Differences in observed and self-reported compliance with the 5 moments for hand hygiene as a function of healthcare workers' empathy

Compliance and Performance of Hand Hygiene in Dutch General Practice Offices Using Electronic Dispensers

INTRODUCTION

One of the most effective measures for the reduction and prevention of healthcare-associated infections (HAI) is hand hygiene (HH). Covert direct observation of HH is difficult to realize in general practice office (GPO). The World Health Organization recognizes electronic monitoring as a form of measuring product use and estimating compliance. This is the first study to monitor HH performance electronically in Dutch GPOs.

OBJECTIVES

The main aim of this study was to evaluate HH compliance in general practice offices.

METHODS

An observational study was conducted at 4 Dutch GPOs between 2019 and 2021. We measured HH compliance using data on HH events (HHE) from alcohol-based hand rub (ABHR) dispensers with a built-in electronic counter. Daily HH opportunities were calculated according to the 'Five Moments for Hand Hygiene' based on the continuously documented activities using general practitioners (GPs) patient electronic dossier systems.

RESULTS

In total, hand hygiene was performed during 1786 of the estimated 4322 opportunities (41%). HH compliance for the general practitioners, practice assistants, and nurse practitioners was 38%, 51%, and 43%, respectively. The overall HH compliance within the same GPOs was 42% pre-pandemic and rose to 56% during the pandemic. The overall mean volume of ABHR was 2.44 ml, varying per HHE between 1.91 to 2.55 ml. The mean volume of ABHR measured before and during the pandemic rose from 2.55 ml to 2.81 ml. The overall self-reported compliance was 86% and was highest among nurse practitioners.

CONCLUSIONS

Hand hygiene compliance among HCWs in Dutch GPOs was found to be 41%, with general practitioners having the lowest compliance and practice assistants the highest compliance. While the mean volume of ABHR used per HHE seems appropriate, directed observations would be needed to ensure that an adequate hand-rub technique was used to cover the whole hand. Multi-modal interventions are needed to improve HH-compliance and stimulate the switch to ABHR with in the Dutch general practice office.

Self-reported frequency of handwashing among pet and non-pet owners in different situations: results of four surveys of the general adult population in Germany

BACKGROUND

Zoonotic diseases are partly associated with pets. However, data is sparse on pet owners' compliance with preventive recommendations. Also, research focuses on self-reports, which are subject to overestimation biases, i.e., assessing one's actual performance to be better than it is. One reason is task difficulty: people tend to overestimate their performance on hard tasks. Regarding handwashing, compliance after touching animals should be harder for pet vs. non-pet owners due to the number of opportunities. This study tests for differences in self-reported handwashing between pet and non-pet owners, and explores reasons for non-compliance. Thus, it aims to provide insights on how to improve self-report behavioral assessment methods in public health and One Health research.

METHODS

Data from cross-sectional computer-assisted telephone surveys of the general population in Germany aged 16-85 years in 2012, 2014, 2017 and 2019 were analyzed (N = 15,559; response rate: 45.9%). Handwashing frequency was operationalized for nine indications using the item "How often do you wash your hands in each of the following situations: 'never/almost never', 'seldom', 'mostly', 'always/almost always'?", with the latter defining compliance. In 2017 and 2019, those reporting to 'never/almost never' or 'rarely' wash hands were questioned regarding possible reasons. Chi²-tests, Cohen's d's and multiple logistic regressions were used.

RESULTS

Pet and non-pet owners differed in self-reported handwashing compliance primarily in the indication "After touching animals" (35.5% vs. 55.7%, effect size: d = 0.45). For other indications (e.g., "After using the toilet"), differences were insignificant (≤|3.6%|, d ≤ 0.11). Additionally, 79% of pet owners who rarely or almost never washed their hands after touching animals felt it is not necessary (non-pet owners: 67.1%; d = 0.34). Reporting to not have an appropriate washing facility available was rarer among pet owners (44.5% vs. 63%, d = 0.41). Differences regarding other reasons were trivial (d ≤ 0.16), including "It takes too long" (16.9 vs. 13.3%; p = .138 in multiple regression).

CONCLUSIONS

Study limitations include that due to unknown true compliance, over- and underestimations have to be inferred. Yet, that the only substantial difference between pet and non-pet owners pertained to "After touching animals" suggests such effects. While pet owners obviously adjust for task difficulty, the likely residual overestimation should be reduced by measures using script-based covert recall or survey items with response categories constructed to better resemble subjective compliance ratios.

Workflows and locations matter - insights from electronic hand hygiene monitoring into the use of hand rub dispensers across diverse hospital wards

Background

While healthcare-associated infections (HAIs) affect approximately 3.2-6.5% of hospitalised patients in the US and Europe, improving hand hygiene (HH) could reduce HAI rates. Investigating HH is time-consuming and not always objective, and comprehensive, unbiased data is needed to develop effective strategies. Using electronic tools can provide new and detailed insights on the determinants of HH.

