Which combination of text and images encourages handwashing? (Part 1)


Around July 2019 before COVID-19 was a thing we were asked to work on project by The University of Sheffield (in collaboration with the University of Glasgow and Leeds).

We all know we should wash our hands but actually many people don’t. In fact, it is
estimated that 51% of us do not wash our hands with soap. This is a problem because washing hands is one of the most important things we can do to reduce our chances of infection-related illness. This in turn reduces our use and dependency on antibiotics.

Posters are widely used in health communication to encourage behaviour change e.g. to stop smoking, eat more healthily and so on. They are also used to encourage handwashing but results have been mixed. Why posters are effective and ineffective is not well understood. Posters are, by their very nature, intended to be a way of exposing people to a persuasive message with the intention of bringing about a change in attitudes and/or behaviour.

So roll on the study, we wanted to know how images can be used to compel people to wash their hands. What type of images work and for whom?

Randomised controlled trials (RCT) are considered the gold standard for evaluating the effectiveness of handwashing campaigns. However, RCTs are expensive to run. It’s also impracticable to test multiple variations of a campaign.

Novel methods were needed to pre-test behaviour change interventions prior to more formal evaluations. In this study, emotional reactions to 32 handwashing messages from four different theoretical perspectives were measured in a lab-based study using Face Reader (software that automatically recognises and numerically analyses facial expressions). Whether participants’ emotional reactions to messages impacted on their
intention to wash hands was further investigated.

The research questions for this study were
– RQ1: Are messages from different theoretical constructs producing different emotional reactions?
– RQ2: Can adding an image to a text message intensify emotional reactions?
– RQ3: Is there a connection between an emotional reaction and participants’ intention to wash their hands?

A within-subjects design was employed with the message order rotated for each participant. Thus, each participant viewed every message but in a different order so the results can be attributed to the message viewed and not the order of messages.

The data was collected over one week. The study took place in the university research lab. After informed consent was received, participants were asked to complete a brief demographics questionnaire (age, gender, home country, first language). Participants were then shown the randomised message sample using PowerPoint.

Participants viewed each message for 8 seconds. Emotional reactions to messages were recorded and measured with Noldus Face Reader. Face Reader automatically analyses emotions using the Facial Action Coding System developed by Ekman and Friesen (1978)

Facial expressions are made up of a combination of emotions. Happiness, Sad, Anger, Surprise, Scared, Disgust are the six basic emotions (i.e. the building blocks of emotional reactions) and are considered universal

Reactions to handwashing messages might be different in locations were handwashing takes place as the environment will be influential. However, an advantage of conducting the study in a research laboratory is that the testing of messages is highly controlled and so the same conditions apply to all messages.

As off today we’re still writing up the results and will post them here in part 2.


Ekman P, Friesen W. 1978. Facial Action Coding System: A Technique for the Measurement of Facial Movement. Palo Alto: Consulting Psychologists Press.

Lawson, A., & Vaganay-Miller, M. (2019). The Effectiveness of a Poster Intervention on Hand Hygiene Practice and Compliance When Using Public Restrooms in a University Setting. International Journal of Environmental Research and Public Health16(24), 5036. doi: 10.3390/ijerph16245036

Wolf, J., Johnston, R., Freeman, M. C., Ram, P. K., Slaymaker, T., Laurenz, E., & Prüss-Ustün, A. (2018). Handwashing with soap after potential faecal contact: global, regional and country estimates. International Journal of Epidemiology48(4), 1204–1218. doi: 10.1093/ije/dyy253 https://academic.oup.com/ije/article/48/4/1204/5238107

World Health Organization. 2020. Infection prevention and control. World Heal Organ [Internet].
Available from: https://www.who.int/infection-prevention/en/

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