'Lifting the Lid on Bacteria': Designing ambient communications to improve hygiene in primary school toilets
Lead Research Organisation:
University of Leeds
Department Name: Sch of Design
Abstract
Context:
AMR can be directly tackled by reducing the spread of infection in the first instance. The primary school toilet is a risk-laden space for the spread of bacterial infection given the behaviour of its users. Research reports that fewer than half of the children who use school toilets wash their hands afterwards. Neutral poster-based messages such as 'Now Wash Your Hands' or classroom material may aid understanding and reinforce hand hygiene messages but what is the potential of using more novel, engaging, friendly and site-specific communication in the toilet environment itself?
Aims and objectives:
The primary aim of this communication design-led research is to investigate the potential of using ambient, surface-based communications in the primary school toilet environment to improve hand hygiene practices (lowering the toilet lid, hand washing and hand drying). Ambient communication involves the clever and unexpected integration of graphics and media messages in specific environments. It is usually employed by commercial companies to improve engagement with a product or brand but it holds much potential for application in other areas. If bacteria and other appropriate message/images were clever represented in the environment, for instance, what impact would it have on behaviour in that space?
This research involves three phases. Firstly a historical review of everyday representations of bacteria and hand hygiene aimed at children will be carried out. This will provide new knowledge of dominant ideas from the 20th Century about children, hygiene and bacteria and provide selected imaginative material to show to children in subsequent workshops. Secondly school children will be directly engaged with to gauge their understanding of the toilet space, what bacteria might look like there and where it is. Participatory design methods will be used to understand what children would design and why. Thirdly a set of ambient designs will be developed, informed by historical and contemporary design practice and children's imaginative ideas, for testing in school toilets and the toilets at Eureka! The National Children's Museum. The installation of the designs will facilitate the testing of the concept and provide opportunity for a pilot study of evaluation methods - what are the most effective and feasible ways to measure success of such an intervention?
Applications and Benefits.
This interdisciplinary, collaborative research project brings together academics and professionals from the areas of communication design, medical history, healthcare, education and microbiology. The project will involve a synthesis of approaches (historical analysis, participatory design methods, communication design practice, and science-led evaluation methods) and thus the application of the research is potentially wide. It can inform medical and public health historians about historical and contemporary ideologies underpinning bacteria representations aimed at children. It can also provide communication designers with an extensive set of designs and analysis to aid the designing of anti-bacterial products/interventions for children today. It will also bring microbiology research into a more public domain since we will use findings directly from microbiology research (related to toilet lid position) for one of the messages. The designs developed may also be applied not only within school toilets more widely but in children's hospitals or wards.
One of the key benefits of the research, if the intervention is successful, is potentially reducing the spread of infection due to school toilet usage. There are number of benefits to this aspect of the work alone: reducing absenteeism, reducing the occurrence of infections within the wider family, and reducing the request for antibiotics. The research will promote discussion amongst teachers and child-focused museums about current and potential future communications in the toilet space.
AMR can be directly tackled by reducing the spread of infection in the first instance. The primary school toilet is a risk-laden space for the spread of bacterial infection given the behaviour of its users. Research reports that fewer than half of the children who use school toilets wash their hands afterwards. Neutral poster-based messages such as 'Now Wash Your Hands' or classroom material may aid understanding and reinforce hand hygiene messages but what is the potential of using more novel, engaging, friendly and site-specific communication in the toilet environment itself?
Aims and objectives:
The primary aim of this communication design-led research is to investigate the potential of using ambient, surface-based communications in the primary school toilet environment to improve hand hygiene practices (lowering the toilet lid, hand washing and hand drying). Ambient communication involves the clever and unexpected integration of graphics and media messages in specific environments. It is usually employed by commercial companies to improve engagement with a product or brand but it holds much potential for application in other areas. If bacteria and other appropriate message/images were clever represented in the environment, for instance, what impact would it have on behaviour in that space?
This research involves three phases. Firstly a historical review of everyday representations of bacteria and hand hygiene aimed at children will be carried out. This will provide new knowledge of dominant ideas from the 20th Century about children, hygiene and bacteria and provide selected imaginative material to show to children in subsequent workshops. Secondly school children will be directly engaged with to gauge their understanding of the toilet space, what bacteria might look like there and where it is. Participatory design methods will be used to understand what children would design and why. Thirdly a set of ambient designs will be developed, informed by historical and contemporary design practice and children's imaginative ideas, for testing in school toilets and the toilets at Eureka! The National Children's Museum. The installation of the designs will facilitate the testing of the concept and provide opportunity for a pilot study of evaluation methods - what are the most effective and feasible ways to measure success of such an intervention?