Aim

To evaluate location-dependent usage of wall-mounted dispensers (WMDs) and point-of-care dispensers (POCs) using an electronic HH recording system.

Methods

In this retrospective study, hand rub volumes were anonymously recorded for 931,446 disinfections from 17 wards in nine German hospitals using the electronic monitoring system NosoEx®. Number of disinfections and rub volumes of WMDs/POCs by ward and room type were analysed.

Findings

Generally, WMDs were most prevalent. With >3 dispensers per bed and >20 disinfections per patient day, availability and use were highest in intensive care (ICU) and intermediate care (IMC), but here rub volumes from WMDs were lowest (∼2.0 mL). Although most dispensers are located in patient rooms (∼42%), they are more frequently used in hallways. In surgical ICUs, dispensers are often used in patient rooms, where contact with open wounds is common. About 3.6 mL of hand rub is used per disinfection in treatment rooms, the highest volume of all room types.

Conclusion

Dispenser use was dependent on location, room type, ward specialisation and workflow. Optimising the location of hand rub dispensers (HRDs)s is not the only solution to improve HH, but can help reduce inconvenience, achieve more ergonomic workflows and better meet user needs.

Examining outpatients' hand hygiene behaviour and its relation to COVID-19 infection prevention measures

BACKGROUND

The increasing demand for outpatient care is associated with a higher risk of infection transmission in these settings. However, there is limited research on infection prevention and control practices in ambulatory clinics, and none focuses on patients.

AIM

To examine outpatients' hand hygiene behaviours, their determinants, and their associations with other infection prevention measures during the COVID-19 pandemic.

METHODS

We observed the hand hygiene behaviour of one cohort of patients in one outpatient clinic and surveyed a separate sample in five clinics about their hand hygiene practice in outpatient facilities. A questionnaire based on the Theoretical Domains Framework (TDF) was used to examine predictors of the behaviour. Moreover, patients indicated their compliance with COVID-19 infection prevention measures, vaccination status, disease risk perception, and vaccine hesitancy.

FINDINGS

Observed hand hygiene rates among 618 patients were low (12.8%), while 67.3% of the 300 surveyed patients indicated sanitizing their hands upon entering the clinic. The TDF domains 'memory, attention, and decision processes' and 'emotions' significantly predicted both current (today's) and general hand hygiene behaviour in outpatient clinics. Hand hygiene behaviour and compliance with COVID-19 infection prevention showed a positive association; however, no significant connection was found with patients' vaccination status, suggesting different behavioural motivators.

CONCLUSION

Hand hygiene among outpatients should be improved through interventions focusing on helping patients remember to clean their hands. More research on infection prevention in outpatient facilities is needed to ensure patient safety.

Exploring the responses of smallscale poultry keepers to avian influenza regulations and guidance in the United Kingdom, with recommendations for improved biosecurity messaging

Understanding how smallscale ('backyard') poultry keepers interpret and respond to governmental directives designed to reduce the transmission of highly pathogenic avian influenza (HPAI) is of paramount importance in preparing for future HPAI outbreaks. Qualitative insights from open questions in an online survey conducted during the 2021-22 HPAI season (1,559 responses) shed light on smallscale poultry keepers' understanding of, and responses to, governmental directives to control HPAI exposure and onwards transmission. A follow-up participatory workshop (21 participants) explored the HPAI-related information sources used by smallscale poultry keepers, their trust in these sources, perceptions of HPAI-related risk, and interpretation of, opinions on and adherence to government regulations and communications regarding biosecurity and housing measures. This paper draws on a multi-scale behaviour change model to explore barriers to compliance with HPAI-related regulations. Insights from behaviour settings theory reveal how poultry-keeping settings and routines might be 'disrupted' and 're-configured' to improve long-term biosecurity and reduce the risk of HPAI exposure. The findings highlight the need for HPAI-related guidance that is tailored to smallscale poultry keepers. This guidance should include clear action points and simple, practical, affordable and sustainable suggestions for improving compliance with biosecurity measures.

