Improving hand hygiene compliance in healthcare settings using behavior change theories: reflections

Disease Information Through Comics: A Graphic Option for Health Education

This paper presents a critical interpretive synthesis of research on the efficacy of comics in educating consumers on communicable diseases. Using this review methodology, the authors drew from empirical as well as non-empirical literature to develop a theoretical framework exploring the implications of comics' combination of images and text to communicate this health promoting information. The authors examined selected works' alignment with the four motivational components of Keller's ARCS Model (Attention, Relevance, Confidence, and Satisfaction) to evaluate research within the context of learner motivation. Findings of this research indicate comics offer a useful method for providing consumer health education, particularly regarding topics that individuals may have difficulty in discussing openly.

A Cohort Study of Seroprevalence of Antibodies Against SARS-CoV-2 Infection Among Healthcare Workers at a Tertiary Hospital in Saudi Arabia

Background

The nature of the healthcare workers’ jobs standing at the frontline against the coronavirus disease 2019 (COVID-19) puts them at a higher risk of unknowingly contracting the disease and potentially contributing to the spread. This study aims to assess the overall positive seroconversion prevalence of SARS-CoV-2.

Methods

This is a longitudinal cohort study of healthcare workers at Johns Hopkins Aramco Healthcare (JHAH). JHAH is a tertiary hospital located in Dhahran serving patients in several districts in the Eastern Province of Saudi Arabia. Participants were recruited between June and December 2020. Each participant had a serology blood test and completed the World Health Organization’s risk factor assessment questionnaire.

Results

This study included 682 participants working in JHAH, representing 15.7% of our population. Out of the 682 participants, 15.2% had a positive SARS-CoV-2 rt-PCR before taking part in the study. However, only 87 tested positive for SARS-CoV-2 antibodies, a prevalence of 12.7% of all participants. Out of the 87 positives for SARS-CoV-2 antibodies, 17 participants never tested positive for COVID-19 rt-PCR, a prevalence of 2.9%. Moreover, not properly using alcohol-based hand rub or soap and water after the risk of body fluid exposure and wearing personal protective equipment when indicated were found to be statistically significant to having a positive SARS-CoV-2 IgG assay.

Conclusion

Positive seroconversion rate was considerably low during the first wave of COVID-19 amongst JHAH’s healthcare workers and similar to other healthcare organizations in Saudi Arabia. Seropositivity correlated significantly with following infection prevention and control recommendations.

Clinicaltrials.gov Identifier

NCT04469647.

Improvement of hand hygiene compliance among health care workers in intensive care units

Aim

Hand hygiene (HH) is an essential component in preventing healthcare associated infections. The purpose of this study was to evaluate HH compliance among health care workers (HCWs) in intensive care units at Beni-Suef university hospital, Egypt before and after an intervention educational program.

Methods

Data were collected by using the standardized WHO method for direct observation ‘‘Five moments for HH’’ approach. Observations were conducted in six ICUs before intervention (March to April 2017) and after the intervention (July to August 2017). The study included 608 opportunities (observations) among 177 HCWs collected before and 673 opportunities among 163 HCWs collected after the intervention.

Results

Overall HH compliance increased significantly from 30.9 (95% CI: 27.2-34.6%) before intervention to 69.5 (95% CI: 65.2-72.6%) post intervention; with the highest HH compliance rate among nurses compared to physicians and workers (P = 0.001). Significantly higher HH compliance rates were observed after body fluid exposure, before aseptic procedures, and after patient contact compared to before patient contact and after patient surrounding contact (P = 0.001). In binary logistic regression analyses a statistically significant difference was shown (P = 0.047) for HH compliance among events before and after patient contact (OR = 1.399, 95% CI: 1.004-1.948).

Conclusions

The interventional educational program improved the HH compliance among ICUs-HCWs at Beni-Suef university hospital. The hospital should conduct monthly observational monitoring for the ICUs units sharing the findings to spread best practices. Provision of sustained training programs to help efficient and effective HH for care delivery is mandatory.

