Using ABA to Reduce Disease Transmission

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By: Elizabeth Zeppernick, M.Ed., BCBA, LBA

The Coronavirus Disease of 2019 (COVID-19) pandemic has brought increased focus on the need to reduce the transmission of disease.   Key components of our individual and group behavior have been the focus of widespread public campaigns in an effort to save lives and minimize the economic burden of the outbreak.  

There have been public and private debates over the responsibility of organizations, families and individuals in controlling the spread of infectious disease.  Focus has been placed on strategies to keep businesses open, particularly those deemed essential.  In a recent paper, Nicole Gravina et. al., highlighted interventions for reducing the spread of disease in the workplace with a focus on behavioral strategies rooted in the science of Applied Behavior Analysis.  

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Hand Hygiene

Proper hand hygiene has been identified as one of the most crucial components in reducing the spread of disease.  Research suggests that compliance with hand hygiene is historically poor across industries. (Bowman et al., 2019; Erasmus et al., 2010; Green et al., 2006).  To that effect, the following interventions can be implemented:

  • Automate the dispensing of hand towels.  Many dispensers have settings that can be changed from user activated (waiving of the user’s hand) to motion-activated (walking by the machine).  This visual serves as a cue for hand washing.  

  • Integrate hand hygiene into work schedules to require employees wash or sanitize their hands upon entering and exiting the building. 

  • Reduce the effort required by having hand sanitizers in their sight and within their immediate work areas. 

  • Reduce the effort required by replacing door handles with foot latches or contactless badges which open the door.  

  • Measure hand washing compliance and share the feedback.  (Choi et al. 2018) found that just by publicly posting feedback on the measured compliance rate, the compliance rates within a university bathroom increased by 20%. 

  • Use a group lottery system where during periods of measurement, all members of the staff must adhere to the policy in order for the group to receive the ‘reward.’ 

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Cleaning and Disinfecting

Research shows that germs causing COVID-19 can remain on surfaces for 4 hours and up to 9 days (Kampf et al., 2020; Van Doremalen et al., 2020).  Cleaning routines can reduce the risk of exposure from frequently touched surfaces if they are done correctly.

  • Use checklists of areas that require disinfection (knobs, handrails, keyboards) with specific directions on who is responsible, when and how to clean them.  Checklists should be short with the most important items listed first. 

  • Provide well designed cleaning tools and designate sufficient time to complete cleaning procedures.   

  • Provide a form for the staff to sign upon completion of the tasks to increase accountability.  

  • Monitor and measure performance and provide prompting for improvement (e.g., You completed 90% of the tasks correctly and next time don’t forget to wipe the microwave.”)

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Stay Home if You’re Sick

It was estimated that people showing up to work when ill caused up to 7 million coworker infections of the H1N1 virus (Institute for Women’s Policy Research, 2010).  There are behavioral strategies to reduce the risk of cross infection.  

  • Offer paid sick time.  The prospect of lost wages creates a negative reinforcement which can increase the incidents of going to work when sick.  Although it comes at a cost for businesses, the cost can be offset with lower medical costs and cumulative absences (Asfaw et al., 2017; DeRigne et al., 2016; Hansen et al., 2018) and reduces turnover (Hill, 2013). 

  • Offer flexibility when possible.  If an employee has symptoms that could put others at risk but feels well enough to complete work then allow them to work remotely so they can stay on top of tasks and access wages which are both reinforcers.  For work where teleworking is not possible, employees with symptoms could be isolated or use protective equipment.  

  • Managers should model behaviors and stay home when sick as their supervisees are likely to mimic their behavior (Scott et al., 1987).

  • Policies should not reward showing up to work when sick.  Criteria that lead to discipline such as a certain number of absences in a given period increase instances of staff attending work when sick (Grinyer & Singleton, 2000; Munir et al., 2007).  

  • When staff have to make up missed work they are also more likely to show up sick (Aronsson & Gustafsson, 2005; Aronsson et al., 2000) so cross training employees to cover each other can mitigate this concern.  Avoid rewards for “perfect attendance” and instead reward adherence to absence notification policies.  

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Personal Protective Equipment and Social Distancing

The use of PPE and practice of social distancing have been identified as key components of preventing the spread of disease. 

  • Limit the response effort by having PPE in close proximity, ensure it fits comfortably and ensure disposal bins are close by and emptied frequently.  

  • Use peer to peer observations with the support of a checklist that are followed by peer driven feedback.

  • Create visual and physical prompts such as playing tape on the floor in six foot increments.  

  • Use technology when possible.  An app to clock-in and out can prevent gathering at a physical time card machine.  

  • Allow for staggered work schedules to prevent gathering at the beginning and end of the day.  

  • Reduce the number of days on-site by increasing the total number of hours in the workday to limit exposure. (Cirrincionne, et al., 2020).

These behavioral strategies, routed in the science of Applied Behavior Analysis, can reduce the transmission of disease, protect populations that are particularly vulnerable, maintain essential services and minimize the economic impact of disease.  



