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WHO research for hand hygiene in health care 2023–2030: summary

Hand hygiene is vital for safe health care delivery, yet practices at the point of care remain suboptimal worldwide. A comprehensive research agenda is therefore necessary to improve our understanding of factors influencing hand hygiene behaviour and to strengthen appropriate interventions. This agenda will provide insightful ideas for researchers to focus their projects and funding proposals and will direct donors towards the areas of hand hygiene evidence that require urgent support and innovation. It will also guide decision-makers and stakeholders at the national and international level and support country efforts in updating and strengthening hand hygiene promotion programmes. Global collaboration and investment in hand hygiene research remain essential to promote safe and effective care worldwide. 

• Research article
• Open access
• Published: 06 February 2020

A systematic review of hand-hygiene and environmental-disinfection interventions in settings with children

• Leanne J. Staniford 1 &
• Kelly A. Schmidtke   ORCID: orcid.org/0000-0001-5993-0358 1  

BMC Public Health volume  20 , Article number:  195 ( 2020 ) Cite this article

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Helping adults and children develop better hygiene habits is an important public health focus. As infection causing bacteria can live on one’s body and in the surrounding environment, more effective interventions should simultaneously encourage personal-hygiene (e.g. hand-hygiene) and environmental-disinfecting (e.g. cleaning surfaces). To inform the development of a future multi-faceted intervention to improve public health, a systematic literature review was conducted on behavior change interventions designed to increase hand-hygiene and environmental-disinfecting in settings likely to include children.

The search was conducted over two comprehensive data-bases, Ebsco Medline and Web of Science, to locate intervention studies that aimed to increase hand-hygiene or environmental-disinfecting behavior in settings likely to include children. Located article titles and abstracts were independently assessed, and the full-texts of agreed articles were collaboratively assessed for inclusion. Of the 2893 titles assessed, 29 met the eligibility criteria. The extracted data describe the Behavior Change Techniques (version 1) that the interventions employed and the interventions’ effectiveness. The techniques were then linked to their associated theoretical domains and to their capability-opportunity-motivation (i.e., COM-B model) components, as described in the Behavior Change Wheel. Due to the heterogeneity of the studies’ methods and measures, a meta-analysis was not conducted.

A total of 29 studies met the inclusion criteria. The majority of interventions were designed to increase hand-hygiene alone ( N  = 27), and the remaining two interventions were designed to increase both hand-hygiene and environmental-disinfecting. The most used techniques involved shaping knowledge ( N  = 22) and antecedents ( N  = 21). Interventions that included techniques targeting four or more theoretical domains and all the capability-opportunity-motivation components were descriptively more effective.

Conclusions

In alignment with previous findings, the current review encourages future interventions to target multiple theoretical domains, across all capability-opportunity-motivation components. The discussion urges interventionists to consider the appropriateness of interventions in their development, feasibility/pilot, evaluation, and implementation stages.

Registration

Prospero ID - CRD42019133735.

Peer Review reports

The World Health Organization describes hygiene practices as those “that help to maintain health and prevent the spread of diseases” [ 1 ]. These practices include behaviors to disinfect one’s body and surrounding environment [ 2 ]. Because bacteria that cause infection can live on one’s body and in the surrounding environment, preventing the spread of infectious diseases may require interventions that simultaneously encourage both personal- and environmental-disinfecting [ 3 ]. To improve public health many hand-hygiene interventions have been conducted in school-settings, wherein students may act as “agents of change” by carrying lessons about hygiene from school back to their home to influence family behavior [ 4 , 5 , 6 ]. The current systematic review was conducted to inform the development of future multifaceted interventions that aim to increase hand-hygiene and environmental-disinfecting behaviors in settings likely to include children.

Two recent systematic reviews closely informed the current review. The first is Willmott et al.’s 2016 review that included 18 school-based randomized controlled trials with hand-hygiene focused interventions [ 7 ]. The effectiveness of the interventions were assessed in terms of their ability to reduce negative health-related outcomes: absences and/or the spread of respiratory tract or gastrointestinal infections. The descriptions of the interventions suggest that most involved education/training ( N  = 15) and fewer involved infrastructural changes ( N  = 4). Only one study included measures of environmental-disinfecting ( N  = 1) and none included direct measures of hand-hygiene behavior ( N  = 0). Overall, they found equivocal evidence for the effectiveness of school-based interventions. However, as none of the studies directly measured hand-hygiene, it is uncertain whether they even influenced the process variable they were designed to most directly influence: hand-hygiene behavior. One of the effective interventions in this review took place in a childcare center, and this intervention simultaneously targeted hand-hygiene and environmental-disinfecting [ 8 ]. To this end, the current review aims to include studies that assess the effectiveness of interventions designed to improve hand-hygiene and/or environmental-disinfecting.

The second review that influenced the current review was conducted by Huis et al. in 2012 [ 9 ]. Huis et al.’s review included 41 intervention studies published between 2000 and 2009 to increase healthcare workers’ hand-hygiene compliance. In this review, the interventions were categorized according to the behavioral determinants that they were designed to influence [ 10 , 11 ]. In so doing, this review brings together a wide range of interventions with a purposeful intervention terminology to guide future intervention development via the Behavior Change Wheel [ 12 , 13 ]. The Behavior Change Wheel is a formal methodology that helps interventionists identify the most common reasons for sub-optimal behavior by providing a comprehensive list of empirically and theoretically informed reasons, e.g. lacking knowledge or resources to perform the desired behavior. The Behavior Change Wheel can be used as part of the first step in the Medical Research Council’s four-step Complex Intervention Development and Evaluation Framework. The steps include (1) Design, (2) Feasibility/piloting, (3) Evaluation and (4) Implementation [ 14 ]. This first step is important, because interventions designed to target uncommon reasons are unlikely to yield practically significant improvements.

Since Huis et al.’s review, the possible reasons for sub-optimal behavior have been more completely described in a taxonomy called the Theoretical Domain Framework (TDF) [ 15 ]. The TDF condenses 112 behavioral constructs into 14 domains that affect behavior: ‘Knowledge,’ ‘Behavioral Regulation,’ ‘Memory attention and decision processes,’ ‘Skills,’ ‘Goals,’ ‘Intentions,’ ‘Beliefs about consequences,’ ‘Beliefs about capabilities,’ ‘Optimism,’ Social/Professional role and identity,’ ‘Reinforcement,’ ‘Emotions,’ ‘Social influences,’ and ‘Environmental context and resources.’ These 14 domains are further condensed into the COM-B model’s three components, which exclusively and exhaustively explain why behaviors do or do not occur. The three COM-B components (and subcomponents) include C apability (physical/psychological), O pportunity (social/physical), and M otivation (reflective/automatic); the ‘B’ stands for B ehavior. If even a single COM-B component is lacking, then a desired behavior is less likely to occur.

The TDF domains and COM-B model components are displayed in the second and third columns of Fig.  1 . The links between them are indicated with shared colors, e.g. a dark red color is used to describe the link between the ‘Knowledge’ domain and the C apability-psychological component. After diagnosing the reasons for suboptimal behavior, the Behavior Change Wheel helps interventionists select the most appropriate intervention techniques. Ninety-three empirically and theoretically informed techniques are grouped into 16 clusters by the Behavior Change Techniques (BCTs) Taxonomy, version 1, e.g. shaping knowledge, goals and planning, social support , etc. [ 16 ]. In Fig. 1 , the 16 BCT clusters are linked to their associated TDF domains by lines drawn across the first and second columns [ 17 ]. For example, the shaping knowledge technique is best suited to influence the ‘Knowledge’ domain.

Links between the BCT clusters, TDF domains, and COM-B model

Huis et al.’s 2012 review found that interventions targeting only one domain, e.g. only ‘Knowledge’ or only ‘Goals,’ were less effective than those that targeted multiple domains, e.g. ‘Knowledge’ and ‘Goals.’ Therefore, they suggest that future interventions should simultaneously target multiple domains, likely across the COM-B components, to increase optimal behavior. As the current review aims to influence the development of future multifaceted interventions, Huis et al.’s use of a purposeful intervention development terminology is desirable. Thus, the current review also categorizes interventions according to the techniques used and the domains/components targeted. In so doing, the current review will also guide future intervention development via the Behavior Change Wheel.

In summary, the current literature review was planned around two broad objectives. First, we aimed to learn what behavior change techniques had already been assessed to increase hand-hygiene and environment-disinfecting in settings likely to include children, e.g. schools, homes, etc. Second, where possible, we aimed to compare the effectiveness of these techniques and the domains/components they targeted. The discussion puts forth recommendations for the development of future multifaceted interventions.

The current systematic review is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement [ 18 ]. The review’s protocol was registered on 28th of May 2019 with PROSPERO: International Prospective Register of Systematic Review (Registration ID: CRD42019133735).

Eligibility criteria

The eligibility criteria were determined using the PICO characteristics, i.e. characteristics describing the studies’ population, intervention(s), comparison(s) and outcome(s) [ 19 ]. The population characteristic was defined to include humans in settings likely to contain children less than 10-years-old and to exclude settings unlikely to contain children (e.g. manufacturing settings) and studies focused on non-human species. The intervention characteristic was defined to include studies that manipulated malleable factors likely to influence human behavior and to exclude comparisons of cleaning materials and non-malleable variables like gender. The comparison characteristic was defined to include any control or comparison condition, i.e. both randomized and pre-post observational trials. Finally, the outcome characteristic was defined to include hand-hygiene and environmental-disinfecting behavior measures. Environmental-disinfecting behavior was understood to entail the use of cleaning products to kill harmful germs that can cause illness.

Information sources and search strategy

The search terms and selected databases were reviewed by the research team and library staff (Table  1 ). In addition to the search terms three inclusion criteria were applied. First, the articles had to be written in English, because no translation services were available to the research team. Second, the articles had to be published in peer-reviewed journals, to narrow the scope of the review to articles more likely to include relevant information. Third, the articles had to be published on or after January 2009. The final search was conducted on the 27th of April 2019 over EBSCOhost Medline and Web of Science Core Collection.

Study selection and data collection process

One researcher located the articles and then uploaded them to EndNote™ to combine, detect, and delete duplicate references. The remaining articles were uploaded to Rayyan QCRI [ 20 ]. Then, two researchers used Rayyan QCRI to independently screen titles and abstracts for inclusion. Full-text articles were collaboratively screened. The stages of the search and screening process are described in Fig.  2 .

Prisma diagram describing how articles were located and screened

Data extraction

Two reviewers extracted study data from the articles using data extraction questions first piloted on smaller samples of included studies. After the data extraction questions were finalized, each reviewer independently extracted data from approximately half of the included articles. The extracted data included study details, intervention descriptions, outcome descriptions, and findings. The interventions were defined according to the Behavioral Change Techniques Taxonomy, version 1 [ 16 ], and each technique’s cluster was linked to the theoretical domains and COM-B components, as described in Fig. 1 (also see Additional file  1 for the list of behavior change techniques and clusters); as discussed in the introduction, these links are informed by previous research [ 15 , 16 , 17 ]. The data extraction process was planned to permit a narrative summary of what types and numbers of behavioral domains and components were most likely to increase hand-hygiene and environmental-disinfecting.

Overall quality assessment

One researcher reviewed articles to assess the studies’ overall quality using tools developed by the United States Department of Health and Human Services for controlled intervention and observational pre-post studies [ 21 ]. Each tool contains a checklist of items, e.g. asking about the sample-size and participant retention rates. To summarize the quality of the articles a five-star assessment was used. Four of the stars were assigned by taking the total number of positively indicated items divided by the total number of items: 1 star was given for positively indicating 25 to 49% of the items, 2 for 50 to 74%, 3 for 75 to 99%, and 4 stars for 100%. An additional star was given to those articles that use a randomized controlled trial methodology.

Data synthesis

Narrative syntheses, with tallies, are used to summarize the findings. Tables are used to describe and aggregate summaries.

Of the 2893 titles assessed, 29 met the eligibility criteria (see Additional file  2 ). The reviewer agreements were moderate for screened titles (89.56%, Kappa = 0.42, p  < 0.001) and abstracts (81.02%, Kappa = 0.36, p  < 0.001). The studies took place mostly in Bangladesh ( N  = 6), and Kenya ( N  = 4). Fewer took place in India ( N  = 2), Peru ( N  = 2), South Africa ( N  = 2), the United States of America ( N  = 2), Zambia ( N  = 2), China ( N  = 1), Indonesia ( N  = 1), Iraq ( N  = 1), Laos ( N  = 1), Malawi ( N  = 1), Malaysia ( N  = 1), Nepal ( N  = 1), Tanzania ( N  = 1), and Zimbabwe ( N  = 1). Most of the studies were publically funded ( N  = 24).

Study characteristics

Regarding the study designs, 7 were pre-post without randomization, 18 were pre-post with randomization, and the remaining 4 were randomized controlled trials with only post-intervention comparisons. Approximately one-third of the studies were pre-registered ( N  = 11). Nearly all of the studies indicated being granted approval by an ethics committee before commencing ( N  = 28). The remaining study did not indicate whether ethical approval was sought [ 22 ]. Prior to collecting data, a power analysis was conducted for most studies ( N  = 22), but this analysis was not always for an observable, behavioral measure, e.g. alternative primary outcomes included diarrhea episodes [ 23 ] and microbial counts [ 24 ]. Most of the interventions took place in schools ( N  = 12) or households with children ( N  = 13); fewer took place in pediatric settings ( N  = 2) or involved multiple locations, such as schools and other community centers or households ( N  = 2).

Regarding whose behavior was measured, 11 studies focused on the behavior of household members including children and adults, 16 focused on children/students, 1 looked at mother and child pairs [ 6 ], and 1 looked at pediatric healthcare workers [ 25 ]. Only 17 of the studies indicated the gender of their participants. In 23 studies some information about participants’ age was provided or could be inferred, e.g. from participants’ grade levels.

All of the studies included a behavioral measure of hand-hygiene, but only 20 reported a significant increase in at least one measure of hand-hygiene, i.e. handwashing, handwashing with soap, or handwashing at key times (e.g. after defecation or before food preparation), compared to a control group or a pre-intervention measure. Nine interventions found no significant effect of the intervention condition on hand-hygiene. Only two studies included a measure of environmental-disinfecting, both were related to food preparation and both found significant increases. As so few articles were found for environmental-disinfecting, the remainder of the current results section focuses on hand-hygiene. In nearly half of the studies ( N  = 13), a health outcome measure was also recorded, such as absenteeism, diarrhea-symptoms, hospitalization episodes, and infection rates. The Additional file  3 provides details about the studies’ settings, participants, interventions, comparisons, outcome measurements, and results.