Cleaning Staff's Attitudes about Hand Hygiene in a Metropolitan Hospital in Australia: A Qualitative Study

Background: In 2009, the National Hand Hygiene Initiative (NHHI) was implemented in hospitals across Australia with the aim of improving hand hygiene practices and reducing healthcare-associated infections. Audits conducted post-implementation showed the lowest rates of compliance with hand hygiene practices are among operational staff including hospital cleaners. There is limited information about hand hygiene issues in hospital cleaners to inform development of evidence-based interventions to improve hand hygiene compliance in this group. Aim: This qualitative study was undertaken to explore the attitudes of hospital cleaning staff regarding hand hygiene and the National Hand Hygiene Initiative. Methodology: Focus groups were conducted with 12 cleaning staff at a large Australian hospital implementing the National Hand Hygiene Initiative. Findings: Hospital cleaners recognise the importance of hand hygiene in preventing healthcare-associated infections. Cleaners cite peer support, leadership, and the recognition and reward of those excelling in hand hygiene as strong motivators. Barriers to optimal hand hygiene practice include the presence of multiple conflicting guidelines, hand hygiene “overload” and a lack of contextualised education programs. This exploratory qualitative study reveals three themes about attitudes of hospital cleaning staff towards hand hygiene. These themes are: (1) “The culture of hand hygiene: It’s drummed into us”; (2) “Reminders and promotion for hand hygiene: We just need a big ‘Please wash your hands’ sign”; and (3) “The personal value of hand hygiene: Like he said, it’s second nature to us”. Conclusion: Hand-hygiene messages and training need to be more consistent and contextualised to achieve improvements in hand hygiene practices in hospital cleaning staff in Australia.

Introduction of New Theory for Hand Hygiene Surveillance: Healthcare Environment Theory

BACKGROUND AND PURPOSE

The purpose of this article is to introduce a theoretical foundation, the healthcare environment theory (HET), tested in a quantitative, cross-sectional, overt observational study measuring the association of demographic variables with consistent hand hygiene compliance of the ICU nurse.

METHODS

Six environments found in a hospital ICU setting (family, church, work, administration, community, and culture) work bi-directionally to influence and be influenced by the nurse, simultaneously influencing each of the other environments in a multidirectional manner. The HET was used as the theoretical foundation for a study, which included a convenience sample of registered nurses (RNs) from five ICUs (64 participating RNs) in four hospitals in Texas who were observed for a total of 18 days (144 hours). The desired sample size of 613 hand hygiene opportunities for each ICU was obtained in 3 days of observation at 3 ICUs, 4 days in one ICU, and 5 days in one ICU. The six environments were used to support the results observed.

RESULTS

Through the variables of age and having children, hand hygiene rates were influenced by the family environment. Community environment was associated with a change in hand hygiene behavior in hospital hand hygiene rates in regards to age of the nurse. Younger nurses had higher hand hygiene compliance rates than older nurses.

IMPLICATIONS FOR PRACTICE

The different hospital environments surrounding the nurse can be used to explain hand hygiene compliance rates in association with demographic variables.

Differences in psychosocial determinants of hand hygiene between health care professional groups: Insights from a mixed-methods analysis

BACKGROUND

Good hand hygiene (HH) prevents health care-associated infections. We compared psychosocial and organizational factors associated with HH compliance and perceived need for improvement among physicians, nurses, and allied health professionals (AHPs).

METHODS

We conducted a mixed-methods study in a 1,600-bed adult tertiary-care hospital in Singapore. Seven focus group discussions were conducted and data were analyzed using thematic analysis. The subsequent cross-sectional survey involved 1,064 staff members. Principal components analysis was performed to derive the latent factor structure that was applied in multivariable analyses.

RESULTS

All staff members acknowledged that HH was an integral part of their work, but were noncompliant due to competing priorities. Physicians were forgetful but appreciated reminders. Nurses were intrinsically motivated for HH. After adjusting for gender, staff category, seniority, and dermatitis history, having positive knowledge-attitudes-behaviors (odds ratio [OR], 1.44; 95% confidence interval [CI], 1.23-1.69), personal motivators-enablers (OR, 1.60; 95% CI, 1.38-1.86), and emotional motivators (OR, 1.62; 95% CI 1.40-1.88) were positively associated with good HH compliance. Women (OR, 3.91; 95% CI, 1.37-11.11), seniors (OR, 2.88; 95% CI, 1.08-7.68), nurses (OR, 4.05; 95% CI, 1.51-10.87), and staff with personal motivators-enablers for HH (OR, 1.60; 95% CI, 1.08-2.37) were more likely to perceive a need for improvement.

