The Emotion of Disgust to
Promote Hand Hygiene in
Interprofessional Education
Endeavors
Deb Hagerty, DNP, RN, CDP, NHA, CDONA,
LBSW, FACDONA
Armstrong State University
Disgust Defined
 Darwin-”Something revolting, primarily in relation to
the sense of taste , as actually perceived or vividly
imagined; and secondarily to anything which causes a
similar feeling, through the sense of smell, touch and
even of eyesight”
 Angyal (1941), Revulsion at prospect of oral
incorporation of an offensive object; body wastes,
degree of intimacy of contact.
(Darwin, 1965, p.253; Angyal, 1941)
Purpose of Disgust
 Disgust dictates what we do.
 Ancient function as a system that
bestows on animals the ability to
avoid parasites.
Disgust
 Informs our attitudes of others: Sick and
Different
 Affects attitudes toward cloning and GM food
 Our Judicial System, Politics
 Product buying behavior
 Can trump Love
 Moral choices
(Curtis, 2013, p. ix)
Disgust Weaves Lives
Weaves through our individual and
social lives without this thread societies
would fall apart
“Strong claim to be essential to
human ability to cooperate on a mass
scale”
(Curtis, 2013, p. ix)
Birth of Parasite Avoidance
Theory (PAT)
 Data Collection: International
departure lounge
 What is disgusting?
 Pus, abnormal appearance people, food
spoilage, animal infections, things
touching a disgusting object.
What is Disgusting
1. Nasty Organic Objects
2. Hygienic lapses
3. Indecency
4. Wickedness
5. Hypocrisy
(Curtis, 2013)
Why is this Important
 Parasite avoidance behavior is
everywhere in the evolutionary tree of
life.
The Way Disgust Works
We Don’t Wash
“Adherence of HCWs to recommended hand
hygiene procedures has been reported with
very variable figures, in some cases
unacceptably poor, with mean baseline rates
ranging from 5% to 89%, representing an
overall average of 38.7%”.
(WHO, 2009, 16.2)
Despite Knowing the
Importance We Don’t
Wash
Is it Important??
 It is estimated that washing hands with soap
and water could reduce diarrheal diseaseassociated deaths by up to 50% .
 Researchers in London estimate that if
everyone routinely washed their hands, a
MILLION deaths a year could be prevented .
(http://www.cdc.gov/healthywater/hygiene/fast_facts.html)
Alcohol Gel?
The use of an alcohol gel hand sanitizer in the
classroom provided an overall reduction in
absenteeism due to infection by 19.8% among
16 elementary schools and 6,000 students.
(http://www.cdc.gov/healthywater/hygiene/fast_facts.html)
Is this Disgusting?
• Average individual swimmer
contributes at least 0.14 grams of fecal
material to the water, usually within the
first 15 minutes of entering.
One Trillion Germs
One Grams of Feces
Improved Handwashing
Meta-analysis
 Reduces rates of Gastrointestinal illness
by 31%
 Respiratory illness by 21%
(Aiello,Coulborn, Perez & Larason, 2008)
LIFE OR DEATH TO
SOMEONE
Clostridium difficile infection HAIs
(2011)
½ Million infections
29,000 deaths within 30 days of
Diagnosis
(http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html)
80,000 Deaths in United States
 HAI complications in 5-10% of admissions to
acute-care hospitals.
 U.S. at least 80,000 fatalities each year
 Approx 200 deaths/day from HAI.
(WHO, 2014)
Handwashing with Soap
 Protects about 1 out of every 3 young
children who get sick with diarrhea
 1 out of 6 young children with respiratory
infections like pneumonia.
(CDC, 2014)
Handwashing Observational
and Self Reported Rates
 Rarely exceeds 50% in most
environments
 Community and professional
Compliance Rate at 50% or
Less
 HH compliance in the U.S. can increase
when monitoring is combined with
feedback.
 HH still occurs at or below 50% for
compliance for both ICUs and non-ICUs
(MC Guckin, M., Waterman, R., & Govednik, J., 2009)
Does Education Work
 Interventions that rely solely on
passive transfer of healthcare
information are ineffective at
instigating change.
(Evans & McCormack, 2008)
Observations Bathrooms
Overall Hand Washing Behavior and Length of Hand
Washing Time (N = 3,749)
Variables
N
%
Not Washing
384
10.3
Wetting w/o soap
856
22.8
Washing with soap
2509
66.9
HAND WASH TIME
0 secs
384
10.3
1-4 secs
824
22.4
5-8 secs
1432
38.2
Hand Wash Time
N=3749
9-14 secs
911
24.2
15 secs or longer
198
5.3
(Borchgrevink, Cha, & Kim, 2013)
Disgust Ancient System
 System that bestows on animals the
ability to avoid parasites.
 How invertebrates and vertebrates,
mammals and primates evolved the
behavioral capacities needed to deal
with threats from parasites and
pathogens.
(Curtis, 2013,p. X)
Human Capacities
 Only species to be able to imagine ourselves
being disgusted in the future.
 Evolutionary benefit when plague/Ebola
avoid encountering sick.
Disgust Lurks
“Disgust lurks on the dark side of human
nature, rearing its ugly head in bullying;
cruelty; class hatred; the exclusion of the
sick, the aged, and the disabled;
homophobia; racism; war and genocide.”
(Curtis, 2013, p. Xi)
Disgust in Public Health
 Psychotherapists learn that disgust can trump love
 Disgust in moral choice
 Ethical and Political components
 First Trimester lower immune response and disgust
elevation.
 Nausea protection from toxins and infections during
this vulnerable time.
Disgust as a Post-It Note
 What makes you feel disgust?