Behavior change technique clusters and the COM-B model

The types and numbers of behavior change technique clusters (BCTs) employed are summarized in Table  2 . Across the 29 studies the most commonly employed BCTs involved shaping knowledge ( N  = 22) and antecedents ( N  = 21). A moderate number of interventions involved associations ( N  = 14), social support ( N  = 12), feedback and monitoring ( N  = 10), comparison of behaviors ( N  = 8), and goals and planning ( N  = 7). Fewer interventions involved repetition and substitution ( N  = 5), reward and threat ( N  = 4), and scheduled consequences ( N  = 1) [ 26 ]. None of the interventions involved comparison of outcomes , regulation , self-belief , or covert learning . The interventions included as few as one BCT cluster [ 43 , 44 , 45 ] and as many as nine [ 34 , 42 ]. Of the 29 included studies, 3 used a single BCT cluster, 15 included 2 to 4, and 11 included 5 or more. The mean number of BCT clusters per intervention that did not find a significant benefit for hand-hygiene was 3.00 ( SD  = 1.94, Mdn  = 3). The mean number of interventions that did find a significant benefit was descriptively higher, i.e. 4.65 ( SD  = 2.30, Mdn  = 4).

Using the links provided in Fig. 1 , the number of studies that targeted each TDF domain and COM-B component were tallied. The most frequently targeted domains were ‘Knowledge’ and ‘Environmental context and resources’ (both N ’s = 22). Fewer studies targeted ‘Emotions’ ( N  = 20), ‘Beliefs in consequences’ ( N  = 15), ‘Social Influences’ ( N  = 14), ‘Behavioral Regulation’ ( N  = 10), ‘Goals’ ( N  = 7), ‘Intentions’ ( N  = 7), ‘Reinforcement’ ( N  = 5), ‘Skills’ ( N  = 4), and ‘Optimism’ ( N  = 1 [ 26 ];. No interventions targeted ‘Beliefs about capabilities.’ As a reminder no BCTs are linked to the ‘Memory attention and decision processes’ domain or ‘Social/Professional role and identity’ domain, and therefore it is not surprising that these domains were not targeted by any interventions. The studies targeted between 1 and 9 domains, with the average study targeting 4.38 domains ( SD  = 2.51, Mdn  = 4). Of the 14 studies that targeted less than 4 domains, 7 (50%) found positive effects of the intervention. In contrast, of the 15 studies that targeted 4 or more domains, 13 (87%) found positive effects of the intervention.

Regarding the COM-B model, almost all the studies targeted Capability ( N  = 28), and many targeted O pportunity ( N  = 24) and M otivation ( N  = 21). Five of the studies only targeted one component, of which four targeted O pportunity and one targeted M otivation; only three of these five studies (60%) found a significant benefit. Four of the studies only targeted two components, of which three targeted C apability and O pportunity and one targeted M otivation and O pportunity; only two of these studies (50%) found a significant benefit. The remaining 20 studies targeted all three COM-B components, and 15 of these studies (75%) found a significant benefit.

Methodological quality

The quality assessment for each study is provided in Additional file  4 . As a reminder the studies were assessed with five stars, where four stars were allocated based on the percentage of assessment criteria met, and one star was added to studies that used a randomized controlled trial methodology. Of the 29 studies included, 2 studies received one star [ 36 , 44 ], 21 received three stars, 2 received four stars [ 6 , 43 ], and 4 received two stars [ 25 , 27 , 32 , 33 ].

Synthesis of results

The co-authors agreed that a pooled estimate of the effects would be misleading, due to the heterogeneity of the populations examined, research methods employed, and outcomes measured.

The current systematic review located 29 studies with interventions designed to increase hand-hygiene in settings likely to include children. Of the 29 studies, only 2 were also designed to increase environmental-disinfecting behavior. Individual study results suggest that interventions may increase hand-hygiene and environmental-disinfecting, but the behavior change techniques they employed and domains/components they targeted varied. The most targeted domains were ‘Knowledge’ and ‘Environmental context and resources.’ Descriptively, interventions targeting four or more theoretical domains and those targeting all the COM-B components were more likely to succeed.

The findings of this literature review align with other reviews emphasizing the value of multifaceted interventions. As stated in the introduction, the COM-B model proposes that people need sufficient C apability, O pportunity, and M otivation to perform a desired behavior. If even a single component is lacking, then people will be less likely to perform the desired behavior [ 12 ]. Agreeing with the COM-B framework, Harvey and Kitson argue that interventions meant to influence a greater range of people with more complex problems often require multifaceted approaches [ 50 ]. As hand-hygiene is likely a complex behavioral problem, interventions designed to affect a single component may prove inadequate to produce either population-level benefits (as individuals experience different barriers) or individual-level benefits (as each individual experiences multiple barriers that need to be simultaneously overcome).

Comparing interventions designed to affect each TDF domain or COM-B component, in isolation and combination, would help interventionists better understand how these domains/components influence each other. However, such factorial experimental designs will prove difficult to conduct given real-world constraints. Further the scientific exactness of factorial designs are likely outside the scope of many studies with more practical aims. In many studies, hand-hygiene is operationalized as a process variable (that may or may not be measured) meant to impact a health outcome (that is measured), and previous systematic reviews have largely focused on practical health outcomes. For example, Willmott et al.’s (2016) review located 18 randomized controlled trials that investigated the effectiveness of hand-hygiene interventions on children’s absences and infections [ 7 ]; Meadows et al.’s (2004) review located 6 studies evaluating the effectiveness of antimicrobial rinse-free hand sanitizer interventions on elementary school children’s absenteeism due to communicable illness [ 51 ]; and Wilson et al.’s (2006) located 12 studies that investigated the effectiveness of hand-hygiene interventions to decrease infections and absenteeism [ 52 ].

Studies focusing on hand-hygiene behavior itself are likely more common in health care settings [ 53 , 54 , 55 ], where hand-hygiene compliance audits are already common. In contrast, in school-settings hand-hygiene compliance audits may prove difficult to fund, develop, and faithfully implement. As a result of these difficulties, interventions in school settings are often evaluated using the data that schools already regularly collect, e.g. absences, or that parents/students can self-report with reasonable face-validity, e.g. diarrhea episodes. While outcomes like absences and diarrhea episodes are certainly important, the present research team argues that there is already sufficient evidence that hand-hygiene impacts these health outcomes [ 56 , 57 ]. Therefore, more studies and reviews looking at the effectiveness of hand-hygiene interventions should prioritize observable hand-hygiene behavior measures when assessing their interventions’ effects.

Limitations

Several limitations of the current review will now be acknowledged. First, the search only included two data-bases, articles published in the English language, and did not extend to the grey literature. Given the current research team’s time and resource constraints, these restrictions were necessary. A future review aiming to understand what techniques have been attempted (with or without being assessed) may find it useful to include the grey literature. Another limitation of the review is its rigid focus on observable behaviors. Indeed, most studies discarded from the review during the full-text screening were lost because they did not include measures of observable behavior, but rather only included self-reported measures.

Recommendations for future intervention studies

The current review recommends that future interventions designed to increase hand-hygiene or environmental-disinfecting in settings likely to include children target multiple theoretical domains and all COM-B components. Which domains are targeted will depend on the particular setting and population. For example, if the particular setting already includes sufficient infrastructure for children to carry out hand-hygiene, e.g. soap and a water basin, then providing more soap or installing new water basins is unlikely to produce a beneficial effect; though, making children aware of such materials might. The only way to be more certain about what barriers a particular population experiences is to conduct formative research in the selected setting with the selected population, e.g. structured observations, focus groups, interviews, surveys, etc. Such formative research should aim to comprehensively examine all the possible barriers that could influence hand-hygiene, because if even a single component is lacking, then beneficial effects of the intervention are less likely to be realized. The Behavior Change Wheel can be used to guide the development of multifaceted interventions, and the selection of the most appropriate intervention functions (e.g. education or persuasion) and policy categories (e.g. guidelines or legislation) through which those interventions can be delivered [ 58 ].

Of course, selecting behavior change techniques is only part of the intervention development process. Beyond targeting the right barriers, the intervention must be implemented through an appropriate mode. To bolster the appropriateness of the ultimate intervention, interventionists can use the APEASE criteria [ 59 ]. APEASE is an acronym in which each letter stands for a different appropriateness-criterion: Affordability, Practicality, Effectiveness, Acceptability, Side-effects, and Equity. A sample of questions researchers might ask themselves about each criterion are provided in Table  3 . The APEASE criteria should be consulted iteratively during an intervention’s development, feasibility/pilot testing, evaluation, and implementation [ 58 ]. Considering the APEASE criteria during the development phase is important; if stakeholders do not believe the intervention is appropriate, then the intervention will prove difficult to scale and spread even if the intervention’s effects are found to be beneficial.

The present review focused on the behavior change techniques, theoretical domains, and COM-B components interventionists should consider when developing a multifaceted intervention. After developing a multifaceted intervention, the Behavior Change Wheel and the Medical Research Council’s Complex Intervention Development and Evaluation Framework recommend feasibility/pilot testing [ 12 , 14 ]. Specific information regarding how to feasibility/pilot test an intervention study is outside the scope of the present review. Briefly here, note that while one may be uncertain about the benefits of a intervention before full-scale testing, feasibility/pilot tests help one to become more certain about the parameters needed for a fair full-scale test of that intervention’s effectiveness. Many, often costly, trials that do not first feasibility/pilot test their interventions ultimately fail to find significant effects due to factors that better planning may have mitigated, e.g. the sample-size was too low, people found the intervention unacceptable, or intervention implementation was inadequate [ 60 , 61 , 62 ].

The current literature review identified 29 studies with interventions that aimed to increase hand-hygiene, 2 of which also aimed to increase environmental-disinfecting. In alignment with previous findings, this review finds that interventions that simultaneously target more theoretical domains and all COM-B components are descriptively more likely to succeed. The review also notes that very few trials examine hand-hygiene and environmental-disinfecting simultaneously and encourages more studies to do so, as this may be the most cost-effective way to halt reinfection cycles. In the discussion, interventionists were urged to consider the appropriateness of their interventions in the development, feasibility/pilot, evaluation, and implementation stages. This iterative and methodical process can encourage better scale and spread of effective interventions that increase hand-hygiene and environmental-disinfecting behaviors in settings likely to include children.

Availability of data and materials

The reviews protocol is available on PROSPERO. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Control Group

Environmental Disinfecting

• Handwashing

Handwashing with soap

Intervention Group

Theoretical Domains Framework

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Acknowledgements

The authors would like to acknowledge the support of the funder and Manchester Metropolitan University’s library staff in conducting the current review. The authors also acknowledge Pendaran Roberts’ help editing the manuscript.

This research was supported by Global Hygiene Council. The Global Hygiene Council had no role in the design of the study and collection, analysis, and interpretation of data, and in writing the manuscript. The views expressed are those of the authors and not necessarily those of the Global Hygiene Council.

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Links between the Theoretical Domains and Behavior Change Technique (version 1) used in the current research project.

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References for articles included in the review.

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Characteristics of included studies in the systematic review.

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Quality assessments conducted using the United States Department of Health and Human Services tool for pre-post studies.

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Staniford, L.J., Schmidtke, K.A. A systematic review of hand-hygiene and environmental-disinfection interventions in settings with children. BMC Public Health 20 , 195 (2020). https://doi.org/10.1186/s12889-020-8301-0

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• New Evidence

The latest evidence on hand hygiene behavior change in different contexts: Insights from the 2022 Hand Hygiene Research Summary

Meriam Zegeye

Aarin Palomares

We highlight the latest evidence on hand hygiene behavior change using evidence from the latest Hand Hygiene Research Summary. As we prepare to mark Global Handwashing Day on October 15 and engage with the upcoming UNC Water and Health Conference starting on October 23, 2023, this month is practically the unofficial ‘hand hygiene awareness’ month of the year. These events provide an impetus to put hand hygiene back in the spotlight. In honor of this month, we highlight the latest evidence on hand hygiene behavior change using evidence from the latest Hand Hygiene Research Summary published by the Global Handwashing Partnership.

What is the Hand Hygiene Research Summary?

Published in May of this year, the 2022 Hand Hygiene Research Summary compiles and synthesizes peer-reviewed literature from the previous year and summarizes the latest findings and lessons learned from hand hygiene activities. These summaries provide guidance on hand hygiene best practices for program implementers, policy actors and researchers.

After searching three databases for handwashing studies published in 2022, 152 studied were identified as including relevant hand hygiene research. The studies were further categorized by study design, outcome focus, and intervention setting (domestic, school-based, healthcare facility, workplace, public space, and humanitarian), revealing context-specific insights.

Lessons learned from the Hand Hygiene Research Summary

Determinants of hand hygiene behavior

Good behavior change programming goes beyond knowledge and education, rather good program design understands the barriers and enablers of hand hygiene behavior. Sustaining hand hygiene behavior change requires addressing a range of behavioral determinants. Behavioral determinants are factors that influence behavior. Determinants for hand hygiene behavior include social norms, affiliation, enabling technologies/infrastructure, nurture, disgust, perceived susceptibility and perceived severity of diseases. The Handwashing Handbook groups these determinants into reflexive, habitual factors (such as culture, environmental cues, and nudges) and more reflective, conscious decision-making factors (such as knowledge and emotional motivators).

Enabling technologies are a critical determinant for hand hygiene behavior. Undoubtedly, it is not possible to maintain good hand hygiene without the necessary facilities. However, in a study surveying 29 countries in Sub-Saharan Africa, Endalew et al. (2022) determined that 66.16% of handwashing facilities lacked either water or soap. Access to facilities and supplies cannot be neglected, but it is not the only determinant for hand hygiene behavior.

Emotional motivators, such as the feeling of affiliation, nurture, or disgust are also crucial factors for hand hygiene behavior. One such example is from a study which assessed the impact of the Mum’s Magic Hands resource in promoting handwashing among mothers in humanitarian settings ( White et al., 2022 ). The storyboard features a mother and her efforts to care for her daughter and instill good handwashing habits despite their difficult emergency context.  This resource uses the emotional motivators of nurture and group affiliation to capture the effect of positive social factors and motivate handwashing. Through its touching and engaging images, the storyboard presents handwashing as a crucial part of a mother’s care for her children. These innate motivators can move mothers to action even in emergency contexts where other pressing needs seem more urgent.