Applications and Benefits.
This interdisciplinary, collaborative research project brings together academics and professionals from the areas of communication design, medical history, healthcare, education and microbiology. The project will involve a synthesis of approaches (historical analysis, participatory design methods, communication design practice, and science-led evaluation methods) and thus the application of the research is potentially wide. It can inform medical and public health historians about historical and contemporary ideologies underpinning bacteria representations aimed at children. It can also provide communication designers with an extensive set of designs and analysis to aid the designing of anti-bacterial products/interventions for children today. It will also bring microbiology research into a more public domain since we will use findings directly from microbiology research (related to toilet lid position) for one of the messages. The designs developed may also be applied not only within school toilets more widely but in children's hospitals or wards.
One of the key benefits of the research, if the intervention is successful, is potentially reducing the spread of infection due to school toilet usage. There are number of benefits to this aspect of the work alone: reducing absenteeism, reducing the occurrence of infections within the wider family, and reducing the request for antibiotics. The research will promote discussion amongst teachers and child-focused museums about current and potential future communications in the toilet space.
Planned Impact
There are a number of non academic beneficiaries of this research project:
PRIMARY SCHOOL CHILDREN
The children that take part in the workshops will directly benefit from the discussions, play and activities of the participatory design workshops. There is evidence to support the notion of empowerment of participants during participatory design research and it is important for children to be feel involved in designing the messages they receive. By seeing the results in their own schools this sense of involvement will be nurtured and they will be able to see themselves 'making a difference'. The children who encounter the design inventions will directly benefit from the research in terms of receiving memorable messages which, if engaged with, may help reduce the spread of infection and school absenteeism.
PARENTS
Since infections that children contract in schools can result in additional infections in up to 50% of household members there is a direct benefit to the health of parents if we can improve hand hygiene practices in schools.
SCHOOLS AND SCHOOL STAFF
A new NICE report (NG63 'Antimicrobial stewardship: changing risk-related behaviours in the general population' in January 2017) presents several recommendations to schools about steps to take and resources to use. None of the recommended resources (including PHE's 'e-bug') provide resources for the toilet environment itself. We see this as an opportunity for our project. This project and its website will provide an accessible and research-led set of guidance about environment-specific communications to help teachers make an effective choice of materials to place there, including a set of resources developed by us that schools can help to test further.
VISITORS TO EUREKA! THE NATIONAL CHILDREN'S MUSEUM
Eureka will directly benefit from the design outcome as it will extend the reach of their general ethos to otherwise very functional spaces. As stated in the letter of support "The Eureka! environment builds on the experiences that are familiar in children's everyday lives but also exposes them to a world of fantasy and imagination, encouraging them to extend their natural curiosity and sense of discovery to believe that anything is possible. This project aligns perfectly with our aim to do this and this project will allow us to extend this ethos to our functional facilities and not just our exhibition spaces". Its visitors will also benefit from enhanced hand hygiene messages that may trigger greater engagement and provide 'take-home' messages.
PUBLIC HEALTH ORGANISATIONS
Organisations such as Public Health England (who produced and funded 'ebug.eu') will benefit from our results. Commissioners and designers of these systems will benefit from our research into how children respond to designs within the toilet space, enabling commissioners to understand and appreciate choice of graphic language and message placement.
COMMERCIAL ORGANISATIONS
Commercial companies who produce materials for schools and children will benefit from the findings of our research with children, encouraging them to adopt certain evaluation methods for their own products and to learn and apply new insights to their own research and development. There is a need for robust testing of hand hygiene products for children in order to provide evidence of their potential impact. This is particularly important where schools are required to make considerable investment (say, in child-friendly hand dryers).
PRIMARY SCHOOL CHILDREN
The children that take part in the workshops will directly benefit from the discussions, play and activities of the participatory design workshops. There is evidence to support the notion of empowerment of participants during participatory design research and it is important for children to be feel involved in designing the messages they receive. By seeing the results in their own schools this sense of involvement will be nurtured and they will be able to see themselves 'making a difference'. The children who encounter the design inventions will directly benefit from the research in terms of receiving memorable messages which, if engaged with, may help reduce the spread of infection and school absenteeism.
