Lentis/Popular Hygiene: Perceptions and Practices

Hygiene practices pervade daily life in much of the developed world. From hand washing to teeth brushing, these activities are considered beneficial, or even essential, in many cultures. However, most of these hygiene practices have become commonplace only in the last century, and their evolution and proliferation is the subject of substantial social science research. This chapter examines the use of hand sanitizer and deodorant in particular, with an emphasis on their places in the United States of America.

Function and Effectiveness


Alcohol-based hand sanitizer works as an antiseptic, killing bacteria on the skin on contact by denaturing protein. It has found particular use in hospitals, where it often replaces soap and water due to its speed and convenience, thereby allowing doctors to spend more time with patients. Hand sanitizers are also particularly popular for use in schools where disease transmission levels can be high. Several studies have shown that the use of hand sanitizer in different environments can decrease the risk of infection, and its use is supported by health organizations such as the World Health Organization (WHO), National Institutes of Health (NIH) and Center for Disease Control and Prevention (CDC). Hand sanitizer allows its users to feel clean, and can allow them to show others that they are concerned with their personal hygiene. Such display is enhanced with brightly-colored bottles or bottle holders.

Perceptions and Practices
Hand sanitizer has become nearly ubiquitous in the United States, and it is marketed to a growing extent outside the U.S. Upon the release of Godrej’s products in India, for example, between 1.5 and 2 million sales were reported in the first week. While many regions are beginning to embrace hand sanitizer, the Muslim world has shown reluctance in adopting it. Some researchers posit that the designation of alcohol as haraam or sinful has led to public perception of alcoholic products as taboo. Regardless, WHO is optimistic about eventual acceptance, noting that for cleaners and perfumes, “…alcoholic content is permitted because it is not for ingestion.”

Function and Effectiveness
Deodorant has both a manifest and a latent function. Its manifest function is to prevent odor and, in some cases, perspiration. Its latent function is to enhance social acceptability. It readily accomplishes its manifest function, but may not accomplish its latent function, at least as characterized by marketing materials. The claims implied in commercials by Old Spice and Axe, for example, are extreme and not substantiated by research. Specifically, their assertion that not wearing deodorant results in noticeable body odor and crippled social acceptability, while wearing deodorant makes one highly alluring, is dubious.

Perceptions and Practices
Deodorant use was rare 100 years ago, but is today ubiquitous in western societies. However, this ubiquity is not necessarily commensurate with its necessity. Two percent of the British population does not need to wear deodorant because they have a gene that does not create odor in their armpits, but an estimated three-fourths of them still use deodorant due to social norms. The New York Times and Esquire have also shown deodorant use to be a product of these norms, rather than necessity, by studying people who ceased using it: in many cases, others did not notice that their deodorant use stopped.

This widespread use is not worldwide. In northeast Asia, where an estimated 99% of the population have the aforementioned gene, deodorant use hovers around seven-percent. This statistic may increase as deodorant manufacturers move into the Asian market, however.

Hand Sanitizer
According to Gojo, hand sanitizer has its origin in the 1940’s when founder Goldie Lippman developed a hand cleaner to remove tough residue from working in a rubber tire plant. This cleaner was developed and marketed for several decades, primarily to people who worked in auto body shops and factories. While a former nursing student at Cal Bakersfield, Lupe Hernandez, claims to have invented hand sanitizer in 1966, the most well-known hand sanitizer on the market is Gojo’s Purell. Released in 1988, Purell kills bacteria on the hands, which previous products did not do.

The overuse of hand sanitizer has become a source of concern. A study of long-term care facilities in northern New England showed that using alcohol based hand sanitizers instead of soap and water actually leads to more norovirus outbreaks. CDC conducted a study that concluded "overall, studies suggest that proper hand washing with soap and running water for at least 20 seconds is the most effective way to reduce norovirus contamination on the hands, whereas hand sanitizers might serve as an effective adjunct in between proper handwashings but should not be considered a substitute for soap and water handwashing." This shows that this technology is not a panacea for maintaining clean hands and preventing the spread of disease, even though many expect hand sanitizer to be able to serve as a replacement for traditional soap and water handwashing.