The presence of role models is also a notable factor for hand hygiene behavior. A cross-sectional study done in Ethiopia by Berhanu et al. (2022) found that students with strong handwashing role models were 4.41 times more likely to wash their hands as compared to students who did not have strong role models. Another study by Ahmadipour et al. (2022) identified improper behavioral patterns of supervisors among one of the main barriers to handwashing among health care workers in Iran. The study found that healthcare workers mirrored the practices of head doctors and nurses, admitting to underestimating the importance of handwashing because of the noncompliance of their supervisors. Managers and supervisors play a large role in setting the norms for hand hygiene practices. Their own behaviors as role models can either reinforce or undermine the training that health workers receive regarding hand hygiene. Interventions should empower supervisors in their positions as role models as a mechanism for social norm change in healthcare environments. The same is true in public settings. A study by Akter et al. (2022) on the barriers and facilitators of a COVID-19 intervention demonstrated that influential community members can act as role models to influence hand hygiene behavior.

Decades of research show us the need to better understand our target audience and the key factors that influence their hand hygiene behavior. Good behavior change programming goes beyond knowledge and education, rather good program design understands the barriers and enablers of hand hygiene behavior to develop effective, context-specific interventions.

Developing sustainable interventions

Several studies in the 2022 report highlight the need for sustainable interventions for lasting behavior change. Behavior change takes time. Not only do people need to be motivated initially to take up a healthy behavior, but this motivation must be sustained for the maintenance of this behavior. Whether due to fatigue or the rise of other immediate needs, without reinforcement, healthy habits drop down on the priority list. Several studies in the 2022 report highlight the need for sustainable interventions for lasting behavior change.

In a domestic setting, Sedekia et al. (2022) conducted a study and held 20 household sessions on soil-transmitted helminth (STH) among children after which 18 households installed handwashing stations. However, after 8 months, only 8 households had maintained the handwashing stations. These findings show that, although the sessions were initially effective, sustained interventions were necessary to motivate households to maintain and utilize the handwashing stations. Similar effects were seen in a study by Nalule et al. (2022) assessing the effectiveness of hand hygiene interventions including building facilities, providing training, and establishing cues on improving hand hygiene practices among midwives and caregivers. The study found significant improvements among midwives and caregivers in healthcare facilities but only limited improvements in the postnatal home environment.

Both examples highlight the need for sustained interventions to maintain behavior change long-term. Once behavioral determinants are identified, program managers must select, refine and implement a set of activities or interventions that best address those determinants to not only change but sustain hand hygiene behavior.

It is important that we build on the latest research and continue to address context-specific motivators and barriers to ensure lasting behavior change. Overall, the 2022 Hand Hygiene Research Summary emphasizes what many of us already know: Increased knowledge of hand hygiene practices does not automatically lead to improved hand hygiene behaviors. While improvements have been made to go beyond health education programs, the latest evidence emphasizes that more should be done to promote hand hygiene behavior change in different contexts.

The research for the use of emotional motivators as a determinant for sustained behavior change is promising. Health-related motivators are a good catalyst to raise perception of susceptibility of disease. However, this needs to be paired with emotional motivators such as the desires to nurture and have group affiliation. Furthermore, nudges, environmental cues, and continued messaging are necessary to maintain compliance. Influential role models also have the potential to uphold good hand hygiene as the norm by modeling positive behaviors and through the motivation for affiliation. For children especially, the involvement of parents and caregivers at home is necessary to reinforce hand hygiene education at school. This determinant should continue to characterize interventions in school, healthcare and public settings. Finally, the evidence shows the importance of interventions that promote long-term behavior change through sustained activities.

The 2022 Hand Hygiene Research Summary shows growing understanding that hand hygiene promotion efforts must move beyond awareness to long term behavior change. As we celebrate this unofficial ‘hand hygiene awareness’ month and look toward the future, it is important that we build on the latest research and continue to address context-specific motivators and barriers to ensure lasting behavior change.

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Publications, Data, & Statistics

What to know.

These articles provide information related to handwashing and the use of hand sanitizer in a variety of settings around the world. They include key publications on related topics but are not intended to be a comprehensive list of references.

Publication Highlight‎

Improved health.

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Contamination & Microbe Removal

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• Luby SP, Halder AK, Huda T, Unicomb L, Johnston RB. The effect of handwashing at recommended times with water alone and with soap on child diarrhea in rural Bangladesh: an observational study. PLoS Med. 2011 Jun;8(6):e1001052.
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• Laestadius JG, Dimberg L. Hot water for handwashing–where is the proof? J Occup Environ Med. 2005 Apr;47(4):434-5.
• Hoque BA. Handwashing practices and challenges in Bangladesh. Int J Environ Health Res. 2003 Jun;13 Suppl 1:S81-7.
• Lin CM, Wu FM, Kim HK, Doyle MP, Michael BS, Williams LK. A comparison of hand washing techniques to remove Escherichia coli and caliciviruses under natural or artificial fingernails. J Food Prot. 2003 Dec;66(12):2296-301.
• Michaels B, Gangar V, Schultz A, Arenas M, Curiale M, Ayers T, Paulson D. Water temperature as a factor in handwashing efficacy. Food Service Technology. 2002;2:139-49.
• McGinley KJ, Larson EL, Leyden JJ. Composition and density of microflora in the subungual space of the hand. J Clin Microbiol. 1988 May;26(5): 950–953.

Antibacterial Soap

Handwashing has been clearly shown to prevent a variety of diseases and is one of the most important ways to protect oneself and others from infections. To date, studies have shown that there is no added health benefit for consumers (this does not include professionals in the healthcare setting) using soaps containing antibacterial ingredients compared with using plain soap. CDC looks forward to any future data about the safety and effectiveness of antibacterial consumer products and will continue to adjust recommendations based on the best available science.

Efficacy of Antibacterial Soaps

• Boyce JM, Dupont HL, Massaro J, Sack D, Schaffner DW. An expert panel report of a proposed scientific model demonstrating the effectiveness of antibacterial handwash products. Am J Infect Control. 2012 Oct;40(8):742-9.
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• Luby SP, Agboatwalla M, Feikin DR, Painter J, Billhimer W, Altaf A, Hoekstra RM. Effect of handwashing on child health: a randomised controlled trial. Lancet. 2005 Jul 16-22;366(9481):225-33.
• Luby SP, Agboatwalla M, Painter J, Altaf A, Billhimer WL, Hoekstra RM. Effect of intensive handwashing promotion on childhood diarrhea in high-risk communities in Pakistan: a randomized controlled trial. JAMA. 2004 Jun 2;291(21):2547-54.
• Larson EL, Lin SX, Gomez-Pichardo C, Della-Latta P. Effect of antibacterial home cleaning and handwashing products on infectious disease symptoms: a randomized, double-blind trial. Ann Intern Med. 2004 Mar 2;140(5):321-9.

Environmental Fate & Potential Health Impact of Antibacterial Soap Additives

• Lankester J, Patel C, Cullen MR, Ley C, Parsonnet J. Urinary Triclosan is associated with elevated body mass index in NHANES. PLoS One. 2013 Nov 21;8(11):e80057.
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• Frederiksen H, Nielsen JK, Mørck TA, Hansen PW, Jensen JF, Nielsen O, Andersson AM, Knudsen LE. Urinary excretion of phthalate metabolites, phenols and parabens in rural and urban Danish mother-child pairs. Int J Hyg Environ Health. 2013 Nov;216(6):772-83.
• Lozano N, Rice CP, Ramirez M, Torrents A. Fate of Triclocarban, Triclosan and Methyltriclosan during wastewater and biosolids treatment processes. Water Res. 2013 Sep;47(13):4519-27.
• Meeker JD, Cantonwine DE, Rivera-González LO, Ferguson KK, Mukherjee B, Calafat AM, Ye X, Anzalota Del Toro LV, Crespo-Hernández N, Jiménez-Vélez B, Alshawabkeh AN, Cordero JF. Distribution, variability, and predictors of urinary concentrations of phenols and parabens among pregnant women in Puerto Rico. Environ Sci Technol. 2013 Apr 2;47(7):3439-47.

Drying Hands

• Huang C, Ma W, Stack S. The hygienic efficacy of different hand-drying methods: a review of the evidence. Mayo Clin Proc. 2012 Aug;87(8):791-8.
• Jensen D, Danyluk M, Harris L, Schaffner D. Quantifying the effect of hand wash duration, soap use, ground beef debris, and drying methods on the removal of Enterobacter aerogenes on hands . J Food Prot. 2015 Apr;78(4):685-690.
• Gustafson DR, Vetter EA, Larson DR, Ilstrup DM, Maker MD, Thompson RL, Cockerill FR 3rd. Effects of 4 hand-drying methods for removing bacteria from washed hands: a randomized trial. Mayo Clin Proc. 2000 Jul;75(7):705-8.
• Patrick DR, Findon G, Miller TE. Residual moisture determines the level of touch-contact-associated bacterial transfer following hand washing. Epidemiol Infect. 1997 Dec;119(3):319-25.

Hand Sanitizer

• Luke Y, Bixler D, Brooks D, et al. Serious Adverse Health Events, Including Death, Associated with Ingesting Alcohol-Based Hand Sanitizers Containing Methanol — Arizona and New Mexico, May–June 2020. Morbidity and Mortality Weekly Report (MMWR) .
• Blaney DD, Daly ER, Kirkland KB, Tongren JE, Kelso PT, Talbot EA. Use of alcohol-based hand sanitizers as a risk factor for norovirus outbreaks in long-term care facilities in northern New England: December 2006 to March 2007. Am J Infect Control. 2011 May;39(4):296-301.
• Pickering AJ, Davis J, Boehm AB. Efficacy of alcohol-based hand sanitizer on hands soiled with dirt and cooking oil. J Water Health. 2011 Sep;9(3):429-33.
• Pickering AJ, Boehm AB, Mwanjali M, Davis J. Efficacy of waterless hand hygiene compared with handwashing with soap: a field study in Dar es Salaam, Tanzania. Am J Trop Med Hyg. 2010 Feb;82(2):270-8.
• Stebbins S, Cummings DA, Stark JH, Vukotich C, Mitruka K, Thompson W, Rinaldo C, Roth L, Wagner M, Wisniewski SR, Dato V, Eng H, Burke DS. Reduction in the incidence of influenza A but not influenza B associated with use of hand sanitizer and cough hygiene in schools: a randomized controlled trial. Pediatr Infect Dis J. 2011 Nov;30(11):921-6.
• Edmonds SL, Mann J, McCormack RR, Macinga DR, Fricker CM, Arbogast JW, Dolan MJ. SaniTwice: a novel approach to hand hygiene for reducing bacterial contamination on hands when soap and water are unavailable. J Food Prot. 2010 Dec;73(12):2296-300.
• Hübner NO, Hübner C, Wodny M, Kampf G, Kramer A. Effectiveness of alcohol-based hand disinfectants in a public administration: Impact on health and work performance related to acute respiratory symptoms and diarrhoea. BMC Infect Dis. 2010;10:250.
• Kampf G, Marschall S, Eggerstedt S, Ostermeyer C. Efficacy of ethanol-based hand foams using clinically relevant amounts: a cross-over controlled study among healthy volunteers. BMC Infect Dis. 2010 Mar 26;10:78.
• Todd EC, Michaels BS, Holah J, Smith D, Greig JD, Bartleson CA. Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 10. Alcohol-based antiseptics for hand disinfection and a comparison of their effectiveness with soaps. J Food Prot. 2010 Nov;73(11):2128-40.
• Miller M, Borys D, Morgan D. Alcohol-based hand sanitizers and unintended pediatric exposures: a retrospective review. Clin Pediatr (Phila). 2009 May;48(4):429-31.
• Grayson ML, Melvani S, Druce J, Barr IG, Ballard SA, Johnson PD, Mastorakos T, Birch C. Efficacy of soap and water and alcohol-based hand-rub preparations against live H1N1 influenza virus on the hands of human volunteers. Clin Infect Dis. 2009 Feb 1;48(3):285-91.
• Oughton MT, Loo VG, Dendukuri N, Fenn S, Libman MD. Hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile . Infect Control Hosp Epidemiol. 2009 Oct;30(10):939-44.
• Kramer A, Galabov AS, Sattar SA, Döhner L, Pivert A, Payan C, Wolff MH, Yilmaz A, Steinmann J. Virucidal activity of a new hand disinfectant with reduced ethanol content: comparison with other alcohol-based formulations. J Hosp Infect. 2006 Jan;62(1):98-106.
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Animal Settings

• National Association of State Public Health Veterinarians, Inc., CDC. Compendium of measures to prevent disease associated with animals in public settings, 2011: National Association of State Public Health Veterinarians, Inc. [PDF – 28 pages] MMWR Recomm Rep. 2011;60(RR-04):1-24.

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Research Article

Determinants of hand hygiene compliance among nurses in US hospitals: A formative research study

Roles Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Department of Infectious Disease, London School of Hygiene and Tropical Medicine, London, United Kingdom, University of Arizona College of Medicine, Tucson, Arizona, United States of America

Roles Conceptualization, Formal analysis, Funding acquisition, Writing – review & editing

Affiliation Department of Infectious Disease, London School of Hygiene and Tropical Medicine, London, United Kingdom

• Madeline Sands, 
• Robert Aunger

• Published: April 7, 2020
• https://doi.org/10.1371/journal.pone.0230573
• Reader Comments

Hand hygiene is the simplest and most effective measure for preventing healthcare-associated infections. Despite the simplicity of this procedure and advances made in infection control, hospital health care workers’ compliance to hand hygiene recommendations is generally low. Nurses have the most frequent patient care interactions, and thus more opportunities to practice hand hygiene. As such, it is important to identify and understand determinants of nurses’ reported compliance. Formative research was undertaken to assess the potential impact of several unexamined factors that could influence HH among nurses: professional role and status, social affiliation, social norms, and physical modifications to the work environment (as well as institutional factors like safety climate). A survey questionnaire was developed primarily to inform the creation of a behaviour change intervention. The survey looked at how these factors influence HH among nurses and sought to identify barriers and levers to reported hand hygiene. It was administered to a survey panel of acute care nurses, working in US hospitals, with a year or more of experience. Multivariate regression modelling suggested that reported hand hygiene compliance was most likely to be a function of a hospital management’s communication openness, perceived performance by peers, increased interactions with patients and other staff members, and the reduction in stress, busyness, and cognitive load associated with role performance. A powerful, effective intervention on HH among nurses therefore could be directed at improving communication openness, consider the impact of perceived performance by peers, increase interactions with patients and staff, and determine how to reduce the stress and cognitive load associated with role performance.

