Increasing vaccine compliance: Coercion and persuasion, shock and shame only work so much

James Colgrove, Ph.D., M.P.H., of the Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, writes in this commentary, in recent years, vaccine refusal and associated declines in herd immunity have contributed to numerous outbreaks of infectious diseases, consumed public health resources, and provoked increasingly polarized debates between supporters and opponents of vaccines.

vaccinationAlthough the prominence of the Internet as a forum for information and misinformation has given these conflicts a distinctly 21st-century character, they have deep historical roots. Many of the scientific, ethical, and political challenges that physicians and public health officials face today in dealing with vaccine refusal would be recognizable to their counterparts of previous eras. The heart of their task entails balancing the use of coercive and persuasive approaches.

Coercion is the older tradition in public health. During the 19th century, many states and localities passed compulsory-smallpox-vaccination laws covering both children and adults. These laws were of a piece with an expansive network of public health regulations that arose in that era concerning practices such as quarantine, sanitation, and tenement construction. Vaccination laws imposed various penalties, including exclusion from school for unvaccinated children and fines or quarantine for adults who refused vaccination. The effectiveness of the laws was soon demonstrated — jurisdictions with them consistently had fewer disease outbreaks than those without — and their constitutionality was upheld in numerous court challenges that culminated in the 1905 Supreme Court case of Jacobson v. Massachusetts.

The use of coercion has always raised concerns about state intrusions on individual liberty and the scope of parental control over child-rearing. Compulsory vaccination laws in the 19th century typically contained no explicit opt-out provisions. Today, all states offer medical exemptions, and almost all offer religious or philosophical exemptions. Nevertheless, even a law with an opt-out provision may exert a coercive effect, to the extent that the availability of the exemption may be limited and conditional and the consequence of the law is to make the choice to withhold vaccination more difficult (if only marginally so) for the parent. These laws continue to be the target of antivaccination activism.

Persuasion became an important part of the public health tool kit in the 1920s, with the rise of modern forms of mass media. Health professionals began to draw on techniques from the emerging fields of advertising and public relations to sell people on the importance of childhood immunization against diphtheria and pertussis. Such appeals began to acquire a more scientific basis in the 1950s, after the development of the polio vaccine, when sociologists, psychologists, and other social scientists began to identify the attitudes, beliefs, and social contexts that predicted vaccine-related behaviors. Their efforts brought increasing theoretical and empirical rigor to the study of why people accepted or declined vaccination for themselves and their children, and health professionals used these insights to develop approaches to increase uptake of vaccines, such as enlisting community opinion leaders as allies.1 Persuasive approaches, because they are less restrictive, are ethically preferable and more politically acceptable, but they are also time consuming and labor-intensive, and evidence indicates that by themselves they are ineffective.

Vaccine refusal revisited — The limits of public health persuasion and coercion

October 12, 2016, New Engl J Med; 375:1316-1317, DOI: 10.1056/NEJMp1608967

Restaurants told to wash hands or be named-and-shamed

Katrina Hodgkinson, the Minister for Primary Industries in New South Wales (the Australian state that includes Sydney), told the Cowra Community News that NSW food businesses to clean up their act.

“Hand-washing is at the very foundation of correct and safe food handling. Over the past 12 months, there have been about 170 offences related to hand-washing listed on the Name and Shame register.

“Whether you’re at home cooking for your family, in the kitchen of the local café, a chef in a high end commercial kitchen or at a fast food chain preparing food for thousands – the key to keeping a safe and hygienic kitchen is washing your hands.

“Each penalty notice carries a fine of $880 for a corporation and $440 for an individual as well as the unenviable honour of being placed on the Name and Shame list where consumers can easily see the breaches of their local food outlets.

“Consumers vote with their feet, so begin by washing your hands to ensure you don’t lose business or worse – make your customers sick.”

The full list of penalty notices and prosecutions can be found at

Dubai rules out naming restaurants failing safety inspections

In its quest for food safety excellence, Dubai has decided to keep restaurants that fail safety inspections a secret.

This is backwards. reports that in May, the Abu Dhabi Food Control Authority (ADFCA) said it will announce the names of restaurants and food outlets facing closure due to poor hygienic conditions.

However, the Dubai municipality believes taking corrective and preventive actions is more important than naming and shaming defiant eateries, director of the Food Control Department at the municipality, Khalid Mohammed Sherif Al Awadhi, said.

