By Jules Storr
“When I asked the doctor if he had cleaned his hands, he looked at me as if I had two heads. I thought I was going to have a heart attack – but I forced myself to ask.”
That quote has stayed with me for years.
It comes from a patient involved in an early hand hygiene campaign that I was part of in Oxford, UK – a campaign designed to protect patients. Yet the experience itself as fed back to me, was stressful, uncomfortable and anxiety-provoking.
It raises an uncomfortable question:
Can health campaigns – even well-intentioned ones – sometimes make people feel worse? I wrote about this in my recent book on infection prevention and control (IPC) and the social sciences. Here I share a few snippets from the chapter “Do campaigns make you anxious?”
Campaigns are everywhere in healthcare
Campaigns have become a cornerstone of modern public health and IPC. We run global awareness days, behaviour-change initiatives, safety drives and advocacy movements.
Hand hygiene campaigns, antimicrobial awareness weeks, patient safety initiatives – all aim to reduce harm and improve outcomes.
The logic is clear:
- Raise awareness
- Bring people together in a common cause
- Change behaviour
- Prevent disease
- Save lives
In IPC, campaigning has been a powerful adjunct to our work moving us beyond simply educating healthcare workers. We have increasingly embraced social marketing, behavioural science and multimodal strategies towards the goal of sustained change.
In my experience campaigns can be powerful. As part of a multifaceted approach to behaviour change they have a profound impact.
What is clear however, is that a blind focus on campaigns as a magic bullet will never end well.
Evidence suggests that health care campaigns historically were measured on their reach, sometimes efforts were made to try and connect a campaign with reductions in infection, and sometimes their impact on compliance with policies and procedures has been used as a metric. Less attention tends to be given to how campaigns “feel” to the people experiencing them.
The missing question: what about unintended consequences?
On the subject of healthcare research, studies have previously explored how infections themselves affect patients’ quality of life. We know for example that hospitalisation, isolation precautions and illness can increase anxiety, depression and distress. Yet surprisingly little research asks whether non-clinical interventions like awareness campaigns might also influence wellbeing.
Behavioural science warns us about the “boomerang effect”: when campaigns unintentionally produce the opposite of the intended outcome. Examples exist across public health:
- Abstinence-only education linked with higher teenage pregnancy rates in some settings
- Policy changes/mandates producing unexpected consumer behaviours
- Messaging strategies that confuse rather than motivate
In the words of one of the above authors, the lesson appears to be that “no matter how much groundwork policy wonks do, the risk of unintended consequences is always lurking.”
When fear works and when it backfires
The COVID-19 pandemic offered a real-time experiment in public health communication. Messages such as “Stay home. Protect the NHS. Save lives” were highly effective. People’s behaviour changed rapidly. But later reflections suggested another consequence: people did stay at home and they protected the NHS, but in many instances, this meant not appropriately seeking treatment in a timely way due to fear. The employment of “fear appeals” came with a cost.
The point here is not that we should avoid using fear appeals – behavioural science tells us they work. The issue is that we must try to understand the downstream effects that come with this approach.
The question for those of us working in IPC, patient safety and other adjacent fields is around whether we are improving safety at the cost of increasing the psychological burden on the very people we’re trying to protect?
Campaigns rarely get tested like clinical interventions
When introducing a new drug or clinical procedure, we expect rigorous testing, monitoring and evaluation. Campaigns sometimes fail to receive the same scrutiny.
In my book chapter I called on colleagues who are involved in developing communications and messages as part of large or small scale campaigns and initiatives to use a multipronged approach. It may be worth, for example, asking a few questions as you sit around the table with the seed of an idea:
- Do we truly understand our audience?
- Have we explored cultural context and power dynamics?
- Did we test messages before scaling up?
- Are we measuring unintended consequences?
- Do we build in pause points to change course?
In other words: are our campaigns safe not just effective? Campaign visibility, energy and reach are important ingredients but are not the only thing we should fix on – the real human impact also matters and remains partially unknown in many cases.
A final thought
Campaigns are powerful tools. They mobilise systems, change behaviour and save lives. Their development and implementation require human and financial resources. To ensure resources are utilised in the most effective and impactful manner we should at the very least make sure that they do not make people feel worse. The ultimate goal of any campaign is not only behaviour change it is care that is safer, kinder and experienced as such by the people we serve.