Citation: Sands M, Aunger R (2020) Determinants of hand hygiene compliance among nurses in US hospitals: A formative research study. PLoS ONE 15(4): e0230573. https://doi.org/10.1371/journal.pone.0230573

Editor: Abrar Ahmad Chughtai, University of New South Wales, AUSTRALIA

Received: October 4, 2019; Accepted: March 3, 2020; Published: April 7, 2020

Copyright: © 2020 Sands, Aunger. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: MHS and RA received financial compensation as affiliates of the London School of Hygiene and Tropical Medicine, which served as a paid consultant to GOJO Industries, Inc. for the creation and evaluation of the intervention. The funders had no role in study design, data analysis, decision to publish, or preparation of the manuscript.

Competing interests: MHS and RA received financial compensation as affiliates of the London School of Hygiene and Tropical Medicine, which served as a paid consultant to GOJO Industries, Inc. for the creation and evaluation of the intervention. GOJO Industries, Inc did not participate in the creation of the questionnaire, in the analysis or interpretation of the data, or in the drafting of the manuscript. This does not alter the authors adherence to PLOS ONE policies on sharing data and materials.

Abbreviations: ABHR, alcohol-based hand rub; BCD, Behaviour Centred Design; BCTs, behaviour change techniques; HAIs, healthcare associated infections; HCWs, healthcare workers; HH, hand hygiene; HHC, hand hygiene compliance; ICU, intensive care unit; SRHI, Self-reported habit index

Introduction

Hand hygiene (HH) is the simplest and most effective measure for preventing healthcare-associated infections (HAIs).[ 1 ] Despite the simplicity of this procedure and advances made in infection control, hospital health care workers’ compliance to HH recommendations is generally low.[ 2 ] Nurses have the most frequent patient care interactions, and thus more opportunities to practice HH.[ 3 ] As such, it is important to identify and understand determinants of nurses’ reported compliance.

Hand hygiene is a complex behaviour with a myriad of motivators and barriers.[ 1 , 4 ] While the basic behavioural aspects surrounding HH practices in hospital settings have been widely researched, there remain gaps in the literature regarding effective psychological promotion of hand hygiene compliance (HHC).[ 4 ] Psychological frameworks have been shown to lead to behaviour change in a wide variety of contexts, especially in the behaviour of healthcare workers (HCWs).[ 5 ] Therefore, focusing on determinants of behaviour change and employing psychological behaviour change models can better inform HH improvement strategies.

Behaviour Centred Design (BCD) is a general approach to behaviour change that offers both a Theory of Change for behaviours in addition to a practical process for designing and evaluating interventions.[ 6 ] The BCD’s Theory of Change incorporates concepts such as reinforcement learning theory,[ 7 ] the evolution of behavioural control,[ 8 ] the evolved structure of human motivation,[ 9 ] and behaviour settings theory.[ 10 , 6 ] The behaviour settings theory explains the relationship between individuals and the environment—both physical and social.[ 10 ] Behaviour is a function of the setting within which it takes place. As such, behaviour settings are situations where people have learned what to expect from the environment and from other people’s behaviours. Each setting has a purpose, a designated place, a set of objects, and a prescribed set of behaviours. Therefore, each person entering a setting expects others, who are also participants, to perform their designated roles.

BCD is associated with a checklist of factors that determine human behaviour, which can be used to direct empirical investigations prior to the design of public health interventions. This checklist includes environmental determinants such as the props and infrastructure that support performance of the behaviour, as well as the psychological characteristics and personal traits required.

The aim of this study is to use the BCD approach to identify determinants that impact the HHC of nurses in intensive and acute care hospital units. A combination of literature review and formative research are used to identify prospective strategies for a behaviour change intervention. Recognizing what motivates and hinders a nurse from practicing HH should aid in the development of successful strategies seeking to improve nurses’ HHC.

Given the complexity of institutional settings for behaviour change, our data gathering strategy focussed on potentially important factors that have not yet been found to be significant. The literature search began with a background search to develop an understanding for the breadth of the body of literature. The iterative search process became more refined and developed as the review progressed. Once the volume and general scope of the HH field had been determined, parameters were set and search strings were developed [ S1 File ]. Search strings were developed for concepts encompassing behaviour change, hand hygiene compliance, healthcare workers, healthcare-associated infections, hand hygiene, and interventions. Medline, Web of Science, CINAHL, and Google Scholar databases were electronically searched selecting only for papers written in English. A total of 187 publications were identified this way; after filtering for papers published from January 2002- January 2015, there were 89 papers left to be reviewed. Additional papers and grey literature were identified by searching the references lists of the retrieved papers. We used the WHO’s tables of factors (WHO Table I.2.1) as well as hand hygiene improvement interventions (WHO Table I.2.2) as a framework.[ 1 ]

Categorizing and identifying modifiable factors using BCD

The BCD Checklist itemises all the types of behavioural determinants identified by the BCD approach. Placing the factors from the literature known to influence HHC ( Table 1 ) into the BCD Checklist enables us to see what categories of factors have potential for deeper investigation and could serve as the foundation for further research into HHC (see Table 2 ). This analysis shows that only a few of these categories have been investigated by intervention-based studies in the literature, and it is apparent that whole categories of factors have not yet been examined by the public health community. Types of potential factors that have been completely ignored thus far are listed without entries in Table 1 . It should be noted that even some categories with entries below have not been fully investigated; additional factors could be identified and explored. If we restrict our attention to categories—either with or without entries—which can be readily changed by the types of mechanisms that are both acceptable and within the budget of an average hospital administration, we arrive at the following list of five categories: (1) motivational psychology , (2) reactive psychology (i.e. habit formation), (3) modification of the relevant behaviour setting stage , (4) role change , and ( 5) social norm manipulation . These categories will be the focus of this formative research.

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Importance of this formative research

Formative research is a critical step in the development of health behaviour change interventions.[ 6 , 11 ] The purpose of formative research is to assess individuals’ beliefs, perceptions, behaviours, and the structure of the environment itself that may help or hinder program effectiveness. Typically, such research involves significant fieldwork in the relevant context. In the case of this study, the ability of the research team to obtain a comprehensive view of the factors associated with HHC was limited by the logistics of access to hospitals. It was neither possible to take nurses from the floor during their shift nor to engage in substantial observation of their practices without introducing bias into the data collection. Further, there is considerable variation and organization-specific intricacies when it comes to the institutional contexts of HHC, which needs to be understood and considered when creating interventions intended to be widely used. Thus, the decision was made to administer a survey to a large number of nurses with a range variety of experiences across the United States, gaining in breadth what was lacking in terms of depth in the investigation. This survey sought to assess the behavioural change potential of the factors identified by the analysis above.

Ethics approval was attained from the London School of Hygiene and Tropical Medicine’s Observational and Interventions Research Ethics Committee (reference number is 14411).

Sampling procedure

An anonymous internet-based cross-sectional survey was administered between November to December 2015 by a global online sampling and digital data collection company called Dynata—formerly known as Research Now—to a survey panel of acute care nurses, working in various types of hospitals that are geographically distributed across the US, with at least a year or more of experience. There were 19,969 hospital nurses available to take the survey. With a confidence interval of 95% and a margin of error 5%, we calculated that we need a minimum of 377 completed surveys. Dynata screened and recruited participants, and it used an incentive scale based on set time increments. Incentive options allowed panellists to redeem from a range of gift cards, charitable contributions, and other products or services upon completing the survey.

Survey design

The survey concentrates on the five unexamined but modifiable factors that are potential determinants of HHC: (1) motivation, (2) habit, (3) roles, (4) behaviour setting stage, and (5) norms. The survey questions, which draw upon various concepts and measurement tools from fields such as sociology and psychology, are designed to measure the degree to which these factors influence reported HHC [ S2 File ]. In doing so, a novel questionnaire was developed using techniques—such as vignettes and the self-reported habit index (SRHI)[ 12 ]—that have not been commonly or consistently used in HH questionnaires before. The movement of the respondent through the survey is depicted in Fig 1 . The explanation of the theoretical underpinnings of the survey with their respective survey questions follow.

To make a more succinct and pertinent list of risk factors for this research project, we first determined which factors have already been found to have a significant impact on HH behaviour from a literature search and review.

https://doi.org/10.1371/journal.pone.0230573.g001

The role of the nurses was explored through professional identity. Identities are the traits and characteristics, social relations, roles, and social group memberships that define an individual.[ 13 ] A professional identity is the sense of self that is associated with the enactment of a professional role.[ 14 , 15 ] This identity gives members of a profession a definition of self-in-role and the goals, values, norms, and interaction patterns that are associated with their job.[ 16 ] This definition of identity is critical to how professionals interpret and behave in various work situations, with identity being both a product of situations and a determinant of behaviour within situations.[ 13 , 17 ] Identity is (a) predicted to influence what individuals are motivated to do, (b) encompasses how individuals think and makes sense of themselves and others, (c) the actions the individuals take, and (d) the individuals’ feelings and abilities to control or regulate themselves.[ 18 , 19 ]

A social norm is a rule of behaviour that individuals conform to conditionally based on the beliefs that (a) most people in their relevant network conform to this behaviour (this is referred to as an empirical expectation ), (b) they themselves believe that they should perform the behaviour ( normative personal belief ), and (c) that most people in their relevant network believe they ought to conform to this behaviour as deviations from the norm could result in potential punishment (referred to as a normative expectation ).[ 28 ] Social norms direct human action, however, norms are situationally contingent, meaning that a norm’s salience and one’s compliance to this norm are conditional upon the situation.[ 29 ] To understand and predict behaviour, it is important to know which social norms individuals find salient in particular contexts—that is, which norms are likely to be dependent on particular settings.[ 30 , 31 ]

The normative system of nursing with respect to HH behaviour can be measured through learning about (a) individual’s preferences for ‘proper’ HH action, (b) expectations of others’ HH behaviour, and (c) beliefs about the expectations others have of them in this regard. We sought to identify nurses’ social norms regarding hand hygiene and whether the social norms have a causal influence on behaviour. Bicchieri (2014) devised a series of questions that diagnose, explain, and predict collective patterns of behaviour, which were adapted for the research purposes here.[ 28 ] This involves ascertaining several aspects of a normative system, including empirical expectations, normative beliefs, and normative expectations. To test empirical expectations, respondents were asked about their own beliefs regarding the prevalence of HH behaviour among their peers; respondents were asked to disclose how many nurses out of a group of ten would always practice HH at the various indications.

To test normative personal beliefs, respondents were also asked if they think they should practice HH at six various moments: (1) before entering a patient’s room, (2) when exiting a patient’s room, (3) after taking a patient’s vitals, (4) after cleaning a patient’s wound, (5) before charting in the nurse station, and (6) after talking with fellow nurses in the break room. Responses along a Likert scale from Never to Always were offered. To test normative expectations, respondents were asked if they believed that other nurses thought that they should use hand sanitizer or soap at the same moments provided above. Once again, the same Likert scale offered five response options.

Habits are defined as psychological tendencies to respond automatically to environmental stimuli, acquired through repeated practice in particular contexts.[ 32 , 33 ] Habitual actions are triggered in response to contextual cues associated with their performance: for example, automatically putting on a seatbelt (action) after getting into the car (contextual cue) or washing hands (action) after using the toilet (contextual cue).[ 34 ] Habit strength is a continuum. Habits that are considered to be of weak or moderate strength are performed with less frequency than strong habits.[ 35 ]

Participants were asked about the strength of their HH habits using the Self-Report Habit Index (SRHI) developed by Vernplanken et al. (1994).[ 36 ] The SRHI is a tool used either as a dependent variable, or to determine or monitor habit strength without measuring behavioural frequency. It discriminates between behaviours varying in frequency and between daily vs. weekly habits. The index is based on features of habit: a history of repetition, automaticity, and expressing one’s identity. Respondents answer the degree to which they felt the statement affected them using a 5-point Likert scale (from Strongly Disagree to Strongly Agree). There is evidence that the SRHI can solicit accurate answers comparable to real behaviours.[ 37 ] The index in this case is phrased to ask respondents about practicing HH before entering and after exiting a patient’s room.

Motivation.

Motives are evolved psychological mechanisms that help individuals choose the appropriate goal-directed behavioural strategy in response to a situation.[ 38 ] An appropriate strategy would most likely lead to a satisfactory outcome in terms of the benefits accruing from that interaction with the environment.[ 9 ] A satisfactory outcome involves an experience that is rewarding—be it a sensory pleasure, a metabolic benefit for the body, or a change to one’s place in the social world.

This research sought to identify what motivates people to practice HH. Thus, the objective of the motive questions was to determine if a person of higher status—such as a nurse manager or direct supervisor—or someone who is dependent on the nurse—such as patient—is a likely motivator of HH. The BCD’s motive mapping technique is used.[ 6 ] Motive mapping attempts to reduce psychological ‘distance’ by simulating the behavioural context using a narrative, and attempts to minimize the participant’s reflection by focusing directly on the rewards from performance.

Participants responded to three scenarios asking about how feedback is likely to influence their own HH behaviour. In each of the scenarios, participants were told that they had taken a patient’s vitals and immediately practiced HH upon exiting the room. At the end of each scenario, positive feedback regarding the practicing of HH was shared with the nurse by the nurse manger, a fellow nurse, and the patient. Respondents answered to what degree they feel this feedback makes them more likely to use hand sanitizer in the future as compared to normal usage. A five-point Likert scale measured responses.

Situational constraints: Vignettes.

Participants were asked to judge their likely compliance to HH in varying situations known as vignettes. Vignettes are closer to real-life judgment-making situations than relatively abstract questions that are typical of most surveys. Respondents were asked to reflect on whether they would practice HH in the following situations: (1) exiting a patient’s room after taking the patient’s vitals, (2) entering a patient’s room before taking vitals, (3) exiting a patient’s room after cleaning and bandaging the patient’s diabetic foot wound, and (4) entering a patient’s room before cleaning and bandaging the patient’s foot wound. These situations were altered slightly for each follow-up question by introducing either a facilitator or a barrier to practicing HH, such as:

• Large patient load, which measures busyness
• Already wearing gloves, which measures the nurse’s inclination to practice HH when wearing protective equipment
• Being observed by the infection prevention manager, which measures higher status social influence
• Being observed by a fellow nurse, which measures peer influence
• Trying to practice hand hygiene but the dispenser is empty, which measures perception of ease
• An interruption during patient care requiring the immediate assistance of the nurse, which measures interruption
• An emergency requiring CPR, which measures reaction to emergency

Through vignettes, we sought to determine the extent to which these factors impact HH behaviour. Responses were presented on a five-point Likert scale based on the likelihoods of behavioural response.

Institutional factors: Safety culture and familiarity with hand hygiene.