Sources: 

Aronsson, G., & Gustafsson, K. (2005). Sickness presenteeism: Prevalence, attendance-pressure factors, and an outline of a model for research. Journal of Occupational and Environmental Medicine, 47(9), 958–966. https://doi.org/10.1097/01.jom.0000177219.75677.17

Aronsson, G., Gustafsson, K., & Dallner, M. (2000). Sick but yet at work. An empirical study of sickness presenteeism. Journal of Epidemiology and Community Health, 54(7), 502–509. https://doi.org/10.1136/jech.54.7.502

Asfaw, A., Rosa, R., & Pana-Cryan, R. (2017). Potential economic benefits of paid sick leave in reducing absenteeism related to the spread of influenza-like illness. Journal of Occupational and Environmental Medicine, 59(9), 822–829. https://doi.org/10.1097/jom.0000000000001076

Bowman, L. G., Hardesty, S. L., Sigurdsson, S. O., McIvor, M., Orchowitz, P. M., Wagner, L. L., & Hagopian, L. P. (2019). Utilizing group-based contingencies to increase hand washing in a large human service setting. Behavior Analysis in Practice, 12(3), 600-611. https://doi.org/10.1007/s40617-018-00328-z

Choi, B., Lee, K., Moon, K., & Oah, S. (2018). A comparison of prompts and feedback for promoting handwashing in university restrooms. Journal of Applied Behavior Analysis, 51(3), 667-674.  https://doi.org/10.1002/jaba.467

Cirrincione, L., Plescia, F., Ledda, C., Rapisarda, V., Martorana, D., Moldovan, R. E., Theodoridou, K., & Cannizaro, E. (2020). COVID-19 pandemic: Prevention and protection measures to be adopted at the workplace.  Sustainability, 12(9), 3603. https://doi.org/10.3390/su12093603

DeRigne, L., Stoddard-Dare, P., & Quinn, L. (2016). Workers without paid sick leave less likely to take time off for illness or injury compared to those with paid sick leave. Health Affairs, 35(3), 520-527.  https://doi.org/10.1377/hlthaff.2015.0965

Erasmus, V., Daha, T. J., Brug, H., Richardus, J. H., Behrendt, M. D., Vos, M. C., & van Beeck, Ed F. (2010). Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infection Control & Hospital Epidemiology, 31(3), 283-294. https://doi.org/10.1086/650451

Gravina, N., Nastasi, J., Sleiman, A., Matey, N. & Simmons, D. (2020). Behavioral strategies for reducing disease transmission in the workplace.  Journal of Applied Behavior Analysis: Online Publication, Fall (2020), 53, 1935-1954. Retrieved from: https://doi.org/10.1002/jaba.779

Green, L. R., Selman, C. A., Radke, V., Ripley, D., Mack, J. C., Reimann, D. W., Stigger, T., Motsinger, M., & Bushnell, L. (2006). Food worker hand washing practices: An observation study. Journal of Food Protection, 69(10), 2417-2423. https://doi.org/10.4315/0362-028X-69.10.2417

Grinyer, A., & Singleton, V. (2000). Sickness absence as risk-taking behaviour: A study of organizational and cultural factors in the public sector. Health, Risk & Society, 2(1), 7–21. https://doi.org/10.1080/136985700111413

Hansen, S., Zimmerman, P.-A., & van de Mortel, T. F. (2018). Infectious illness prevention and control methods and their effectiveness in non-health workplaces: An integrated literature review. Journal of Infection Prevention, 19(5), 212–218. https://doi.org/10.1177/1757177418772184

Hill, H. D. (2013). Paid sick leave and job stability. Work and Occupations, 40(2), 143-173. https://doi.org/10.1177/0730888413480893

Institute for Women’s Policy Research (2010, February). Sick at Work: Infected Employees in the Workplace During the H1N1 Pandemic. https://iwpr.org/wp-content/uploads/wpallimport/files/iwpr export/publications/B284.pdf

Kampf, G., Todt, D., Pfaender, S., & Steinmann, E. (2020). Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. Journal of Hospital Infection, 104(3), 246–251. https://doi.org/10.1016/j.jhin.2020.01.022

Munir, F., Yarker, J., Haslam, C., Long, H., Leka, S., Griffiths, A., & Cox, S. (2007). Work factors related to psychological and health-related distress among employees with chronic illnesses. Journal of Occupational Rehabilitation, 17(2), 259–277. https://doi.org/10.1007/s10926-007-9074-3

Scott, K. D., Markham, S. E., & Taylor, G. S. (1987). Employee attendance: Good policy makes good sense. Personal Administrator, 98-106. Retrieved from: https://works.bepress.com/dow_scott/25/

Van Doremalen, N., Bushmaker, T., Morris, D. H., Holbrook, M. G., Gamble, A., Williamson, B. N., Tamin, A., Harcourt, J. L., Thornburg, N. J., Gerber, S. I., Lloyd-Smith, J. O., de Wit., E., & Munster., V. J. (2020). Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. New England Journal of Medicine, 382(16), 1564-1567. https://doi.org/10.1056/NEJMc2004973

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Hygiene, Vocational Skills, AdultsElizabeth Zeppernick