PARENTS
Since infections that children contract in schools can result in additional infections in up to 50% of household members there is a direct benefit to the health of parents if we can improve hand hygiene practices in schools.
SCHOOLS AND SCHOOL STAFF
A new NICE report (NG63 'Antimicrobial stewardship: changing risk-related behaviours in the general population' in January 2017) presents several recommendations to schools about steps to take and resources to use. None of the recommended resources (including PHE's 'e-bug') provide resources for the toilet environment itself. We see this as an opportunity for our project. This project and its website will provide an accessible and research-led set of guidance about environment-specific communications to help teachers make an effective choice of materials to place there, including a set of resources developed by us that schools can help to test further.
VISITORS TO EUREKA! THE NATIONAL CHILDREN'S MUSEUM
Eureka will directly benefit from the design outcome as it will extend the reach of their general ethos to otherwise very functional spaces. As stated in the letter of support "The Eureka! environment builds on the experiences that are familiar in children's everyday lives but also exposes them to a world of fantasy and imagination, encouraging them to extend their natural curiosity and sense of discovery to believe that anything is possible. This project aligns perfectly with our aim to do this and this project will allow us to extend this ethos to our functional facilities and not just our exhibition spaces". Its visitors will also benefit from enhanced hand hygiene messages that may trigger greater engagement and provide 'take-home' messages.
PUBLIC HEALTH ORGANISATIONS
Organisations such as Public Health England (who produced and funded 'ebug.eu') will benefit from our results. Commissioners and designers of these systems will benefit from our research into how children respond to designs within the toilet space, enabling commissioners to understand and appreciate choice of graphic language and message placement.
COMMERCIAL ORGANISATIONS
Commercial companies who produce materials for schools and children will benefit from the findings of our research with children, encouraging them to adopt certain evaluation methods for their own products and to learn and apply new insights to their own research and development. There is a need for robust testing of hand hygiene products for children in order to provide evidence of their potential impact. This is particularly important where schools are required to make considerable investment (say, in child-friendly hand dryers).
Publications
Rutter S
(2020)
Communicating Handwashing to Children, as Told by Children.
in Health communication
Rutter S
(2020)
Effectiveness and Efficiency of Persuasive Space Graphics (PSG) in Motivating UK Primary School Children's Hand Hygiene.
in International journal of environmental research and public health
Rutter S
(2021)
Evaluating children's handwashing in schools: an integrative review of indicative measures and measurement tools.
in International journal of environmental health research
Stark J
(2019)
Constructing Representations of Germs in the Twentieth Century
in Cultural and Social History
Stones C
(2020)
The visual representation of germs: a typology of popular germ depictions
in Visual Communication
| Title | Designs for Toilet Spaces: Persuasive Space Graphics |
| Description | This artefact comprises a set of graphics for display in toilet spaces. The set is made up of multiple components to be displayed in different areas of the space. The creative concept for the designs is 'Use 1,2,3 to get germ free' where 1 is soap, 2 is water and 3 is the dryer. The designs feature various images of hands and germs and include motivational messages based on research with children who acted as both designers and informants. |
| Type Of Art | Artefact (including digital) |
| Year Produced | 2019 |
| Impact | The designs are currently displayed in 3 locations and have impacted on increasing soap usage of up to 60% during the evaluative period. At a school where hand swabs were tested, instances of very dirty hands were significantly reduced. Both these impacts make it likely that germ transmission in these spaces has been reduced if new hygiene behaviour continues. The reach of the designs is significant so far. Eureka Museum receives approximately 300,000 visitors each year. Since the designs have been placed in their toilets for approximately a year, they are are likely to have reached well over 50,000 visitors. The management at Eureka are keen to continue support for version 2 of the project. Parent visitors were also very positive about the project. For example a parent stated "I just think it is brilliant, it should be everywhere." The designs are still displayed in 2 out of 3 original primary school sites (first installed in March 2019) and will have reached at least 1000 primary school children during their display. Children seeing the displays reported high levels of understanding the messages (at the school sites in particular) and recalling features (e.g. the personified washing devices and key messages). They were also positively received by the teachers and head teachers in the schools where the designs were placed, with further requests for additions such as classroom resources and take-home packs. Two unintended benefits of the design cited by a head teacher was a reduction in toilet paper on the floor and brightness and colourfulness of the environment - "I think this has probably had a bit of an impact that we weren't really thinking about." 4 new schools have independently requested the designs having seen them at Eureka. This indicates the potential for further distribution and evaluation in the future. |