Nurse behaviour takes place within the context of hospital life. Hospitals can be considered institutions, which have an impact on the settings that occur within them. Therefore, this research sought to assess the culture of safety within the respondents’ institutions. It has been widely accepted that the safety culture of one’s hospital affects HHC rates.[ 1 , 39 – 41 ] To measure the safety culture of the hospitals where the respondents work, the research team selected and modified questions from the hospital survey on patient safety culture developed by the US Agency for Healthcare Research and Quality.[ 42 ] Questions were grouped according to the safety culture dimensions they are intended to measure. Groups included: rating overall perceptions of safety, frequency of event reporting, supervisor/manager expectations and actions, teamwork within units, closeness, communication openness, feedback and communication about error, non-punitive response to error, staffing, and hospital management support. Five point Likert scales asking for agreement/disagreement and frequency were used.

Participants were also asked about their engagement and participation in past HH training and interventions, both as nursing students and as practicing professionals. In addition, participants were asked about their hospital’s own HH programs. Questions were all phrased so that a yes/no response was appropriate.

Modification to physical setting.

Finally, the research aimed to investigate various ways to disrupt a behaviour setting, specifically by identifying how the stage and arrangement of props of the setting surrounding the act of HH serve as constraints or opportunities to practicing HH. Respondents are presented with two photos—one of a hallway in a non-descript hospital and one of a patient’s room—and then asked how both the hallway and the room could be altered to better facilitate HH. These questions allowed for open-ended responses.

Formatting the survey

The survey was a self-administered online task. Each question was presented on its own webpage. Respondents were first asked a series of screener questions to determine if they were eligible: they had to be an acute care nurse, working in a US hospital, with a year or more of experience.

Those who are eligible were then presented with a series of photos related to the modification of the physical setting. These questions were asked first because the research team wanted responses that were not influenced by other questions in the survey. In addition, the photos served to ground the respondents in the survey by providing visual context. The vignettes immediately followed; the research team reasoned that the vignettes would likely solicit the most accurate responses about HH performance. As such, the vignettes were placed early in the survey so that the respondents were not biased or primed by subsequent specific queries. The professional identity questions were asked next as these questions tapped into values. Questions about norms followed and were followed by questions on habit and motivation. The final questions focused on the safety culture of the hospital as well as the respondents’ history with HH interventions and programs. A diagram of the survey questions and flow are provided in Fig 2 .

The survey is broken into sections; the movement of the respondent through the survey is depicted in this figure.

https://doi.org/10.1371/journal.pone.0230573.g002

Analysis of the survey

Descriptive statistics were first used to characterize the sample. Univariate analyses were therefore first conducted to determine which variables were associated with reported levels of HHC. Next, a multivariate regression of the variable of interest—reported HH on exiting a patient room after taking vitals—was conducted on demographic, role, safety culture, and norm variables. This variable of interest was chosen as it was asked in the form of a vignette, which is closer to real-life judgment-making situations and thus provided a better sense of compliance than asking respondents directly about their HHC. In addition, this specific vignette question was used as nurses are more likely to practice HH upon exiting a room, but less likely to practice HH after conducting a low-risk procedure. As an ordinary least squares regression of outcome on predictors was inappropriate for a model with this number of predictors but only 500 observations, we performed a bidirectional stepwise procedure to build the model, using the Akaike Information Criterion (AIC) as the model-building criterion for adding or removing variables; any variable that, when removed, changed the model AIC by ≤ 1 was discarded by the procedure.

Study population

A total of 540 surveys were completed. Table 2 summarizes selected characteristics of the participants. The median age was 49 (range: 24–70). In a typical workday, more than two-thirds of the respondents (68%) reported spending 80% or more of their time performing direct patient care. Familiarity with HH practices was indicated by 459 (85%) of respondents, who reported that HH was emphasized during professional training to be a nurse. Furthermore, the clear majority of respondents (456, or 84%) had participated in a hospital-led hand hygiene initiative before.

Summary variables were standardized before analysis. Variables included habit , safety culture , norms , motivation , role , hand hygiene familiarity , and demographics . Means were taken across Likert scale questions per the prescribed groupings. Sums were calculated across yes/no variables and demographic variables were encoded with a binary number system.

Univariate analysis

The results for each of the five main potential determinants of HHC have been provided in their respective tables and figures enumerated below. Major findings have been summarized for norms , habit , and motives .

The results for every question in this section of the survey are included in Table 3 . The most salient findings were that nurses were more likely to practice HH upon exiting a patient’s room than entering, and that when the procedure was perceived as being high-risk—such as cleaning and bandaging a wound—there was an increased likelihood of practicing HH. Most notably, 90.7% (n = 490) of nurse respondents reported being likely to practice HH upon exiting a patient’s room after cleaning and bandaging the diabetic foot wound.

https://doi.org/10.1371/journal.pone.0230573.t003

The results for empirical expectations, normative personal beliefs, and normative expectations have been presented in Table 4 . Regarding empirical expectations , respondents felt that most nurses practiced hand hygiene before entering a patient’s room, when exiting a patient’s room, after taking a patient’s vitals, and after cleaning a patient’s wound. Concerning normative personal beliefs , for each moment apart from charting, most respondents claimed that HH should always be practiced. Of the 540 respondents, 81.7% (n = 441) of respondents said it should always be practiced before entering a patient’s room, 90.4% (n = 488) when exiting a patient’s room, 75.6% (n = 408) after taking patient’s vitals, and 98.7% (n = 533) after cleaning a patient’s wound. With normative expectations , over 50% of respondents claimed that most other nurses always think that one should practice hand hygiene before entering a patient’s room, when exiting a patient’s room, after taking a patient’s vitals, and after cleaning a patient’s wound. [Figs H and I in the S1 Fig display the results.]

https://doi.org/10.1371/journal.pone.0230573.t004

Respondents answered the SRHI about practicing HH before entering a patient’s room and after exiting a patient’s room. Responses were made on five point Likert scales anchored by the terms strongly agree-strongly disagree and were coded such that high values indicated strong habits (1 = strongly disagreeing and 5 = strongly agreeing). The means of the questions were calculated, and these in turn became the habit strength scores. Regarding HH upon entering a room, 59.1% (n = 319) of respondents had a score of 4.5 or over ( Fig 3 ). In the case of exiting, 68.0% (n = 367) of respondents had a habit strength score of 4.5 and over ( Fig 4 ).

https://doi.org/10.1371/journal.pone.0230573.g003

https://doi.org/10.1371/journal.pone.0230573.g004

Upon receiving feedback from nurse managers and fellow nurses, 50.7% (n = 274) of participants and 55.4% (n = 299) said that there would be no difference in future HH action, respectively. Regarding receiving feedback from patients, 59.3% (n = 320) respondents said that feedback would positively impact their HH behaviour in the future. Results are summarized in Table 5 .

https://doi.org/10.1371/journal.pone.0230573.t005

Safety culture.

The results for each question in this section of the survey are included in Table 6 .

https://doi.org/10.1371/journal.pone.0230573.t006

Multivariate regression

Presented in Table 7 are the results from the bidirectional stepwise procedure to analyse the relationships between various predictors and the outcome: reported HH on exiting a patient room after taking vitals. Included in the table are only the variables which met the selection criteria. Values are provided for the regression Estimate, as well as its Standard Error, T-value, and Pr(>|t|) coefficients. Coefficients were assigned to each predictor; the sign on the coefficient (positive or negative) provides the direction of the effect of the predictor on the outcome variable.

https://doi.org/10.1371/journal.pone.0230573.t007

The reported higher likelihood of practicing HH upon performing a high-risk procedure as compared to a low-risk procedure aligns with the literature which shows that HHC is greater when involving higher-risk tasks.[ 2 , 43 , 44 ] In addition, nurses reported being more likely to practice HH upon exiting a patient’s room than entering, which is interpreted as nurses practicing HH as a form of self-protection.[ 44 ]

Nurses work in close relationships with patients who are vulnerable and largely dependent on the nurse for care.[ 45 ] Nurses work with one another and on inter-professional healthcare teams to deliver care and provide support. Fagermoen’s (1997) proposed theoretical model for professional identity of nurses maintains that nurses’ perceptions of the ‘professional self’ focuses on both other-oriented and self-oriented values .[ 45 ] Other-oriented values encompass the nurse’s actions on behalf of the patient’s well-being and the interactions with patients in providing care. Self-oriented work values include work performance and collaboration with other professionals. While self-oriented work values directly impact the self, these values also affect the care delivered. For instance, better stress management can lead to a nurse feeling more confident, capable, and in control, which can then lead to better care delivered.

When asked which values the participants wish they had exhibited more of during their last shift, the traits most widely selected were those of self-oriented values such as stress management, patience, good communication, and physical and mental endurance. These in turn impact other-oriented values to a degree since work performance directly influences the kind of care delivered. Other-oriented values are the foundation of nursing care and an integral part of the nurses’ relationships with patients. Areas of improvement could be seen in how nurses engage in the work-setting and the actualization of the other-oriented values . When asked what the nurses would least like to hear said about them, the top responses were about the inadequacy in the delivery of care. This again demonstrates how integral other-oriented values are to the discipline of nursing.

There is agreement amongst participants as to when to practice HH—upon entering and exiting a patients’ room and after performing a procedure such as vitals or cleaning a wound. It is apparent that participants believed these to be norms, and believed others to hold the same norms in addition to conforming to such norms. This suggests that HH indications are well understood and agreed upon by nurses.

Habit is the cognitive mechanism by which actions occur reflexively and in a fixed sequence.[ 46 ] Habit scores were quite high, which is not unexpected for a behaviour that is practiced many times a day. This suggests that the SRHI may not be useful in measuring behaviour that is already being practiced intensively.

Over half of participants indicated that receiving feedback from a patient or a colleague would likely lead to an increase in future HH action. There is evidence that HH behaviour of HCWs is positively influenced by the presence and proximity of peers.[ 47 , 48 ] Regarding patients, patient involvement in supporting their own safety has been widely discussed. [ 49 – 51 ]. Patient involvement in HH—such as praising HCWs for practicing HH or reminding HCWs to wash their hands—and its impact on HH behaviour has not been extensively studied [ 51 ], but our results show that it would be acceptable to HCWs for patients to recognize nurses for practicing HH.

The variable of interest was the reported HHC upon exiting a patient’s room after taking their vitals. This question had the most variance in responses. The regression analysis shows that reported HHC is a function of specific variables at all possible levels: the hospital, unit, and individual. At the hospital level, increased openness of communication —which was asked about in the safety culture portion of the survey—led to a higher reporting of HHC. There is evidence that features of a hospital’s safety climate are related to how well standard precautions and safety practices, such as HH, are adhered to.[ 52 – 54 ] Communication openness is a component of a hospital’s patient safety culture and is defined as the extent to which the staff freely speak up if they see something that may negatively affect a patient and/or question those with more authority.[ 40 , 55 ] A core tenet behind communication openness is that all have a responsibility to speak out when certain actions, objects, or processes pose danger to the safety of the patient and others, and those who speak out should be able to do so without fear of being reprimanded. It could be surmised that those who are comfortable enough to speak out about threats to patient safety would also act on their own accord to protect patient safety by practicing HH at the proper indications.

At the unit level, the type of hospital unit played a role in the HHC reported—overall, participants who work in an emergency department reported lower HHC rates. This could be attributed to the fact that nurses must respond to various unpredictable situations that could be life-threatening to the patient, and the patient’s need for immediate attention and care is put first before practicing HH. Practicing HH in an emergency could be perceived as dilatory. This could also be because the emergency department is an environment with a high density of invasive procedures that require glove usage, and there is evidence that glove usage is inversely correlated with adequate HH. [ 1 , 56 , 57 ]

An interesting finding was that nurses who indicated having a higher proportion of shift time allocated to interaction with patients and with fellow healthcare professionals reported higher HHC. More time spent with a patient could lead to more opportunities to practice HH and thus more events completed. However, this challenges the notion that the higher the demand for hygiene (the more opportunities to practice it), the lower the adherence rates. Nevertheless, the more time spent with other HCWs could result in a nurse feeling the ‘watching eyes’ effect thus leading to increased HHC. More time with the patient could also result in the nurse bonding with the patient and is thus more cognisant of practicing HH to ensure the patient’s safety.

At the individual level, one’s personal ability to manage subjectively important aspects of the professional role—such as stress management, communication skills, and being confident in one’s self as a nurse—leads to increased reporting of HHC. All the individual-level variables in the analysis could be defined as other-oriented to a degree as presumably successful stress management can lead to providing better care. The significant individual variables show other-oriented values involving care and communication as being of highest professional importance to nurses, and this orientation fosters better HH.

It has been noted in the literature that poor working conditions, increased levels of stress, and insufficient communication have a direct negative impact on the quality of nursing and have severe consequences for patients.[ 58 – 61 ] In addition, low HHC can result from fatigue or burnout. As a nurses’ shift progresses, HHC declines towards the end of the shift.[ 62 ] Continuous long shifts can lead to nurse burnout which in turn has been associated with increased HAI levels.[ 63 ] Thus, nurses who feel in control, confident in their abilities, supported, and have lower stress levels can better focus on and execute safety procedures such as HH.

Limitations

Surveys administered to HCWs are relatively inexpensive and allow for HCWs to focus and reflect on their own practices. However, self-report of infection prevention can be flawed, especially as reported HH practices and actual HH practice can differ significantly.[ 54 , 64 , 65 ] In using vignettes, we may have reduced socially desirable responses by allowing participants to report their HH practice and the practices of others through the vignette character(s) and situations.[ 65 , 66 ] This may have reduced the potential for disparity between reported and actual behaviour. Additionally, generalizability of the findings may be limited by certain characteristics of the sample, achieved through online data recruitment. This limitation was addressed by administering the survey online, which allowed for us to collect responses from a wide variety of participants located in different regions and hospitals of the United States with varying degrees of experience and specialisation.

Formative research was undertaken to assess the potential impact of several unexamined factors that could influence HH among nurses: professional role and status , social affiliation , social norms , and physical modifications to the work environment , as well as institutional factors (like safety climate). A survey questionnaire looked at how these factors influence nurses’ reported HHC and also sought to identify barriers and levers to HH. Multivariate regression modelling suggested that HHC was most likely to be a function of a hospital management’s ‘openness’, perceived performance by peers, increased interactions with patients and other staff members, and the reduction in stress, busyness, and cognitive load associated with role performance. Thus, a powerful and effective intervention focusing on nurses’ HHC should address improving communication openness, consider the impact of perceived performance by peers, increase interactions with patients and staff, and determine how to reduce the stress and cognitive load associated with role performance. Use of Behaviour Centred Design increased the informativeness of the survey tool, and could be used more widely in formative research studies.

Supporting information

S1 file. search strings..