CONCLUSIONS

Factors influencing self-reported HH differed between health care professional groups. Group-specific interventions are needed to improve compliance.

Hand hygiene knowledge of primary health care workers in Abha city, South Western Saudi Arabia

Purpose:

The aim of this is to find out the hand hygiene (HH) knowledge among primary health care workers (PHCWs) in Abha health district, southwestern Saudi Arabia.

Methods:

Data were collected through an anonymous self-administered questionnaire. The questionnaire was based on a WHO “Knowledge Questionnaire for Health Care Workers.”

Results:

The study included 478 PHCWs (239 males and 239 females). The sample included 186 physicians, 212 nurses, and 80 technicians. The highest proportion receiving formal training was nurses (82.1%). Females (77.4%) received significantly more training than males (70.3%). Only 59.2% (283) of the HCWs properly identified unclean hands of HCWs as the main route of the cross. Only 26.4% (126) of the HCWs properly identified germs already present on or within the patient as the most frequent source of pathogens in a health-care facility. Only 54.8% (262) of HCWs properly identified 20 s as the minimal time needed for alcohol-based hand rub to kill most germs on hands.

Conclusion:

The study revealed gaps in the knowledge regarding HH. To promote HH at primary health care setting, WHO bundle of multimodal strategies should be adopted including system change; training/education; evaluation and feedback; reminders in the workplace; and institutional safety climate.

Identifying behavioural determinants for interventions to increase handwashing practices among primary school children in rural Burundi and urban Zimbabwe

BACKGROUND

This article presents the development of a school handwashing programme in two different sub-Saharan countries that applies the RANAS (risk, attitudes, norms, ability, and self-regulation) systematic approach to behaviour change.

METHODS

Interviews were conducted with 669 children enrolled in 20 primary schools in Burundi and 524 children in 20 primary schools in Zimbabwe. Regression analyses were used to assess the influence of the RANAS behavioural determinants on reported handwashing frequencies.

RESULTS

The results revealed that, in both countries, a programme targeting social norms and self-efficacy would be most effective. In Burundi, raising the children's perceived severity of the consequences of contracting diarrhoea, and in Zimbabwe, increasing the children's health knowledge should be part of the programme.

CONCLUSIONS

The school handwashing programme should create awareness of the benefits of handwashing through educational activities, raise the children's ability and confidence in washing hands at school through infrastructural improvements, and highlight the normality of washing hands at school through events and poster creation.

Can theoretical intervention improve hand hygiene behavior among nurses?

Background

Hand washing is the best strategy to prevent known nosocomial infections but the nurses’ hand hygiene is estimated to be poor in Iran.

Objective

This study aimed to determine the effectiveness of BASNEF (Behavior, Attitude, Subjective Norms, and Enabling Factors) model on hand hygiene adherence education.

Methods

This controlled quasi-experimental study was conducted on 70 hemodialysis unit nurses (35 case and 35 control) in the health and educational centers of the University of Medical Sciences of Urmia, Iran. To collect the data, a six-part validated and reliable questionnaire was used. The data were analyzed using SPSS version18, using Wilcoxon, Mann–Whitney, chi-square, and Fisher’s exact tests. The significance level was considered P<0.05.

Results

The mean age was 38.4±8.1 years for the intervention group and 40.2±8.0 years for the control group. There was no significant difference between the two groups for any demographic variables. Also, before the intervention, there was no significant difference between the two groups for any components of the BASNEF model. Post-intervention, the attitude, subjective norms, enabling factors, and intention improved significantly in the intervention group (P<0.001), but hand hygiene behavior did not show any significant change in the intervention group (P=0.16).