Early History
Humans have tried to cover up their scent since antiquity. Ancient Egyptian women used scented wax that melted throughout the day and the ancient Greeks and Romans used scented oils and perfumes to mask unpleasant odors. The first chemically-based deodorant, Mum, appeared in 1888. The first antiperspirant, Everdry, was introduced soon afterwards. Neither product caught on; they were unpleasant to use, with side effects including a stinging sensation on the skin and acid burns through clothing. Women who wanted to mask their perspiration instead used rubber or cotton pads called "dress shields" that were placed in the armpit. Men typically made no attempt to hide sweat or body odor.

Odorono
The first commercially successful deodorant was created by a Cincinnati high school student named Edna Murphy. The daughter of a surgeon who invented an Aluminum Chloride solution to prevent perspiration during surgery, Murphy decided to commercialize the formula into a product called "Odorono". Sales were slow until 1912, when her booth at an Atlantic City exposition brought the product to the public's attention as an antiperspirant. Sales immediately increased and orders came in from as far as England and China.

Advertising Shift
Odorono sales plateaued in 1918, following years of growth. The J. Walter Thompson Company, Odorono's marketing agency, conducted a survey to find out why. They discovered that though women knew of Odorono, two thirds felt they had no need for it. James Young, the man that ran the account, devised a plan that would change the marketing world: instead of billing the product as a medical treatment, he presented it as a beauty aid. The resulting ad, "Within the Curve of a Woman's Arm", ran in Ladies Home Journal in 1919. Considered sensational for the time, the ad brought up the taboo topic of body odor, suggesting that the reader might be ignorant of her need for deodorant. 200 readers of Ladies Home Journal canceled their subscriptions in protest, but Odororno sales rose by 112% that year. Young continued this strategy throughout the 1920s, and by 1927, Odorono annual sales reached one million dollars.

Men's Deodorant
While sales for women's deodorant skyrocketed, the male market was untouched. Body odor fit within societal ideals of masculinity so advertisers could not apply the same marketing they used for women. The first male deodorant, Top-Flite, was introduced in 1935. Advertisers continued to prey upon insecurities, but in male-specific ways. Ads showed men losing their jobs due to odor, or women refusing to go on a second date. Marketers realized that men's deodorant needed to be hyper-masculine to overcome the stigma of the original women's product. For instance, the makers of the male deodorant Sea-Forth sold their product in ceramic containers that looked like whisky jugs, as the company owner claimed that he couldn't think of anything more masculine. Male deodorant use increased gradually, but the perceived need to make it seem masculine can still be seen in over-the-top and highly sexualized ads today.

Modern Usage
Deodorant sales have consistently climbed since the early 1900s. In 2012, sales reached 1.3 billion dollars, and over 90% of Americans used some sort of deodorant or antiperspirant. The method of application has also changed with time. While products like Odorono were swabbed on, the invention of roll-on and aerosol deodorants in the 1950s made application much easier. Stick deodorants are now the most popular type, having gained market share after fears over CFCs in aerosol cans emerged in the late 1970s.

Participants: Hand Sanitizer
In the United States, the social interface of hand sanitizers is largely dominated by participants advocating the general use of hand sanitizers. Other participants, often authoritative regulatory bodies, caution against the dangers of hand sanitizer overuse. There are also individual participants who adamantly oppose hand sanitizers.

Advocates
Hand sanitizer producers, such as Gojo and Vi-Jon (producers of brands Purell and Germ-X, respectively), are major participants in favor of the use of hand sanitizer. They are financially incentivized as their businesses depend on the success of the product and use advertisements to enhance consumer demand. Shown on the right is an example of an advertisement from the brand Protex that clearly depicts their agenda, as they use a gross pictorial exaggeration of a germ-filled hand to persuade consumers to use hand sanitizer. These participants have found other ways of promoting their product. For example, Gojo supported a study that showed a decrease in school absenteeism due to use of hand sanitizer.

Global health authorities such as CDC and WHO both include hand sanitizers in their suggested hand hygiene guidelines. Recognition from these global authorities provides hand sanitizer manufacturers with consumer trust. On the producers’ websites, CDC and WHO support of hand sanitizer use is clearly presented. Furthermore, these companies have made sure to definitively address the concerns of hand sanitizer opponents on their FAQ pages.

Opponents
Organized health groups, such as Mayo Clinic, caution against the dangers associated with the excessive use of hand sanitizers. Other participants are individuals who warn against the potential dangers of hand sanitizers. For example, an article in the New York Times warned consumers that hand sanitizers with less than 60% ethanol are ineffective at killing germs and should be avoided. An article in the Houston Chronicle reports several instances where children consumed hand sanitizer and suffered intoxication, although there were "no reported deaths or other major medical outcomes."