Concepts and their corresponding search strings.

https://doi.org/10.1371/journal.pone.0230573.s001

S2 File. Survey tool.

https://doi.org/10.1371/journal.pone.0230573.s002

S1 Fig. Results presented in figures.

https://doi.org/10.1371/journal.pone.0230573.s003

Acknowledgments

We are grateful to Rahul Singh for guiding the preliminary analysis of formative research results and for writing the code in R-studio for the multivariate analysis.

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• Published: 27 August 2024

Predictors of hand hygiene attitudes among Saudi healthcare workers of the intensive care unit in Saudi Arabia

• Norah Alhodaithy 1 &
• Salah Alshagrawi   ORCID: orcid.org/0000-0003-2800-4794 2  

Scientific Reports volume  14 , Article number:  19857 ( 2024 ) Cite this article

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Healthcare-associated infections present a challenge to healthcare systems, particularly critical care units. Hand hygiene emerges as a crucial element in infection control, acting as a vital link between healthcare workers, patients, and pathogens. Positive attitudes, motivated by a genuine concern for patient safety, are recognized as major predictors of hand hygiene compliance among healthcare workers. This study aims to assess the attitudes of ICU staff toward hand hygiene and identify factors that influence these attitudes. A cross-sectional survey of intensive care unit staff in seven large Saudi hospitals was conducted using an anonymous, self-reporting questionnaire to examine the attitudes of ICU personnel about hand hygiene and determine the factors that impact these attitudes. A regression analysis was used to determine the determinants of hand hygiene attitudes. Of the 600 respondents, 93% rated their hand hygiene knowledge as good, and 71% received hand hygiene training from their hospital. Most respondents (78%) had previously experienced healthcare-associated infections. The majority reported a favorable overall attitude toward hand hygiene (M = 4.15, SD = 0.85). Attitudes toward hand hygiene were significantly associated with perceived knowledge (β = 0.32, p  < 0.001), prior hand hygiene training (β = 0.13, p  < 0.05), and years of experience (β = − 0.10, p  < 0.05). Healthcare workers in the ICU have a generally positive attitude toward hand hygiene. Such attitudes were correlated with hand hygiene knowledge, prior training, and job experience. The study’s findings can help to inform health promotion initiatives and campaigns aimed at achieving long-term improvements in hand hygiene behaviors.

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Introduction.

Healthcare-related infections (HAIs) pose a challenge within healthcare systems that face the weight of longer hospital stays and increasing financial expenditures, while Healthcare Workers (HCWs) battle with the emotional toll of witnessing the agony of patients 1 . The urgency of addressing this issue cannot be emphasized, with lives at stake and healthcare resources stretched thin 2 . Even though the intensive care unit (ICU) typically occupies only a small proportion of all hospital beds, it is responsible for a disproportionate amount of hospital activities 3 . Patients in ICUs are especially vulnerable due to the additional complexity of their illness, the amount of disruptive monitoring and assistance equipment they utilize, and the frequency of procedures and blood draws 4 . These predictors increase the likelihood of safety errors and subsequent harm. HAIs can cause additional preventable patient harm in any setting 4 . Nearly 20% of all hospitalized patients' HAI diagnoses are obtained in ICUs. These infections have high rates of morbidity and death as well as substantial expenditures for the healthcare system, patients, and their families 5 .

Hand hygiene plays a vital role in infection control. It is the most effective and efficient way to minimize the further spread of the infection 6 . Handwashing or sanitization, when done rigorously and regularly, acts as a sentinel, interrupting this transmission chain. However, the achievement of compliance with hand hygiene procedures is a complicated process due to several predictors, encompassing human, organizational, and environmental variables 7 . Understanding the predictors of hand hygiene could enhance compliance and maintenance, which helps to reduce HAIs. Individual-level characteristics, such as HCW attitudes, appear as important predictors 8 . Positive attitudes, motivated by a real concern for patient safety, are the driving force behind rigorous hand hygiene measures. The literature highlights the varying degrees of attitudes toward hand hygiene among HCWs 9 .

Analyzed data from the Saudi Ministry of Health (MoH) about sentinel incidents from 2012 to 2015 revealed that 91% of these occurrences were categorized as avoidable. Saudi Arabia took measures to address this problem by implementing strategies to minimize risks and enhance the safety and quality of healthcare. However, few studies have focused on the patient's safety measures in the ICU 10 . The primary aim of this study is to assess the attitudes of ICU staff toward hand hygiene and identify factors that influence these attitudes. To the best of our knowledge, this is the first study that examines the attitudes toward hand hygiene among a randomized sample of ICU HCWs recruited from various Saudi hospitals. The study aims to contribute to current efforts to improve patient safety and quality of treatment in the ICU environment by understanding the attitudes and their influencing predictors to adopt the best practices in hand hygiene.

Study design and setting

The study was carried out in the intensive care units of seven large hospitals in the Saudi Arabian region of Riyadh. We employed a cross-sectional analytical design, conducted from November 1st to 15th, 2023.

Study participants and sampling

The study involved a random selection of HCWs who provide ICU care to patients in seven major hospitals located in the Riyadh region of Saudi Arabia. The hospitals had an average capacity of 800 beds with a 1:4 average nurse-to-patient ratio in the ICUs. A minimal sample size of 580 was determined by utilizing a 5% margin of error, a 95% confidence level, a 50% response rate, and an 80% prior estimate level of hand hygiene attitudes 11 . The method of simple random sampling was used by creating a comprehensive list of all HCWs in the ICU and then selecting individuals using an automated random selection process. A total of 680 HCWs received the invitation to participate in the online survey, and 600 of these individuals responded (response rate = 88%).

Measures and data collection

A self-reporting, anonymous questionnaire that was adopted from a reliable and valid source was employed as the study instrument, which used a behavior change theoretical framework to identify items that specifically attitudes toward hand hygiene 12 . The questionnaire has undergone pre-validation using both qualitative and quantitative methodologies. The first stage included doing a content analysis of qualitative open-ended questions. In the second step, exploratory factor analysis was used to analyze the quantitative data 12 . In our study, the questionnaire was tested with a subset of our population and no modifications were required. Table 1 displays the questionnaire consisting of 20 questions that pertain to demographic data, prior hand hygiene instruction, and attitudes toward hand hygiene. The study measurement presented a good internal consistency with Cronbach’s alpha = 0.85, illustrated in Table 2 . A Likert scale with five points, ranging from “strongly disagree” to “strongly agree,” is used for each attitude measuring item. A computed score of more than 75% was regarded as good, a score of 50–74% as moderate, and a score of less than 50% as poor 13 , 14 , 15 . The questionnaire was distributed online to randomly selected HCWs who were given explicit instructions on how to complete the survey. Before the study’s implementation, a pilot study was undertaken to assess the practicality and applicability of the research design and data collection procedures. Ethical considerations” where you can add the paragraph presented in the measure’s subsection “Before data collection, informed consent was obtained from all subjects. Methods were performed in accordance with the Declaration of Helsinki and relevant guidelines and regulations The study was approved by the King Fahad Medical City Institutional Review Board under number1R800010471 and Federal Wide Assurance number FWA00018774.

Statistical analysis

Descriptive statistics were used to summarize the respondents' demographics, perceived knowledge, and attitudes. Inferential statistics were used to explore the relationships between variables and discover predictors of hand hygiene compliance. Logistic and multiple regression were utilized to investigate the relationship and association between included variables. The quantitative data from the survey questionnaire was analyzed using the IBM SPSS v.28 software (IBM Corp., Armonk, NY, USA); URL link. https://www.ibm.com/spss .

Descriptive findings overview

Of the 680 distributed questionnaires, a total of 600 HCWs completed the study (response rate 88%). Table 1 presents the respondent's demographic characteristics, including their profession, sex, years of experience in healthcare, direct care provision to patients, perceived hand hygiene knowledge, previous hand hygiene training, history of HAIs, as well as perceived job workload. The majority of HCWs in our study were females (75.1%) and nurses (50%). Additionally, 78% of respondents had at least a year’s experience, 71% had previously received training on hand hygiene, 93% evaluated their understanding of hand hygiene as good, and around 70% indicated managing their workload was challenging.

Hand hygiene knowledge

Most respondents (93%) reported having good hand hygiene knowledge. However, there was variation in the level of knowledge on hand hygiene. Compared to male respondents, more female respondents (β = 0.14, p  < 0.001) indicated they have good hand hygiene knowledge. Furthermore, the knowledge of respondents who had previously received hand hygiene instruction was greater (β = 5.57, p  < 0.05) compared to respondents who did not receive any hand hygiene training.

Prior hand hygiene training

A majority of respondents (71%) stated that they had received previous training in hand hygiene. Comparing the respondents, we found that more female respondents than male respondents reported having had prior hand hygiene training (β = 3.39, p  < 0.001). Furthermore, compared to all other professions, a higher percentage of nurses reported having previous training in hand hygiene (β = 7.76, p  < 0.001).

History of HAI infection

The percentage of responders who have been infected due to HAI was high (60%). Respondents with high workloads were more likely to report hospital-associated infections (β = 1.58, p  < 0.05). Additionally, respondents who had experienced HAIs were more likely to report having hand hygiene training (β = 6.171, p  < 0.001).

Attitudes toward hand hygiene

In the examination of the attitudes of ICU HCWs regarding hand hygiene (Table 2 ), a considerable majority had a good overall attitude toward hand hygiene (M = 4.15, SD = 0.85). One-third of the respondents disagreed that hand hygiene is a crucial aspect of their work, while 18% said they would not feel guilty if they disregarded hand hygiene regulations. Additionally, 17% of the respondents thought hand hygiene would not stop infections from contaminated surfaces, 4% said they were unaware of their employer’s hand hygiene policy, and 6% disagreed that hand hygiene can help spread infection.

The multiple linear regression model

The multiple linear regression model examined how the healthcare profession, sex, years of experience, direct patient care, hand hygiene knowledge, previous hand hygiene training, past HAI experience, and perceived workload influenced attitudes toward hand hygiene (Table 3 ). The suggested model explains around 15% of ICU respondents' attitudes towards hand hygiene, as indicated by an adequate fit (F (583) = 6.05, p  < 0.001) and R 2  = 0.15. The model identified significant associations between respondents’ attitudes toward hand hygiene and perceived knowledge about hand hygiene (β = 0.32, p  < 0.001), previous training in hand hygiene practices (β = 0.13, p  < 0.05), and having experience, less than a year of experience compared to more than 10 years of experience (β = − 0.10, p  < 0.05), and being a physician compared to being a nurse (β = − 0.07, p  < 0.05).

The current study aims to explore the attitudes of ICU HCWs toward hand hygiene and determine the associations between such attitudes and HCWs' knowledge of hand hygiene, prior hand hygiene training, history of HAIs, perceived workload, and HCWs’ demographic factors. We found that most respondents had a good overall attitude toward hand hygiene that was correlated positively with the respondent’s knowledge and training on hand hygiene. In addition, physicians exhibited lower attitudes than nurses, while HCWs with less than 1 year of experience reported lower attitudes than more experienced HCWs.

We found that hand hygiene knowledge was high among the majority of participants. Similar findings have been demonstrated by other studies 16 . However, non-compliance with hand hygiene was not necessarily related to hand hygiene knowledge among healthcare workers 17 . Compared to male HCWs, more female HCWs in our study reported knowing a lot about hand hygiene. Other research demonstrated similar findings in Saudi Arabia 18 , and in other countries 19 , 20 . No clear rationale has been provided; therefore, additional quantitative and qualitative studies are necessary to throw more light on such gender discrepancies. We also identified a positive correlation between prior training in hand hygiene and perceived hand hygiene knowledge among HCWs. As a result, training healthcare staff on proper hand washing techniques and providing them with reminders may greatly increase their awareness and proficiency regarding hand hygiene 21 .

In our study, although it was more common among women, the majority of respondents had received some form of hand hygiene training in the past. Such findings are in contrast with other studies that showed no significant difference 17 . Additionally, we observed that more nurses reported having hand hygiene training compared to other professions. Other studies have found that nurses receive greater training in hand hygiene practices than physicians and other healthcare workers 21 . The increased level of training among nurses might be justifiable considering the frequency of direct contact with the patient in the ICU. Thus, hospital management should routinely schedule essential training programs, praise, and reward HCWs for meeting established objectives and ensuring patient care and safety.

We found that most of the respondents had a history of HAIs, which was shown to be positively associated with the amount of work they performed. It should be noted that the development of HAI combined with the inherent complexity of care for ICU patients can directly impact HCWs and cause work overload, which might contribute to the increase of HAIs 5 . Despite other patient-related and procedure-related variables, an excessive workload for healthcare workers was found to be a major risk factor for the development of HAIs in clinical patients admitted to the ICU 9 , 22 , 23 .

The examination of the attitudes of the participants regarding hand hygiene reveals that a significant majority displayed a positive overall attitude toward hand hygiene. The participant's attitude toward hand hygiene was high compared to other research that revealed HCWs' moderate to poor attitudes 15 , 24 , 25 . Studies have demonstrated that the positive attitude of healthcare personnel is associated with an increase in hand-washing behaviors 26 , 27 . As a result, establishing educational programs will play an important role in boosting HCW's attention and good attitudes about hand washing practices, as well as standardizing health habits to promote hand hygiene 6 , 28 , 29 .

The findings of our research indicate that most of the items in the attitude construct demonstrated a favorable attitude toward hand hygiene. However, more emphasis was placed on predicting oneself compared to others (i.e. patients). Such results have been shown in other research 30 . For instance, HCWs were shown to be more inclined to participate in self-protective procedures for hand hygiene (e.g., after being exposed to bodily fluid, after patient interaction) than patient-protective activities (e.g., before an aseptic task) 5 , 31 . Therefore, efforts can be undertaken to shift the emphasis away from a protecting oneself exercise to an activity that benefits oneself and others to enhance HCWs’ attitudes and adherence 32 .

Our study findings indicate that physicians exhibit a diminished percentage of positive attitudes compared to nurses, potentially due to many underlying factors. For instance, training initiatives might largely target nurses, with doctors and other HCWs either infrequently included or overlooked 33 , 34 . Moreover, nurses are far more compliant than doctors, and doctors have been shown to have improper attitudes regarding hand hygiene, believing there is insufficient evidence to support the use of hand cleanliness in preventing HAIs 35 , 36 .

This study has some limitations. First, practicing good hand hygiene is a socially valued activity. As a result, respondents may overestimate their conduct. Future research might use alternative objective ways to achieve more reliable evaluations. Second, although self-reports are the simplest approach to collecting data on hand hygiene attitudes, they might introduce bias owing to cognitive and psychological variables. Third, this study used a random sample from the Riyadh region, limiting the generalizability of the findings.