Variations of name and shame has proven a strong incentive in Toronto, Los Angeles, New York City and Sydney (New South Wales). Dubai isn’t there.

Will machines that go Ping increase handwashing compliance?

Money is a good way to get an administrator’s attention.

Monty Python figured this out in 1983’s, The Meaning of Life.

In The Miracle of Birth bit, as a laboring woman is wheeled into the delivery room surrounded by the machines meant to assist birth, the hospital administrator, Mr. Pycroft, arrives.

“Wonderful what we can do nowadays.

“Aah! I see you have the machine that goes ‘ping’.

“You see, we lease this back from the company we sold it to, and that way, it comes under the monthly current budget and not the capital account.

“Thank you. Thank you. We try to do our best. Well, do carry on.”

Tina Rosenberg of the N.Y. Times reports on the health blog today that handwashing compliance in hospitals generally sucks, provides a thorough overview of why it sucks, and notes that hospitals are now paying more attention to the matter: money.

“In 2008, hospitals were told that Medicare would no longer reimburse them for the cost of treating preventable hospital-acquired conditions it calls “never events,” which includes many kinds of hospital-acquired infections. The new health care reform bill instructs states to do the same with Medicaid. Many insurance companies also now refuse to pay for never events. This tends to concentrate the minds of hospital executives. …

“In the last year or two, several new ways to promote hand-washing – all things that beep – have made their debut: HyGreen, BioVigil, Patient Care Technology System’s Amelior 360 and Proventix’s nGage are some of them, but there are others. Some are spinoffs of systems widely used to track hospital equipment (this is how hospitals can find a wheelchair when it is needed). All employ new technology that can detect alcohol — which in hospitals is a component not only of rubbing gel but also soap.

“They work like this: every health care worker wears an electronic badge. When she washes her hands or uses alcohol rub, a sensor at the sink or dispenser or her own badge smells the alcohol and registers that she has washed her hands.

“Another sensor near the patient detects when her badge enters a room or the perimeter around a patient that the hospital sets. If that badge shows that her hands were recently washed, it displays a green light or something else the patient can see. If she hasn’t washed, her hands, the badge says so and emits a signal to remind her to do so. The sensor also sends this information to a central data base. Information about the hand-washing practices of a particular unit, shift or individual is instantly available.”

There is some evidence the systems work, but they are also expensive.

And sorta useless without a culture change.

Rosenberg writes any technological fix should be accompanied by “creating a culture of accountability, redesigning hand hygiene systems to make hand-washing easy and automatic, and other strategies.”

We prefer shock and shame.

Shock and Shame: graphic messages can increase handwashing compliance

Graphic messages and reminders that use a shock-and-shame approach may get more people to wash their hands, according to a Kansas State University professor and his colleagues.

"Those ‘Employees Must Wash Hands’ signs in bathrooms may not be the most effective reminder," said Doug Powell, professor of food safety at K-State. "We wanted a comprehensive review of what others had done, and combined this with our own work on food safety messages that lead to behavior change. We weren’t interested in self-reported surveys where everyone says they always wash their hands, but studies based on observed increases in handwashing compliance."

Powell worked with Casey Jacob, a former K-State research assistant in the department of diagnostic medicine and pathobiology, and Sarah Wilson, formerly of the University of Guelph. Their review of techniques to improve handwashing behavior was just published in the journal Critical Public Health.

The review was conducted as background for several ongoing experiments involving Powell and colleagues to increase handwashing rates in cafeterias, restaurants, hospitals, veterinary clinics and petting zoos. The team has previously designed handwashing campaigns at K-State involving both shock and shame.

"Social pressure, or shame, has been successfully used, especially within an entire organization," Powell said. "If you were in the bathroom at a restaurant and saw an employee not washing his or her hands, would you say, ‘Dude, wash your hands?’ The shock approach is designed to get people to ‘be the bug’ — just for a moment — and think about where their hands have been and where they are going to be, especially when around hospitals, food service or animals. Dangerous microorganisms move around a lot."