Conclusion

Despite the improving attitudes and intention, the intervention had no significant effect on hand hygiene behavior among the studied nurses.

Improving hand hygiene compliance among healthcare workers: an intervention study in a Hospital in Guizhou Province, China

OBJECTIVE

Hand hygiene (HH) is a critical component for controlling hospital-acquired infection (HAI). The present study was designed to develop an intervention approach to improve compliance with HH among healthcare workers in a hospital setting.

METHODS

The HH intervention study was conducted in Guizhou Provincial People's Hospital, Guiyang, China and organized by its Department of HAI Management. It was an observational, prospective, quasiexperimental (before-after intervention) study. The study was divided into two phases: the baseline phase and the intervention phase. The investigative team included clinical monitoring staff and infection control practitioners who received a series of instructions on HH compliance, monitoring skills, and measurement of the use of HH products.

RESULTS

Based on 27,852 observations in a 17-month period, the rate of compliance with HH improved from 37.78% at baseline to 75.90% after intervention. Significant improvement in compliance and an increase in consumption of HH products was observed after intervention. The per patient-day consumption of alcohol-based hand rub products and handwash agents increased by 4.75mL and 4.55mL, respectively. The consumption of paper towels increased 3.41 sheets per patient-day. During the same period, the prevalence rate of HAI decreased 0.83%.

CONCLUSIONS

This study demonstrates that a significant improvement in compliance with HH can be achieved through a systemic, multidimensional intervention approach involving all categories of healthcare workers in a hospital setting, which may result in a decrease of the HAI rate.

Resilience, tipping, and hydra effects in public health: emergent collective behavior in two agent-based models

Background

Collective health behavior often demonstrates counter-intuitive dynamics, sometimes resisting interventions designed to produce change, or even producing effects that are in the opposite direction than intended by the intervention, e.g. lowering infectivity resulting in increased infections. At other times collective health behavior exhibits sudden large-scale change in response to small interventions or change in the environment, a phenomenon often called “tipping.” I hypothesize that these seemingly very different phenomena can all be explained by the same dynamic, a type of collective resilience.

Methods

I compared two simple agent-based models of interactions in networks: a public health behavior game, in which individuals decide whether or not to adopt protective behavior, and a microbial-level game, in which three different strains of bacteria attack each other. I examined the type of networks and other conditions that support a dynamic balance, and determined what changes of conditions will tip the balance.

Results

Both models show lasting dynamic equilibrium and resilience, resulting from negative feedback that supports oscillating coexistence of diversity under a range of conditions. In the public health game, health protection is followed by free-riding defectors, followed by a rise in infection, in long-lasting cycles. In the microbial game, each of three strains takes turns dominating. In both games, the dynamic balance is tipped by lowering the level of local clustering, changing the level of benefit, or lowering infectivity or attack rate. Lowering infectivity has the surprising effect of increasing the numbers of infected individuals. We see parallel results in the microbial game of three bacterial strains, where lowering one strain’s attack rate (analogous to lowering infectivity) increases the numbers of the restrained attacker, a phenomenon captured by the phrase, “the enemy of my enemy is my friend.”

Conclusions

Collective behavior often shows a dynamic balance, resulting from negative feedback, supporting diversity and resisting change. Above certain threshold conditions, the dynamic balance is tipped towards uniformity of behavior. Under a certain range of conditions we see “hydra effects” in which interventions to lower attack rate or infectivity are self-defeating. Simple models of collective behavior can explain these seemingly disparate dynamics.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-2938-8) contains supplementary material, which is available to authorized users.

Effect of hand sanitizer location on hand hygiene compliance

BACKGROUND

Hand hygiene is the most important intervention to prevent infection in hospitals. Health care workers should clean their hands at least before and after contact with patients. Hand sanitizer dispensers are important to support hand hygiene because they can be made available throughout hospital units. The aim of this study was to determine whether the usability of sanitizer dispensers correlates with compliance of staff in using the sanitizer in a hospital. This study took place in a Midwest, 404-bed, private, nonprofit community hospital with 15 inpatient care units in addition to several ambulatory units.