The language of vaccination campaigns during COVID-19

Understanding what makes communication effective when designing public health messages is of key importance. This applies in particular to vaccination campaigns, which aim to encourage vaccine uptake and respond to vaccine hesitancy and dispel any myth or misinformation. This paper explores the ways in which the governments of Great Britain (England, Scotland and Wales) promoted COVID-19 vaccination as a first-line strategy and studies health message effectiveness by examining the language of official vaccination campaigns, vaccine uptake across the different nations and the health message preferences of unvaccinated and vaccine sceptic individuals. The study considers communications beginning at the first lockdown until the point when daily COVID-19 updates ended for each nation. A corpus linguistic analysis of official government COVID-19 updates is combined with a qualitative examination of the expression of evaluation in governmental discourses, feedback from a Public Involvement Panel and insights from a nationally representative survey of adults in Great Britain to explore message production and reception. Fully vaccinated, unvaccinated and sceptic respondents showed similar health messaging preferences and perceptions of health communication efficacy, but unvaccinated and sceptic participants reported lower levels of compliance for all health messages considered. These results suggest that issues in health communication are not limited to vaccination hesitancy, and that in the future, successful vaccination campaigns need to address the determining factors of public attitudes and beliefs besides communication strategies.

Validity of self-reported compliance and behavioural determinants of observed compliance: an application of the COM-B hand hygiene questionnaire in nine Dutch hospitals

BACKGROUND

Hand hygiene compliance (HHC) can be influenced by behavioural determinants, but knowledge on this is still scarce. The Capability, Opportunity, Motivation-Behaviour (COM-B) hand hygiene questionnaire was developed by Lydon et al. to gain insight in self-reported behavioural determinants and self-reported HHC.

AIM

To determine the validity of self-reported HHC, by using the COM-B questionnaire. To investigate the influence of self-reported behavioural determinants on observed HHC, while taking environmental determinants into account.

METHODS

Cross-sectional study, from September to November 2019, in nine hospitals in the Netherlands. Healthcare workers (HCW) filled in the COM-B questionnaire and direct hand hygiene observations were performed. In addition, information on environmental determinants (workload, ward category, type of hospital, infrastructure of a ward) was collected. Validity of self-reported HHC was determined by the intraclass correlation coefficient (ICC). Univariable and multivariable regression analyses were performed to investigate the relation between behavioural- and environmental determinants and observed HHC.

FINDINGS

The ICC showed no association between self-reported HHC and observed HHC (0.04 (-0.14, 0.21)). In the univariable regression analyses, ward category and the subscales opportunity and motivation were significantly associated with observed HHC. In the multivariable regression analysis, only ward category and motivation remained significant.

CONCLUSION

The self-reported HHC is not a valid substitute for direct hand hygiene observations. The behavioural determinant motivation was significantly associated with HCC, while almost none of the environmental determinants had an effect on observed HHC. In further development of hand hygiene interventions, increasing the intrinsic motivation of HCW should get extra attention.

Do task and item difficulty affect overestimation of one's hand hygiene compliance? A cross-sectional survey of physicians and nurses in surgical clinics of six hospitals in Germany

BACKGROUND

One barrier to hand hygiene compliance is overestimation of one's own performance. Overconfidence research shows that overestimation tends to be higher for difficult tasks, which suggests that the magnitude of overestimation also depends on how it is assessed. Thus, we tested the hypothesis that overestimation was stronger for hand hygiene indications with low compliance (i.e., high difficulty), and the hypothesis that self-reported overall compliance based on a single item is higher than based on "5 Moments of Hand Hygiene" (WHO-5) items, since the single item implies an aggregation across indications.

METHODS

In the WACH trial (German Clinical Trials Register [DRKS] ID: DRKS00015502), a questionnaire survey was conducted among physicians and nurses in nine surgical clinics (general/visceral surgery or orthopedics/trauma surgery) of six German hospitals. Self-reported compliance was assessed both by a single item and the WHO-5-items using percentage scales. These were compared with each other and with direct observations. Relative frequencies of the WHO-5 indications used to calculate the WHO-5-based self-reported overall compliance rate were estimated by a systematized review of the literature (see appendix). In analysis, t-tests, Chi2-tests and multiple linear regressions were used.

RESULTS

Ninety-three physicians (response rate: 28.4%) and 225 nurses (30.4%) participated. Significant compliance differences between physicians and nurses were found for direct observations and were in favor of nurses, while no such differences were found for self-reports. Across the WHO-5, overestimation showed inverse correlations with observed compliance (physicians: r = -0.88, p = 0.049; nurses: r = -0.81, p = 0.093). Support for the hypothesis that the self-reported overall compliance based on one item is higher than that based on WHO-5 items was found for physicians (M = 87.2 vs. 84.1%, p = 0.041; nurses: 84.4 vs. 85.5%, p = 0.296). Exploratory analyses showed that this effect was confined to orthopedic/trauma surgeons (89.9 vs. 81.7%, p = 0.006).

CONCLUSION

Among physicians, results indicate stronger hand hygiene overestimation for low-compliance indications, and when measurements are based on a single item versus the five WHO-5 items. For practice, results contribute to infection prevention and control's understanding of overestimation as a psychological mechanism that is relevant to professional hand hygiene.