While there are health organizations that discourage the excessive use of hand sanitizers, there are, however, no existing organized groups that are entirely anti-hand sanitizer. The strongest opposition to hand sanitizers consists primarily of individuals who voice their opinions via health or science blogs or newspaper articles. These individuals are concerned about the immediate dangers, overall ineffectiveness, and long-term risks associated with hand sanitizer use. As an example, one individual claims hand sanitizer use is correlated to autism, while another claims that hand sanitizers kill not only germs but also human cells.

Participants: Deodorant
Whether one is an advocate or opponent of deodorant is often dependent on whether he or she is affected negatively or positively by its use. This is related to the economic idea of externalities. If one is affected by the negative externalities of deodorant use, they tend to be opposed to it. If one is affected by the positive externalities of deodorant use, they tend to be for it. These participants often differ from the actual users.

Advocates
Unsurprisingly, advocates of deodorant use are often those who are affected by its lack of use in children going through puberty. Teachers have been documented making appeals to parents to instruct their children to use the product. Parents themselves are typically in favor of deodorant, but unsure when their children ought to begin using it.

Other deodorant proponents include manufacturers and advertisers. These advocates are often highly vocal and willing to spend a great deal of money promoting their views. In 2009 alone, Old Spice and Axe spent 36 million and 125 million respectively on advertising. Companies also have websites to actively oppose opponents, especially those that raise health-related concerns, and promote reasons to use deodorant.

Opponents
Some of the strongest opponents to deodorant use are schools. Because of marketing and advertising efforts on the part of deodorant manufacturers, young males have begun to overuse deodorant. This creates distractions in the classroom that can be as inconsequential as overbearing scents or as life-changing as hospitalizations. Young men spray themselves and each other with aerosol deodorant that creates breathing issues for some students and may get in eyes. Schools have trouble dealing with this problem, since there is no established "appropriate" amount of deodorant that they may use as a standard. However, some have nonetheless limited its use during the school day.

There is also opposition to the use of deodorant brands that include an antiperspirant, based on fear of cancer and Alzheimer's. In particular, there is fear that because breast cancer frequently develops near the armpit, there is a link between it and the aluminum in antiperspirants. Additionally, because Alzheimer's has been linked with high levels of aluminum, antiperspirant use has also been hypothesized to cause Alzheimer's. However, in both of these cases, further studies have concluded that there is a weak link, if any.

Scare Tactics
Both products gain popularity by implying that a failure to use them will result in negative outcomes. Hand sanitizer assures customers that bacteria are everywhere and that they or their children will become sick if they fail to sanitize their hands. Deodorant marketers, particularly in the 1920s and 1930s, have warned users that their body odor may be causing others to dislike them, even if they themselves can't smell it.

The Power of Habit
Over 90% of human behavior is habitual. Once a customer begins using either product on a regular basis when in a particular situation, it is likely that they will continue to use it in that situation in the future. For example, if one always uses hand sanitizer before eating their lunch, this behavior will become habit that will lead to purchasing more hand sanitizer with no need for persuasion on the part of marketers. The same may occur for an individual that applies deodorant each morning.

Negative Reinforcement
Both products reward users via negative reinforcement; i.e., they let users avoid something undesirable. An important characteristic of such reinforcement is that it can prevent future learning. For example, if a laboratory dog learns to avert a shock by moving to a different part of its enclosure when a light turns on, it will always do so when the light appears, and thus never learn what would have happened had it not done so. Similarly, an individual who always wears deodorant to avoid smelling bad will never learn whether the product is actually necessary for them to avoid body odor, and a hand sanitizer user will never learn if they would have gotten sick had they not sanitized their hands.

Lack of Testability
Because the onset of illness is correlated with a number of different factors, it may be difficult for an individual to determine whether hand sanitizer is effective at preventing sickness. Along the same lines, because of olfactory fatigue, it may be difficult for individuals to determine if they possess mild body odor. As a result, the true utility of both products remains difficult for users to verify. This allows both preconceived notions and beliefs instilled by advertising to remain unchallenged.

Inherent and Elective Hand Hygiene
Inherent hand hygiene is the instinctive need to clean one's hands. For example, people's hands will typically feel unclean after using the restroom, and they will wash them. Inherent hand hygiene is typically developed in approximately the first ten years of life, and it is often difficult to effect change in cultures with poor inherent hand hygiene practices. Inherent hand hygiene is developed as a result of the formative effect, which states "how we become accustomed to acting in the present is how we are likely to act in the future."