METHODS

The usability and standardization of sanitizers in 12 participating inpatient units were evaluated. The hospital measured compliance of staff with hand hygiene as part of their quality improvement program. Data from 2010-2012 were analyzed to measure the relationship between compliance and usability using mixed-effects logistic regression models.

RESULTS

The total usability score (P = .0046), visibility (P = .003), and accessibility of the sanitizer on entrance to the patient room (P = .00055) were statistically associated with higher observed compliance rates. Standardization alone showed no significant impact on observed compliance (P = .37).

CONCLUSION

Hand hygiene compliance can be influenced by visibility and accessibility of dispensers. The sanitizer location should be part of multifaceted interventions to improve hand hygiene.

Social-cognitive factors mediating intervention effects on handwashing: a longitudinal study

Handwashing with soap effectively prevents diarrhoea, a leading cause of death in infants. Theory-based interventions are expected to promote handwashing more successfully than standard approaches. The present article investigates the underlying change processes of theory-based handwashing interventions. A nonrandomised field study compared a standard approach to two theory-based interventions that were tailored to the target population, the inhabitants of four villages in southern Ethiopia (N = 408). Data were collected before and after interventions by structured interviews and analysed by mediation analysis. In comparison to the standard approach (i.e., education only), education with public commitment and reminder was slightly more effective in changing social-cognitive factors and handwashing. Education with an infrastructure promotion and reminder was most effective in promoting handwashing through enhancing social-cognitive factors. The results confirm the relevance of testing interventions' underlying change processes.

Achieving Hand Hygiene Success With a Partnership Between Graduate Medical Education, Hospital Leadership, and Physicians

Engaging physicians in hand hygiene programs is a challenge faced by many academic medical centers. Partnerships between education and academic leaders present opportunities for effective collaboration and improvement. The authors developed a robust hand hygiene quality improvement program, with attention to rapid-cycle improvements, including all levels of staff and health care providers. The program included a defined governance structure, clear data collection process, educational interventions, rapid-cycle improvements, and financial incentive for staff and physicians (including residents and fellows). Outcomes were measured on patients in all clinical areas. Run charts were used to document compliance in aggregate and by subgroups throughout the project duration. Institutional targets were achieved and then exceeded, with sustained hand hygiene compliance >90%. Physician compliance lagged behind aggregate compliance but ultimately was sustained at a level exceeding the target. Successfully achieving the institutional goal required collaboration among all stakeholders. Physician-specific data and physician champions were essential to drive improvement.

Behavior-based interventions to improve hand hygiene adherence among intensive care unit healthcare workers in Thailand

OBJECTIVE

To evaluate behavioral-based interventions to improve hand hygiene (HH) among healthcare workers (HCWs) at a Thai tertiary care center.

METHODS

A quasi-experimental study was performed in 6 intensive care units with computer-generated allocation. Baseline demographic characteristics, self-reported stage of HH behavioral commitment, and observed HH adherence were examined from January 1, 2012, through December 31, 2012 (preintervention), and from January 1, 2013, through December 31, 2013 (postintervention). Self-reported HH was categorized by the stages construct from the Transtheoretical Model of Health Behavior Change. The intensive care unit group randomization was to either standard-of-care HH education every 3 months (S1), intensified HH interventions (S2), or intensified HH interventions plus increased availability of alcohol-based handrub throughout the unit (S3).

RESULTS

Among 125 HCWs from 6 intensive care units (42 in S1, 41 in S2, 42 in S3) there were 1,936 total HH observations; most HCWs (100 [ 80%]) were nurses or nurse assistants. Compared with preintervention, overall postintervention HH adherence improved in HCWs assigned to S2 (65% vs 85%; P=.02) and S3 (66% vs 95%; P=.005) but not S1 (68% vs 71%; P=.84). Improvement in HH adherence was demonstrated among HCWs who reported lower stages of HH commitment in S2 (21% vs 84%; P<.001) and S3 (24% vs 89%; P<.001) and in HCWs who self-reported higher stages of commitment in S3 (78% vs 96%; P<.001).

CONCLUSIONS

HCW HH programs may benefit from stage-based tailored strategies to promote sustained HH adherence.