| URL | http://www.123germfree.co.uk |
| Description | Firstly, we made a number of discoveries about the way germs have been visually represented in the UK over the past 100 years. In one study, that examined the context of production and dissemination of important popular images and animations of bacteria from 1920-1950, we were able to argue that still and moving images of germs made visible social anxieties surrounding health, race, class, and national security in ways that had not been recognised. We also identified, by classifying germ images (n.200), a typology of germs. Using these categories we were able to show that social anxieties, particularly visible through the alignment of germs with obesity and ugliness, are still very much prevalent in popular images today. Second, it was found that HH messages that children considered most effective were that 'germs that you can't see are on hands', and that 'germs can make you ill'. A child-centred-criteria to guide the selection of children's ideas and to inform the design process was created recommending the following: Feature positive characters, ideally superheroes not in a traditional position of authority. • Prioritise visuals featuring large hands, germs, washing devices and steps to take • Consider carefully the use of provocative/scary images • Germs should be green • Design the visual form of the germ with some elements of mild disgust • Avoid overt use of analogy • Ensure simplicity of layout and boldness of visual approach • Use bright colours • Cartoon style is valued with some use of photography Third, during the project we identified a new structure for considering the design problem, based on observing the toilet areas and through discussion with our child design participants. We named our approach 'persuasive space graphics' and defined a persuasive space as an architectural environment that features integrated visual communications to encourage particular behaviours. A clear structure was devised to guide the design components that designers can use to structure their thinking about any space where persuasive elements are required. Fourth, we created a set of persuasive space graphics. These were placed in 3 schools and Eureka Museum for evaluation purposes. A soap count (pre and post-test) taken at 2 schools and Eureka Museum revealed a rise in soap usage (in some cases as high as 60%). Hand swabs at Eureka and one school (pre and post-test) also revealed, at the school only, a statistically significant reduction in the instances of very dirty hands. The design outcome therefore had some tangible effects. Qualitative research carried out at all the locations (n.134) revealed a positive view of the designs. Character-led devices and the slogan 'Use 1,2,3 to get germ free' proved to be the most memorable of all the elements. The most appealing aspects of the designs were how they brightened up and added interest to the toilets. The designs were seen to act as a welcome reminder providing useful information. Whist most of the feedback received was positive, the most disliked aspects of the designs were the references to poo which the children, earlier in the design phase identified as motivational. |
| Exploitation Route | The findings are of use to any organisation dealing with the hand hygiene practices of young children such as local authorities, schools, nurseries or Public Health England. The design insights should see a shift in the way hand hygiene message are chosen and presented in public health campaigns or other hygiene-related campaigns. The typology of germ representations easily allows designers of new germ images to understand the main tropes of germ visualisation and, it is hoped, through its use, we may challenge/change some unsettling design practices. The typology may also be used by other researchers interested in the topic. Further outcomes of the project, including a new model of co-design creativity for graphics ('The Co-design Bridge of Creativity') will have benefit for the co-design community and in particular, for those researching/working in graphic design. As the design themselves are shaped through further evaluation they could be trialled more extensively and placed in the public domain with further reach. This is already beginning to occur. The designs can provoke organisations to question their own toilet provisions, their visual appeal and how well they fulfil their communicative potential. |
| Sectors | Healthcare,Other |
| URL | http://www.123germfree.co.uk |