Hand hygiene emerges as a fundamental measure in infection control, serving as a critical bridge between HCWs, patients, and pathogens. HAIs present a significant and complex challenge in the realm of global healthcare, with Saudi Arabia being no exception. This study was conducted to better understand the attitudes of HCWs toward hand hygiene and to examine potential predictors that influence such attitudes. We found that HCWs in the ICU had an average high attitude toward hand hygiene. Such attitudes were correlated with hand hygiene knowledge, previous training, and job experience. The findings underscore the multifaceted nature of hand hygiene attitudes. By addressing individual, organizational, and environmental factors, healthcare institutions in Saudi Arabia can foster a culture of hand hygiene, ultimately contributing to the reduction of HAIs and improving patient safety. In addition, certain populations or healthcare settings may obtain more benefits from certain procedures or combinations of treatments compared to others. Therefore, the healthcare organization’s involvement should be tailored to meet local needs and use available resources accordingly.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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Alhodaithy, N., Alshagrawi, S. Predictors of hand hygiene attitudes among Saudi healthcare workers of the intensive care unit in Saudi Arabia. Sci Rep 14 , 19857 (2024). https://doi.org/10.1038/s41598-024-68494-5

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Predictors of hand hygiene attitudes among Saudi healthcare workers of the intensive care unit in Saudi Arabia

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• 1 King Fahad Medical City, Riyadh, Saudi Arabia.
• 2 Department of Public Health, College of Health Sciences, Saudi Electronic University, Riyadh, Saudi Arabia. [email protected].
• PMID: 39191820
• DOI: 10.1038/s41598-024-68494-5

Healthcare-associated infections present a challenge to healthcare systems, particularly critical care units. Hand hygiene emerges as a crucial element in infection control, acting as a vital link between healthcare workers, patients, and pathogens. Positive attitudes, motivated by a genuine concern for patient safety, are recognized as major predictors of hand hygiene compliance among healthcare workers. This study aims to assess the attitudes of ICU staff toward hand hygiene and identify factors that influence these attitudes. A cross-sectional survey of intensive care unit staff in seven large Saudi hospitals was conducted using an anonymous, self-reporting questionnaire to examine the attitudes of ICU personnel about hand hygiene and determine the factors that impact these attitudes. A regression analysis was used to determine the determinants of hand hygiene attitudes. Of the 600 respondents, 93% rated their hand hygiene knowledge as good, and 71% received hand hygiene training from their hospital. Most respondents (78%) had previously experienced healthcare-associated infections. The majority reported a favorable overall attitude toward hand hygiene (M = 4.15, SD = 0.85). Attitudes toward hand hygiene were significantly associated with perceived knowledge (β = 0.32, p < 0.001), prior hand hygiene training (β = 0.13, p < 0.05), and years of experience (β = - 0.10, p < 0.05). Healthcare workers in the ICU have a generally positive attitude toward hand hygiene. Such attitudes were correlated with hand hygiene knowledge, prior training, and job experience. The study's findings can help to inform health promotion initiatives and campaigns aimed at achieving long-term improvements in hand hygiene behaviors.

Keywords: Attitudes; Hand hygiene; Healthcare workers; Healthcare-associated infections; Intensive care units; Knowledge.

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Determinants of hand hygiene compliance among nurses in US hospitals: A formative research study

Madeline sands.

1 Department of Infectious Disease, London School of Hygiene and Tropical Medicine, London, United Kingdom

2 University of Arizona College of Medicine, Tucson, Arizona, United States of America

Robert Aunger

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Hand hygiene is the simplest and most effective measure for preventing healthcare-associated infections. Despite the simplicity of this procedure and advances made in infection control, hospital health care workers’ compliance to hand hygiene recommendations is generally low. Nurses have the most frequent patient care interactions, and thus more opportunities to practice hand hygiene. As such, it is important to identify and understand determinants of nurses’ reported compliance. Formative research was undertaken to assess the potential impact of several unexamined factors that could influence HH among nurses: professional role and status, social affiliation, social norms, and physical modifications to the work environment (as well as institutional factors like safety climate). A survey questionnaire was developed primarily to inform the creation of a behaviour change intervention. The survey looked at how these factors influence HH among nurses and sought to identify barriers and levers to reported hand hygiene. It was administered to a survey panel of acute care nurses, working in US hospitals, with a year or more of experience. Multivariate regression modelling suggested that reported hand hygiene compliance was most likely to be a function of a hospital management’s communication openness, perceived performance by peers, increased interactions with patients and other staff members, and the reduction in stress, busyness, and cognitive load associated with role performance. A powerful, effective intervention on HH among nurses therefore could be directed at improving communication openness, consider the impact of perceived performance by peers, increase interactions with patients and staff, and determine how to reduce the stress and cognitive load associated with role performance.

Introduction

Hand hygiene (HH) is the simplest and most effective measure for preventing healthcare-associated infections (HAIs).[ 1 ] Despite the simplicity of this procedure and advances made in infection control, hospital health care workers’ compliance to HH recommendations is generally low.[ 2 ] Nurses have the most frequent patient care interactions, and thus more opportunities to practice HH.[ 3 ] As such, it is important to identify and understand determinants of nurses’ reported compliance.

Hand hygiene is a complex behaviour with a myriad of motivators and barriers.[ 1 , 4 ] While the basic behavioural aspects surrounding HH practices in hospital settings have been widely researched, there remain gaps in the literature regarding effective psychological promotion of hand hygiene compliance (HHC).[ 4 ] Psychological frameworks have been shown to lead to behaviour change in a wide variety of contexts, especially in the behaviour of healthcare workers (HCWs).[ 5 ] Therefore, focusing on determinants of behaviour change and employing psychological behaviour change models can better inform HH improvement strategies.

Behaviour Centred Design (BCD) is a general approach to behaviour change that offers both a Theory of Change for behaviours in addition to a practical process for designing and evaluating interventions.[ 6 ] The BCD’s Theory of Change incorporates concepts such as reinforcement learning theory,[ 7 ] the evolution of behavioural control,[ 8 ] the evolved structure of human motivation,[ 9 ] and behaviour settings theory.[ 10 , 6 ] The behaviour settings theory explains the relationship between individuals and the environment—both physical and social.[ 10 ] Behaviour is a function of the setting within which it takes place. As such, behaviour settings are situations where people have learned what to expect from the environment and from other people’s behaviours. Each setting has a purpose, a designated place, a set of objects, and a prescribed set of behaviours. Therefore, each person entering a setting expects others, who are also participants, to perform their designated roles.

BCD is associated with a checklist of factors that determine human behaviour, which can be used to direct empirical investigations prior to the design of public health interventions. This checklist includes environmental determinants such as the props and infrastructure that support performance of the behaviour, as well as the psychological characteristics and personal traits required.

The aim of this study is to use the BCD approach to identify determinants that impact the HHC of nurses in intensive and acute care hospital units. A combination of literature review and formative research are used to identify prospective strategies for a behaviour change intervention. Recognizing what motivates and hinders a nurse from practicing HH should aid in the development of successful strategies seeking to improve nurses’ HHC.

Given the complexity of institutional settings for behaviour change, our data gathering strategy focussed on potentially important factors that have not yet been found to be significant. The literature search began with a background search to develop an understanding for the breadth of the body of literature. The iterative search process became more refined and developed as the review progressed. Once the volume and general scope of the HH field had been determined, parameters were set and search strings were developed [ S1 File ]. Search strings were developed for concepts encompassing behaviour change, hand hygiene compliance, healthcare workers, healthcare-associated infections, hand hygiene, and interventions. Medline, Web of Science, CINAHL, and Google Scholar databases were electronically searched selecting only for papers written in English. A total of 187 publications were identified this way; after filtering for papers published from January 2002- January 2015, there were 89 papers left to be reviewed. Additional papers and grey literature were identified by searching the references lists of the retrieved papers. We used the WHO’s tables of factors (WHO Table I.2.1) as well as hand hygiene improvement interventions (WHO Table I.2.2) as a framework.[ 1 ]

Categorizing and identifying modifiable factors using BCD

The BCD Checklist itemises all the types of behavioural determinants identified by the BCD approach. Placing the factors from the literature known to influence HHC ( Table 1 ) into the BCD Checklist enables us to see what categories of factors have potential for deeper investigation and could serve as the foundation for further research into HHC (see Table 2 ). This analysis shows that only a few of these categories have been investigated by intervention-based studies in the literature, and it is apparent that whole categories of factors have not yet been examined by the public health community. Types of potential factors that have been completely ignored thus far are listed without entries in Table 1 . It should be noted that even some categories with entries below have not been fully investigated; additional factors could be identified and explored. If we restrict our attention to categories—either with or without entries—which can be readily changed by the types of mechanisms that are both acceptable and within the budget of an average hospital administration, we arrive at the following list of five categories: (1) motivational psychology , (2) reactive psychology (i.e. habit formation), (3) modification of the relevant behaviour setting stage , (4) role change , and ( 5) social norm manipulation . These categories will be the focus of this formative research.

Importance of this formative research

Formative research is a critical step in the development of health behaviour change interventions.[ 6 , 11 ] The purpose of formative research is to assess individuals’ beliefs, perceptions, behaviours, and the structure of the environment itself that may help or hinder program effectiveness. Typically, such research involves significant fieldwork in the relevant context. In the case of this study, the ability of the research team to obtain a comprehensive view of the factors associated with HHC was limited by the logistics of access to hospitals. It was neither possible to take nurses from the floor during their shift nor to engage in substantial observation of their practices without introducing bias into the data collection. Further, there is considerable variation and organization-specific intricacies when it comes to the institutional contexts of HHC, which needs to be understood and considered when creating interventions intended to be widely used. Thus, the decision was made to administer a survey to a large number of nurses with a range variety of experiences across the United States, gaining in breadth what was lacking in terms of depth in the investigation. This survey sought to assess the behavioural change potential of the factors identified by the analysis above.

Ethics approval was attained from the London School of Hygiene and Tropical Medicine’s Observational and Interventions Research Ethics Committee (reference number is 14411).

Sampling procedure

An anonymous internet-based cross-sectional survey was administered between November to December 2015 by a global online sampling and digital data collection company called Dynata—formerly known as Research Now—to a survey panel of acute care nurses, working in various types of hospitals that are geographically distributed across the US, with at least a year or more of experience. There were 19,969 hospital nurses available to take the survey. With a confidence interval of 95% and a margin of error 5%, we calculated that we need a minimum of 377 completed surveys. Dynata screened and recruited participants, and it used an incentive scale based on set time increments. Incentive options allowed panellists to redeem from a range of gift cards, charitable contributions, and other products or services upon completing the survey.

Survey design

The survey concentrates on the five unexamined but modifiable factors that are potential determinants of HHC: (1) motivation, (2) habit, (3) roles, (4) behaviour setting stage, and (5) norms. The survey questions, which draw upon various concepts and measurement tools from fields such as sociology and psychology, are designed to measure the degree to which these factors influence reported HHC [ S2 File ]. In doing so, a novel questionnaire was developed using techniques—such as vignettes and the self-reported habit index (SRHI)[ 12 ]—that have not been commonly or consistently used in HH questionnaires before. The movement of the respondent through the survey is depicted in Fig 1 . The explanation of the theoretical underpinnings of the survey with their respective survey questions follow.

To make a more succinct and pertinent list of risk factors for this research project, we first determined which factors have already been found to have a significant impact on HH behaviour from a literature search and review.

The role of the nurses was explored through professional identity. Identities are the traits and characteristics, social relations, roles, and social group memberships that define an individual.[ 13 ] A professional identity is the sense of self that is associated with the enactment of a professional role.[ 14 , 15 ] This identity gives members of a profession a definition of self-in-role and the goals, values, norms, and interaction patterns that are associated with their job.[ 16 ] This definition of identity is critical to how professionals interpret and behave in various work situations, with identity being both a product of situations and a determinant of behaviour within situations.[ 13 , 17 ] Identity is (a) predicted to influence what individuals are motivated to do, (b) encompasses how individuals think and makes sense of themselves and others, (c) the actions the individuals take, and (d) the individuals’ feelings and abilities to control or regulate themselves.[ 18 , 19 ]

By learning what qualities, skills, and traits nurses value, the perceived responsibilities of the professional role can be modified to include the responsibility of practicing HH. There is potential for hand hygiene to be integrated into the qualities that nurses perceive to be what a “good” or “ideal” nurse possesses. Respondents are therefore asked to choose five qualities or traits they wish they had exhibited more of during their most recent shift. The following qualities and traits were identified from the literature:[ 20 – 27 ]

Respondents were then asked to choose five statements they would least like to hear said about them as a nurse. The statements address undesirable qualities and traits or unfavourable working conditions identified in the literature.[ 20 – 27 ]

A social norm is a rule of behaviour that individuals conform to conditionally based on the beliefs that (a) most people in their relevant network conform to this behaviour (this is referred to as an empirical expectation ), (b) they themselves believe that they should perform the behaviour ( normative personal belief ), and (c) that most people in their relevant network believe they ought to conform to this behaviour as deviations from the norm could result in potential punishment (referred to as a normative expectation ).[ 28 ] Social norms direct human action, however, norms are situationally contingent, meaning that a norm’s salience and one’s compliance to this norm are conditional upon the situation.[ 29 ] To understand and predict behaviour, it is important to know which social norms individuals find salient in particular contexts—that is, which norms are likely to be dependent on particular settings.[ 30 , 31 ]

The normative system of nursing with respect to HH behaviour can be measured through learning about (a) individual’s preferences for ‘proper’ HH action, (b) expectations of others’ HH behaviour, and (c) beliefs about the expectations others have of them in this regard. We sought to identify nurses’ social norms regarding hand hygiene and whether the social norms have a causal influence on behaviour. Bicchieri (2014) devised a series of questions that diagnose, explain, and predict collective patterns of behaviour, which were adapted for the research purposes here.[ 28 ] This involves ascertaining several aspects of a normative system, including empirical expectations, normative beliefs, and normative expectations. To test empirical expectations, respondents were asked about their own beliefs regarding the prevalence of HH behaviour among their peers; respondents were asked to disclose how many nurses out of a group of ten would always practice HH at the various indications.

To test normative personal beliefs, respondents were also asked if they think they should practice HH at six various moments: (1) before entering a patient’s room, (2) when exiting a patient’s room, (3) after taking a patient’s vitals, (4) after cleaning a patient’s wound, (5) before charting in the nurse station, and (6) after talking with fellow nurses in the break room. Responses along a Likert scale from Never to Always were offered. To test normative expectations, respondents were asked if they believed that other nurses thought that they should use hand sanitizer or soap at the same moments provided above. Once again, the same Likert scale offered five response options.