 Do we always have to see to feel?
What is Disgust?
 Lice, mucous, feces, spoiled food,….
 Discarded bloody Band-Aid
 Where a cockroach has been
 Biting into a restaurant meal only to find
a hair in it
 The thought of someone spitting in your
food before it is served.
Effectiveness of Disgust
 The emotion of disgust prompts hand
hygiene primarily when dirt is visible.
(Whitby et al., 2007)
Ghana
Public Health Partnerships
Handwash Trigger: Powerful
emotional disgust response Woman
leaving toilet with digitalized red stain
on her hands which she transferred to
the fufu (food staple) which her child
then ate.
(Curtis, Garbrah-Aidoo, & Scott, 2007)
Disgust As A Strategy
1. Education video
2. Disgust video conveying
knowledge in a disgusting context.
3. Control Nature video
96 PARTICIPANTS, RANDOM ASSIGNMENT
Results
One week later the disgust intervention had
modestly improved hand hygiene practice
over those with education and control
intervention combined.
(Porzig-Drummond, Stevenson, Case, & Oaten, 2009)
Disgust as Strategy
Graphic disgust-promoting posters in two
washrooms at a university library
Similar educational information but without
the disgust inducing content in two
washrooms
Results
Disgust Intervention Significantly Increased
Hand-hygiene Behavior Over The
Education Intervention.
(Porzig-Drummond, Stevenson, Case, & Oaten, 2009)
Hygiene is a World Value
 Hygiene is a common value around the
world.
 Hygiene practices may have more to do
with social and aesthetic considerations
than health.
(WHO, 2011)
Mothers Want to Hold and
Love Kids
This Will Only Happen If They Are
Clean
Social Motivation
Motives 11 Country Study
 Disgust at the idea that fecal material might be
present on hands was consistently reported to
be the most powerful motivator of hand
washing with soap and water after using the
toilet.
(Curtis, 2013, p. 83)
DO IT YOURSELF VACCINE
LOW COST DEFENSE
Ethics of Disgust
Practitioners are Challenged to Ensure
Interventions Meet Ethical Standards
of Professional Practice.
The Global Public Private
Partnership for Handwashing
(PPPHW)
 Global Handwashing Day is October 15
 May 5 is Hand Hygiene Day
Collaboratives
 Colgate-Palmolive
 FHI-360
 London School of Hygiene and Tropical Medicine
 Procter & Gamble
 The Water and Sanitation Program
 The Water Sanitation and Supply Collaborative
Council
Collaboratives
 UNICEF
 Unilever
 University at Buffalo-The State University of New
York
 USAID
 Dow Chemical (Resources)
YOUR NEW
COLLABORATIVE ACTION
 Organizational Data Collection between
cooperating institutions or clinics
 Target the problem
 Celebrate the National Day-May 5
 Talk about it-Have The Conversation and ask…
Do You Know How to
Save Lives??
Should Disgust Be In Your
Intervention Toolbox???
References
Agency for Healthcare Research and Quality. (2013). Making health care
safer II: An updated critical analysis of the evidence for patient safety
practices. (Evidence Reports/Technology Assessments, No. 211). Rockville
(MD): Author
Aiello, A. E., R. M., Coulborn, Perez, V., & Larson, E. L. (2008). The effect of hand
hygiene on infectious disease risk in the community setting: A meta-analysis.
American Journal of Public Health, 98, 1372-1381.
Angyal, A. (1941). Disgust and related aversions. Journal of Abnormal and Social
Psychology, 36, 393-412
Borchgrevink, C. P., Cha, J., & Kim, s. (2013). Handwashing practices in a college
town environment. Journal of Environmental Health, 75(8), 18-24.
CDC (2014). Show me the science-why wash your hands. Retrieved from
http://www.cdc.gov/handwashing/why-handwashing.html
References
Curtis, V. (2013). Don’t look, don’t touch, don’t eat. The science behind revulsion.
Chicago, Illinois: The University of Chicago Press
Darwin, C. R. (1965). The expression of the emotions in man and animals.
University of Chicago Press.
Chicago:
Evans, W. D., and McCormick, L. (2008). Appying social Marketing in health care:
Communicating evidence to change consumer behavior. Medical Decision
Making, 28, 781-792.
Glenn, L., Bolls, P., Thomas, E. (2009). Scare’em or disgust’em: The effects of
graphic health promotion messages. Health Communication, 24,
458.
doi: 10.1080/10410230903023493
447-
Porzig-Drummond, R., Stevenson, R, Case, T., & Oaten, M. (2009). Can the emotion
of
disgust be harnessed to promote hand hygient? Experimental and fieldbased tests,
Social Science & Medicine, 68, 1006-1012.
References
World Health Organization. (2001). Water for health: Taking charge. Retrieved from
ile:///Users/admin/Desktop/Interprofessional%20conf%20Disgust/
wwdreportchap4.pdf
Whitby, M, Pessoa-Silva, C. L., McLaws, M. L., Allegranzi, B., Sax, H., Larson,
…
Pittet, D. (2007). Behavioural considerations for hand hygiene
of Hospital Infection, 65, 1-8.
E.,
practice:The basic building blocks, Journal
World Health Organization. (2009) Guidelines On hand hygiene in health care: First
global patient safety challenge clean care is safer care. Hand hygiene practices
among health-care workers Retrieved from http://
www.ncbi.nlm.nih.gov/books/NBK144026/
References
World Health Organization. (2014). Clean care is safer care: Evidence for hand
hygiene guidelines. Retrieved from http://www.who.int/gpsc/tools/
faqs/evidence_hand_hygiene/en/