| Description | Given the project finished in October 2019 (and it was a pump priming project), a broad overview of the impact from a health or cultural perspective has not yet fully emerged. However, I outline below some initial impacts that are likely to increase as the development of the designs and their dissemination (and the reach of the project/research findings) grows, particularly amid recent calls for more frequent hand washing. The designs are still on display at Eureka Museum, and at two of the three schools they were originally displayed in. Therefore dissemination of the project is still high and being seen on thousands of visitors and school children. 4 schools independently have been in touch requesting use of the designs highlighting a number of ways in which the designs have had an impact. An examples of an email received is as follows: "I visited Eureka yesterday with my two children aged 6 and 3. We were all so impressed by your germ free labelling in the toilets. They washed their hands so thoroughly and have asked if they can make their own labels for our toilet seats at home to remind us all to put down the lid when we flush. It would be amazing to have copies of the labels for their school and nursery. Is there somewhere we can purchase the labelling?". Though only anecdotal this quote highlights how the designs are provoking discussion beyond academia and how this is likely to continue. Given the findings regarding soap usage increase, it is hoped that the designs may have an impact on lowering bacterial transmission in primary schools longer term. To evidence this impact, further evaluation methods will be required in order to ascertain any effect on infection rates in schools. |
| First Year Of Impact | 2019 |
| Sector | Education,Culture, Heritage, Museums and Collections |
| Impact Types | Societal |
| Description | Membership of University AMR Steering Committee |
| Geographic Reach | Local/Municipal/Regional |
| Policy Influence Type | Membership of a guideline committee |
| Description | 'Use 123 to get Germ Free': Extending the Reach and Impact of a Hand Hygiene Intervention |
| Amount | £80,646 (GBP) |
| Funding ID | AH/T008601/1 |
| Organisation | Arts & Humanities Research Council (AHRC) |
| Sector | Public |
| Country | United Kingdom |
| Start | 01/2021 |
| End | 03/2022 |
| Description | Collaboration with De Montfort University: Industry Research Grant |
| Organisation | De Montfort University |
| Country | United Kingdom |
| Sector | Academic/University |
| PI Contribution | Myself and Dr Sophie Rutter (former RF) have worked alongside Professors Katie Laird (Microbiology) and Professor Sarah Younie at De Montfort University to develop an industrial grant proposal for Fedex Europe to improve hand hygiene in their head office. We are hoping this will lead to a larger research project. We contributed design methods and advice regarding evaluation methods. |
| Collaborator Contribution | They contributed subject knowledge (microbiology) and knowledge about educationally-led co-design methods. |
| Impact | There are no outputs yet but a grant proposal has been submitted. |
| Start Year | 2022 |
| Description | Article in Health Europa |
| Form Of Engagement Activity | A magazine, newsletter or online publication |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | This article outlined the research findings and outcomes of the Lifting the Lid project. |
| Year(s) Of Engagement Activity | 2021 |
| URL | https://www.healtheuropa.eu/hand-hygiene-messaging/107106/ |
| Description | Talk at 'Changing the Story' Event in Kathmandu, Nepal |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Other audiences |
| Results and Impact | I was invited to attend the 'Changing the Story' event in Nepal, which was a GCRF funded event pulling together projects related to AMR from across the globe. It was attended by over 100 delegates from many countries. Much discussion was had during the event, particularly around the issue of communicating AMR to children. During this meeting a new contact was made who has since become a named partner in a Follow-on-Fund grant application to the AHRC which, if successful. could see the '123' concept (that came out of the project) reach a global south audience. |
| Year(s) Of Engagement Activity | 2019 |
| URL | https://changingthestory.leeds.ac.uk/2019/07/28/community-engagement-for-antimicrobial-resistance-ce... |
| Description | Talk at the National Toilet Day in Denmark |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Other audiences |
| Results and Impact | I was invited to give a talk at this event after having presented the work in London 2019. The talk was organised by the The Danish Council for Better Hygiene. The talks consisted of Danish and Swedish presentations focusing in on toilet spaces and hygiene-related behaviour. There were approximately 50 delegates from schools, universities, hygiene-related industry and public health organisations. The presentation sparked discussion and in particular led to a connection with a Danish designer working with electronic devices in school toilets. We are hoping to collaborate in the future by testing his technology in a British setting and testing out which incentives are most effective. |
| Year(s) Of Engagement Activity | 2019 |
| URL | http://www.skoletoiletdagen.dk |
| Description | Talk at the e-Bug 10 Year Anniversary Meeting 2019, London |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Schools |
| Results and Impact | A talk was given at the e-bug 10 Year Anniversary Meeting, organised by Public Health England. The designs themselves were shown for the first time at this event in a lightening talk in front of an audience made up of a diverse audience. Our presentation won the prize for best presentation award for Education and Research. In addition, new contacts were made. An academic who has since created a small AMR-related project invited me to be a named Co-I on the project. In addition, the Head of International Projects Unit at the Danish Committee for Health Education, who also spoke at the event, invited us to present our work at the National Toilet Day in Aarhus, Denmark. |
| Year(s) Of Engagement Activity | 2019 |
| URL | https://www.ase.org.uk/events/e-bug-10-year-anniversary-meeting |