Elective hand hygiene refers to consciously cleaning one's hands. It is basically any hand hygiene practices that are not inherent. If a hospital enforces a new rule that requires nurses to wash their hands before handling patients, for example, this can be considered elective hand hygiene.

Germ Panic
Historians identify two germ "panics" that occurred in the US. During these panics, our modern inherent hand hygiene culture developed. The first germ panic was from 1900 to 1940, and it was a reaction to scientific advancements made in understanding germs and disease. Germ theory, which was fleshed out and developed in the late 19th century, brought about changes to plumbing, medical care, and general hygiene practices. This was probably the more important of the two panics. Much of modern hygiene practice can be attributed to this time period.

The second panic began in 1985 and is ongoing. Many believe this panic is a reaction to the AIDS epidemic, superbugs, and possibly even biological weapons. This panic is more tame in its effects when compared with the first germ panic, but it is evident in modern germ-averse culture.

Companies and marketers took advantage of both of these panics by creating germ fighting products. Some of these played to the public's germ fears and had little function, but many were effective in helping fight disease and infection rates. Hand sanitizer can be viewed as a product of this second germ panic.

Sanophilic Culture
The term "sanophilic," or germ-averse, sanitary and hygiene-conscious, can be used to describe our modern culture. This is not as severe as Mysophobia, also known as Germophobia, which indicates a sharper, more unhealthy fear of germs. Many aspects of this sanophilia are beneficial. WHO launched its Clean Your Hands annual global campaign in 2009, noting that cleaner hand hygiene is one of the lowest-hanging fruit to address in decreasing the infection rate of hospital visits. One study over four years at the University of Geneva hospitals, for example, found that improving hand hygiene compliance from 48% to 66% led to a 16.9% drop in hospital infection rates. The primary method of the study was increasing the use of hand disinfecting products.

However, many researchers believe our germ-cleansing culture has negative consequences. According to the hygiene hypothesis, which has taken shape in the past decade, the spike in allergies and other immune disorders over the past century can be attributed to children growing up in modern, sterile, germ-free environments. The hypothesis purports that our immune systems require exposure to bacteria and pathogens at a young age in order to be properly "trained." A lack of this exposure will lead to a malfunctioning immune system that attacks harmless particles. Though the hypothesis is still an area of ongoing research, there is some general consensus among scientists that our early lack of exposure to bacteria plays some role in the rise of these diseases.

Appeal to Major Drives
According to Maslow and others, not all human drives are equally potent; the desire for social power is less potent than the desire for food and water, for example. Consistent with this, deodorant usage increased sharply when marketing efforts shifted towards targeting social insecurity or a desire to remain gainfully employed, rather than a desire for personal hygiene. More recently, many deodorant advertisements have shifted towards making extreme promises of sexual attractiveness, as in the Old Spice and Axe commercials mentioned above. In all cases, the appeal is not to desires to fight odor itself, but to more fundamental and powerful drives that create more impetus to buy the product.

Big But Believable Claims
As described, deodorant marketing does not just target powerful human drives, but often makes extreme claims regarding the extent to which the product will help one fulfill them. Importantly, however, these claims remain plausible (at least in a tempered form) due to the aforementioned unverifiability of the product's effectiveness. That is, Odorono may not actually be necessary to avoid social rejection (for example), but such rejection is a severe outcome and it is plausible that Odorono could prevent it. It is therefore reasonable for a consumer to buy it, even if not skeptical of its benefits.

An analogy can be made to the notion of expected value in probability theory. If one has a 10% chance of avoiding a loss of $20, this has an "expected value" of 10% * $20 = $2. Similarly, if deodorant offers even a small chance of avoiding social ostracism (a terrible outcome), then the utility it imparts (a small chance of avoiding something terrible) is quite large.

Deodorant as a Dominant Strategy
As previously mentioned, deodorant was not always seen as necessary by women and was seen as effeminate and undesirable by men. However, the private nature of deodorant usage makes its application a winning strategy for individuals who believe that it has a benefit. Put simply, no one knows if one uses deodorant (so there's no social cost for using it), but others do know if one fails to use it and smells (so there may be a social cost for not using it). Monetary incentives aside, this means that one is always at least as well off wearing it as not wearing it. This is simple to see if one spells out each case (Table 1). In game theoretic terms, this makes wearing deodorant a dominant strategy.