41, eta2 = .01; or Gender x Location x
Condition, F(2, 208) = .65, p = .52, eta2 = .01.
DISCUSSION
The current investigation was an outcome-based study on the
effects of sign prompts to increase hand washing. Consistent
with expectation, results showed that women washed their hands
more often than men. The greater use of hand washing in
women than men is consistent with past research (Monk-Turner,
et al., 2005). This finding suggests that men should be targeted
for a more intrusive intervention for hand washing. However,
there were three soap dispensers in the men's room as compared
to four in the women's room. Perhaps soap dispensers
themselves serve as prompts for hand washing.
Although the average amount of soap usage appeared to
increase after the implementation of the first hand washing
prompt in all restrooms except in the men's business restroom,
no statistically significant results were found. The lack of
significant increase in hand soap usage following the first
prompt is likely a function of the high levels of variability
between observations, genders, and locations. However, soap
usage actually significantly declined in every restroom to
baseline levels or lower than baseline after the implementation
of the second treatment, which included an informational
message regarding the spread of influenza along with a hand
washing prompt. This finding was unexpected due to the fact
that the only manipulation difference between the prompt alone
and the prompt plus information poster was the addition of
information about influenza. Thus, the content of the message
may have caused psychological reactance where persons engage
in behaviors inconsistent with the message (e.g., Campo &
Cameron, 2006). Several explanations for these findings include
habituation to the signs in general and psychological reactance,
causing patrons to disregard the message or act in a manner

12. inconsistent with the message. Excessive exposure to a message
can sometimes cause a boomerang effect (Miller, 1976). An
alternative explanation is that with regard to hand washing,
prompting alone is not sufficient to change behavior and that
behavioral modeling is necessary to enact changes in hand
washing behavior. The need for a behavioral model to enact
change is supported by the findings of Sussman and Gifford
(2013), who found that a behavioral model was necessary to
increase composting behavior whereas written messages were
ineffective.
Additionally, the message may have provoked fear in patrons
that caused them to behave in a manner inconsistent with the
message. Previous research has found that the element of fear in
a message generally leads to changes in behavior (e.g., Floyd,
Prentice-Dunn, & Rogers, 2000). However, the fear-based
message may actually make the desired behavior changes less
likely (e.g., Witte, 1992, 1994). Das, de Wit, and Stroebe
(2003) found that individuals who feel more vulnerable to a
threat (e.g., contracting influenza) are more likely to experience
negative emotions and cognitive changes in favor of fear
reduction; however, cognitive changes may not correspond with
true behavior changes.
An alternative explanation for the decrease in hand washing
following the posting of the influenza warnings may be a
function of the content of the message. Results of the current
study imply that in order to increase hand washing behaviors, a
fear-based message may be a demotivating factor. According to
the Terror Management Health Model (TMHM), messages that
solicit a conscious fear of dying motivate individuals into
changing a health-related behavior; however, according to
TMHM, the health-related behavior may also be attenuated or
avoided (Goldenberg & Arndt, 2008). Previous research
indicates that messages resulting in subconscious thoughts of
death are ineffective in changing health-related behaviors (Hunt
& Shehryar, 2011). Thus, care should be given when
determining the most effective method to increase hand

13. washing. Coupling the possibility of becoming very ill and
developing a potentially fatal illness with hand washing may
result in an unconscious internalization of the fear-based
message that may have resulted in avoidant behaviors. Future
research should also examine changes in the number of persons
seeking the influenza vaccines after exposure to the second
treatment condition.
One major limitation of the current study was the
methodological constraints of relying on average quantity of
soap used per person because of IRB restrictions. Due to this
limitation, individual differences in hand washing behavior may
not have been detected, as hand washing behaviors were
inferred based on total soap usage divided by the number of
patrons. Individual differences in hand washing could not be
observed and differences in soap usage were assessed using a
secondary measure. The current methodology did not allow
assessment of changes in the percentage of individuals who
wash their hands or differences in the amount of soap used by
different persons (i.e., the amount of soap pumps). Additionally,
soap was measured using 1000 ml cups and on some days the
soap usage appeared unchanged. The lack of differences in soap
measurements between some days was partially attributed to the
type of soap utilized; the soap was a foaming soap, where very
small amounts of soap volume are in each foaming pump. With
the current measures, differences could only be detected in 25
ml increments.
A curious finding of this research was the interaction effect of
gender and academic building (i.e., education and business).
Women in the education building used significantly more soap
than women in the business building. One potential explanation
for this is that the education building not only houses the
education department but also contains the psychology
department. Psychology students, who are predominantly
women, may be more primed to respond to changes in the
environment. The current research should be replicated to
determine if the gender by building difference is enduring.

14. Anecdotally, another limitation occurred during the treatment
condition phase because there were numerous instances when
restroom patrons removed the signs. Signs were checked by the
experimenters repeatedly throughout the day and those signs
that were removed were replaced. However, all persons
considered to be in the prompting conditions may not have been
exposed to the prompting signage; thus the lack of a statistically
significant difference in average hand washing between the
baseline condition and the hand washing prompt may be an
artifact of sabotage. The number of persons who missed the
signs during the treatment conditions remains unknown.
Future research should be conducted to directly observe
participants' hand washing behaviors. Such a study may help
determine the conditions under which a person is more likely to
wash his/her hands. In addition, knowing such information
could lead to the discovery of how to increase the desired
behavior. Different forms of interventions can be tested to
determine the effects on hand washing, including verbal
interventions, video interventions, peer-based interventions, and
the use of a confederate model. Special efforts should be
directed towards men, who use significantly less soap than
women. Using a confederate model may be particularly useful in
the men's room, considering that men engage in significantly
less hand washing than women.
Sidebar
Note: Figure 1 depicts the data from the women's restroom in
the education building and the women's restroom in the business
building. Figure 2 depicts the data from the men's restroom in
the education building and the men's restroom in the business
building. These figures are available upon request from the
authors.