Behavior-change interventions to improve hand-hygiene practice: A review of alternatives to education
Critical Public Health
Sarah Wilson; Casey J. Jacob; Douglas Powell
Despite the role of hand hygiene in preventing infectious disease, compliance remains low. Education and training are often cited as essential to developing and maintaining hand-hygiene compliance, but generally have not produced sustained improvements. Consequently, this literature review was conducted to identify alternative interventions for compelling change in hand-hygiene behavior. Of those, interventions employing social pressures have demonstrated varying influence on an individual’s behavior, while interventions that focus on organizational culture have demonstrated positive results. However, recent research indicates that handwashing is a ritualized behavior mainly performed for self-protection. Therefore, interventions that provoke emotive sensations (e.g., discomfort, disgust) or use social marketing may be the most effective.

Shock and shame: How to increase handwashing compliance

A British study by the London School of Hygiene and Tropical Medicine concluded that people are more likely to wash their hands properly after using the toilet if they are shamed into it or think they are being watched.

As part of a flood of handwashing information for today’s World Handwashing Day, the study, published in the American Journal of Public Health found that with no reminders, 32 percent of men and 64 percent of women used soap.

The observational study reported on the behavior of people using toilets at motorway service stations in Britain over 32 days.

When prompted by an electronic message flashing up on a board asking: "Is the person next to you washing with soap?," around 12 percent more men and 11 percent more women used soap.

Other messages flashed on the electronic boards included:

• Water doesn’t kill germs, soap does; and,
• Don’t be a dirty soap dodger.

The message that produced the strongest positive response was: "Is the person next to you washing with soap?"

The researchers also noted "intriguing differences" in the behavior of men and women: While women responded to simple reminders, men tended to react best to messages that invoked disgust, such as:

• Don’t take the loo with you — wash with soap, and
• Soap it off or eat it later.

I like the last one.

We’ve undertaken both shock and shame attempts at handwashing messages (below). Results pending.

Restaurants challenge ‘name and shame’ in Sydney

The Sydney Morning Herald reports that a Sydney restaurant is considering legal action against the NSW Food Authority over its controversial name-and-shame website.

Satasia opened in Balmain 28 years ago and has become one of the most popular restaurants in Sydney’s inner west.

The owner, Andrew Lum, says that reputation is in tatters after his eatery was fined by the Food Authority, then included on its name-and-shame list alongside rat- and cockroach-infested restaurants.

The database was launched in July to try to improve hygiene standards.

But Mr Lum and other restaurateurs argue its format is unfair.

Several businesses, including Satasia, have consulted lawyers about suing the State Government.

But the Food Authority appears to be immune from legal action, including defamation, under section 133G of the 2003 Food Act, which states: "No liability is incurred by the state, the minister or the Food Authority, for publishing in good faith any information contained on a register."

A University of Sydney senior law lecturer, David Rolph, said,

"The Food Authority clearly takes the view that when you balance it out between the rights of the trader and the right of the public not to consume food prepared in unsafe places, public interest has to prevail."

Lavender Blue Cafe, at McMahons Point, joined the list in November after receiving a fine for a broken probe thermometer. The manager, Andrew Menczel, said: "The list is a good idea in principle but to lump everyone together is wrong. There should be clearer categories for different offences.”

Live crabs in loo highlight Sydney’s name and shame

A fish market that stored crabs in a toilet cubicle is amongst the newest addition to the NSW Government’s name and shame list, available at

Primary Industries Minister Ian Macdonald said Jemes Fish Market on Liverpool Road, Ashfield, in the city’s inner west, was hit with two fines of $660 for storing live crabs in a toilet cubicle.

"This is one of the most outrageous cases of food storage I have ever heard about. It is unhygienic and is just not fair on consumers who pay good money for their food."

Among the other 45 additions to the website this week is Jesters at Forestville in Sydney’s north, fined $1980 for having containers of raw foods encrusted with food waste and cockroach activity, and Choy Restaurant in Belmore Road, Randwick, in Sydney’s east, which was been slapped with three fines worth $1980 for having a dead rodent in the storage area, as well as vermin activity and unclean premises.

Cockroach sandwich? Calls to name and shame dirty school canteens

The Australians are really getting into restaurant inspection disclosure — via the name and shame route.

Sydneysiders are now saying school canteens should be held to the same standards. reports that,

Gastro outbreaks, cockroaches in sandwiches and mice droppings in pie ovens are among a number of complaints that have seen 38 Sydney schools targeted by the food safety authority since 2004.

Shadow Education Minister Andrew Stoner said,

“We don’t allow other businesses – takeaways and restaurants – to get away with this. We can’t allow school canteens to do it. … name and shame the schools where canteens are not up to scratch.”

Go for it.