Habits are defined as psychological tendencies to respond automatically to environmental stimuli, acquired through repeated practice in particular contexts.[ 32 , 33 ] Habitual actions are triggered in response to contextual cues associated with their performance: for example, automatically putting on a seatbelt (action) after getting into the car (contextual cue) or washing hands (action) after using the toilet (contextual cue).[ 34 ] Habit strength is a continuum. Habits that are considered to be of weak or moderate strength are performed with less frequency than strong habits.[ 35 ]

Participants were asked about the strength of their HH habits using the Self-Report Habit Index (SRHI) developed by Vernplanken et al. (1994).[ 36 ] The SRHI is a tool used either as a dependent variable, or to determine or monitor habit strength without measuring behavioural frequency. It discriminates between behaviours varying in frequency and between daily vs. weekly habits. The index is based on features of habit: a history of repetition, automaticity, and expressing one’s identity. Respondents answer the degree to which they felt the statement affected them using a 5-point Likert scale (from Strongly Disagree to Strongly Agree). There is evidence that the SRHI can solicit accurate answers comparable to real behaviours.[ 37 ] The index in this case is phrased to ask respondents about practicing HH before entering and after exiting a patient’s room.

Motives are evolved psychological mechanisms that help individuals choose the appropriate goal-directed behavioural strategy in response to a situation.[ 38 ] An appropriate strategy would most likely lead to a satisfactory outcome in terms of the benefits accruing from that interaction with the environment.[ 9 ] A satisfactory outcome involves an experience that is rewarding—be it a sensory pleasure, a metabolic benefit for the body, or a change to one’s place in the social world.

This research sought to identify what motivates people to practice HH. Thus, the objective of the motive questions was to determine if a person of higher status—such as a nurse manager or direct supervisor—or someone who is dependent on the nurse—such as patient—is a likely motivator of HH. The BCD’s motive mapping technique is used.[ 6 ] Motive mapping attempts to reduce psychological ‘distance’ by simulating the behavioural context using a narrative, and attempts to minimize the participant’s reflection by focusing directly on the rewards from performance.

Participants responded to three scenarios asking about how feedback is likely to influence their own HH behaviour. In each of the scenarios, participants were told that they had taken a patient’s vitals and immediately practiced HH upon exiting the room. At the end of each scenario, positive feedback regarding the practicing of HH was shared with the nurse by the nurse manger, a fellow nurse, and the patient. Respondents answered to what degree they feel this feedback makes them more likely to use hand sanitizer in the future as compared to normal usage. A five-point Likert scale measured responses.

Situational constraints: Vignettes

Participants were asked to judge their likely compliance to HH in varying situations known as vignettes. Vignettes are closer to real-life judgment-making situations than relatively abstract questions that are typical of most surveys. Respondents were asked to reflect on whether they would practice HH in the following situations: (1) exiting a patient’s room after taking the patient’s vitals, (2) entering a patient’s room before taking vitals, (3) exiting a patient’s room after cleaning and bandaging the patient’s diabetic foot wound, and (4) entering a patient’s room before cleaning and bandaging the patient’s foot wound. These situations were altered slightly for each follow-up question by introducing either a facilitator or a barrier to practicing HH, such as:

• Large patient load, which measures busyness
• Already wearing gloves, which measures the nurse’s inclination to practice HH when wearing protective equipment
• Being observed by the infection prevention manager, which measures higher status social influence
• Being observed by a fellow nurse, which measures peer influence
• Trying to practice hand hygiene but the dispenser is empty, which measures perception of ease
• An interruption during patient care requiring the immediate assistance of the nurse, which measures interruption
• An emergency requiring CPR, which measures reaction to emergency

Through vignettes, we sought to determine the extent to which these factors impact HH behaviour. Responses were presented on a five-point Likert scale based on the likelihoods of behavioural response.

Institutional factors: Safety culture and familiarity with hand hygiene

Nurse behaviour takes place within the context of hospital life. Hospitals can be considered institutions, which have an impact on the settings that occur within them. Therefore, this research sought to assess the culture of safety within the respondents’ institutions. It has been widely accepted that the safety culture of one’s hospital affects HHC rates.[ 1 , 39 – 41 ] To measure the safety culture of the hospitals where the respondents work, the research team selected and modified questions from the hospital survey on patient safety culture developed by the US Agency for Healthcare Research and Quality.[ 42 ] Questions were grouped according to the safety culture dimensions they are intended to measure. Groups included: rating overall perceptions of safety, frequency of event reporting, supervisor/manager expectations and actions, teamwork within units, closeness, communication openness, feedback and communication about error, non-punitive response to error, staffing, and hospital management support. Five point Likert scales asking for agreement/disagreement and frequency were used.

Participants were also asked about their engagement and participation in past HH training and interventions, both as nursing students and as practicing professionals. In addition, participants were asked about their hospital’s own HH programs. Questions were all phrased so that a yes/no response was appropriate.

Modification to physical setting

Finally, the research aimed to investigate various ways to disrupt a behaviour setting, specifically by identifying how the stage and arrangement of props of the setting surrounding the act of HH serve as constraints or opportunities to practicing HH. Respondents are presented with two photos—one of a hallway in a non-descript hospital and one of a patient’s room—and then asked how both the hallway and the room could be altered to better facilitate HH. These questions allowed for open-ended responses.

Formatting the survey

The survey was a self-administered online task. Each question was presented on its own webpage. Respondents were first asked a series of screener questions to determine if they were eligible: they had to be an acute care nurse, working in a US hospital, with a year or more of experience.

Those who are eligible were then presented with a series of photos related to the modification of the physical setting. These questions were asked first because the research team wanted responses that were not influenced by other questions in the survey. In addition, the photos served to ground the respondents in the survey by providing visual context. The vignettes immediately followed; the research team reasoned that the vignettes would likely solicit the most accurate responses about HH performance. As such, the vignettes were placed early in the survey so that the respondents were not biased or primed by subsequent specific queries. The professional identity questions were asked next as these questions tapped into values. Questions about norms followed and were followed by questions on habit and motivation. The final questions focused on the safety culture of the hospital as well as the respondents’ history with HH interventions and programs. A diagram of the survey questions and flow are provided in Fig 2 .

The survey is broken into sections; the movement of the respondent through the survey is depicted in this figure.

Analysis of the survey

Descriptive statistics were first used to characterize the sample. Univariate analyses were therefore first conducted to determine which variables were associated with reported levels of HHC. Next, a multivariate regression of the variable of interest—reported HH on exiting a patient room after taking vitals—was conducted on demographic, role, safety culture, and norm variables. This variable of interest was chosen as it was asked in the form of a vignette, which is closer to real-life judgment-making situations and thus provided a better sense of compliance than asking respondents directly about their HHC. In addition, this specific vignette question was used as nurses are more likely to practice HH upon exiting a room, but less likely to practice HH after conducting a low-risk procedure. As an ordinary least squares regression of outcome on predictors was inappropriate for a model with this number of predictors but only 500 observations, we performed a bidirectional stepwise procedure to build the model, using the Akaike Information Criterion (AIC) as the model-building criterion for adding or removing variables; any variable that, when removed, changed the model AIC by ≤ 1 was discarded by the procedure.

Study population

A total of 540 surveys were completed. Table 2 summarizes selected characteristics of the participants. The median age was 49 (range: 24–70). In a typical workday, more than two-thirds of the respondents (68%) reported spending 80% or more of their time performing direct patient care. Familiarity with HH practices was indicated by 459 (85%) of respondents, who reported that HH was emphasized during professional training to be a nurse. Furthermore, the clear majority of respondents (456, or 84%) had participated in a hospital-led hand hygiene initiative before.

Summary variables were standardized before analysis. Variables included habit , safety culture , norms , motivation , role , hand hygiene familiarity , and demographics . Means were taken across Likert scale questions per the prescribed groupings. Sums were calculated across yes/no variables and demographic variables were encoded with a binary number system.

Univariate analysis

The results for each of the five main potential determinants of HHC have been provided in their respective tables and figures enumerated below. Major findings have been summarized for norms , habit , and motives .

The results for every question in this section of the survey are included in Table 3 . The most salient findings were that nurses were more likely to practice HH upon exiting a patient’s room than entering, and that when the procedure was perceived as being high-risk—such as cleaning and bandaging a wound—there was an increased likelihood of practicing HH. Most notably, 90.7% (n = 490) of nurse respondents reported being likely to practice HH upon exiting a patient’s room after cleaning and bandaging the diabetic foot wound.

The results for empirical expectations, normative personal beliefs, and normative expectations have been presented in Table 4 . Regarding empirical expectations , respondents felt that most nurses practiced hand hygiene before entering a patient’s room, when exiting a patient’s room, after taking a patient’s vitals, and after cleaning a patient’s wound. Concerning normative personal beliefs , for each moment apart from charting, most respondents claimed that HH should always be practiced. Of the 540 respondents, 81.7% (n = 441) of respondents said it should always be practiced before entering a patient’s room, 90.4% (n = 488) when exiting a patient’s room, 75.6% (n = 408) after taking patient’s vitals, and 98.7% (n = 533) after cleaning a patient’s wound. With normative expectations , over 50% of respondents claimed that most other nurses always think that one should practice hand hygiene before entering a patient’s room, when exiting a patient’s room, after taking a patient’s vitals, and after cleaning a patient’s wound. [Figs H and I in the S1 Fig display the results.]

Respondents answered the SRHI about practicing HH before entering a patient’s room and after exiting a patient’s room. Responses were made on five point Likert scales anchored by the terms strongly agree-strongly disagree and were coded such that high values indicated strong habits (1 = strongly disagreeing and 5 = strongly agreeing). The means of the questions were calculated, and these in turn became the habit strength scores. Regarding HH upon entering a room, 59.1% (n = 319) of respondents had a score of 4.5 or over ( Fig 3 ). In the case of exiting, 68.0% (n = 367) of respondents had a habit strength score of 4.5 and over ( Fig 4 ).

Upon receiving feedback from nurse managers and fellow nurses, 50.7% (n = 274) of participants and 55.4% (n = 299) said that there would be no difference in future HH action, respectively. Regarding receiving feedback from patients, 59.3% (n = 320) respondents said that feedback would positively impact their HH behaviour in the future. Results are summarized in Table 5 .

Safety culture

The results for each question in this section of the survey are included in Table 6 .

Multivariate regression

Presented in Table 7 are the results from the bidirectional stepwise procedure to analyse the relationships between various predictors and the outcome: reported HH on exiting a patient room after taking vitals. Included in the table are only the variables which met the selection criteria. Values are provided for the regression Estimate, as well as its Standard Error, T-value, and Pr(>|t|) coefficients. Coefficients were assigned to each predictor; the sign on the coefficient (positive or negative) provides the direction of the effect of the predictor on the outcome variable.

The reported higher likelihood of practicing HH upon performing a high-risk procedure as compared to a low-risk procedure aligns with the literature which shows that HHC is greater when involving higher-risk tasks.[ 2 , 43 , 44 ] In addition, nurses reported being more likely to practice HH upon exiting a patient’s room than entering, which is interpreted as nurses practicing HH as a form of self-protection.[ 44 ]

Nurses work in close relationships with patients who are vulnerable and largely dependent on the nurse for care.[ 45 ] Nurses work with one another and on inter-professional healthcare teams to deliver care and provide support. Fagermoen’s (1997) proposed theoretical model for professional identity of nurses maintains that nurses’ perceptions of the ‘professional self’ focuses on both other-oriented and self-oriented values .[ 45 ] Other-oriented values encompass the nurse’s actions on behalf of the patient’s well-being and the interactions with patients in providing care. Self-oriented work values include work performance and collaboration with other professionals. While self-oriented work values directly impact the self, these values also affect the care delivered. For instance, better stress management can lead to a nurse feeling more confident, capable, and in control, which can then lead to better care delivered.

When asked which values the participants wish they had exhibited more of during their last shift, the traits most widely selected were those of self-oriented values such as stress management, patience, good communication, and physical and mental endurance. These in turn impact other-oriented values to a degree since work performance directly influences the kind of care delivered. Other-oriented values are the foundation of nursing care and an integral part of the nurses’ relationships with patients. Areas of improvement could be seen in how nurses engage in the work-setting and the actualization of the other-oriented values . When asked what the nurses would least like to hear said about them, the top responses were about the inadequacy in the delivery of care. This again demonstrates how integral other-oriented values are to the discipline of nursing.

There is agreement amongst participants as to when to practice HH—upon entering and exiting a patients’ room and after performing a procedure such as vitals or cleaning a wound. It is apparent that participants believed these to be norms, and believed others to hold the same norms in addition to conforming to such norms. This suggests that HH indications are well understood and agreed upon by nurses.

Habit is the cognitive mechanism by which actions occur reflexively and in a fixed sequence.[ 46 ] Habit scores were quite high, which is not unexpected for a behaviour that is practiced many times a day. This suggests that the SRHI may not be useful in measuring behaviour that is already being practiced intensively.

Over half of participants indicated that receiving feedback from a patient or a colleague would likely lead to an increase in future HH action. There is evidence that HH behaviour of HCWs is positively influenced by the presence and proximity of peers.[ 47 , 48 ] Regarding patients, patient involvement in supporting their own safety has been widely discussed. [ 49 – 51 ]. Patient involvement in HH—such as praising HCWs for practicing HH or reminding HCWs to wash their hands—and its impact on HH behaviour has not been extensively studied [ 51 ], but our results show that it would be acceptable to HCWs for patients to recognize nurses for practicing HH.

The variable of interest was the reported HHC upon exiting a patient’s room after taking their vitals. This question had the most variance in responses. The regression analysis shows that reported HHC is a function of specific variables at all possible levels: the hospital, unit, and individual. At the hospital level, increased openness of communication —which was asked about in the safety culture portion of the survey—led to a higher reporting of HHC. There is evidence that features of a hospital’s safety climate are related to how well standard precautions and safety practices, such as HH, are adhered to.[ 52 – 54 ] Communication openness is a component of a hospital’s patient safety culture and is defined as the extent to which the staff freely speak up if they see something that may negatively affect a patient and/or question those with more authority.[ 40 , 55 ] A core tenet behind communication openness is that all have a responsibility to speak out when certain actions, objects, or processes pose danger to the safety of the patient and others, and those who speak out should be able to do so without fear of being reprimanded. It could be surmised that those who are comfortable enough to speak out about threats to patient safety would also act on their own accord to protect patient safety by practicing HH at the proper indications.

At the unit level, the type of hospital unit played a role in the HHC reported—overall, participants who work in an emergency department reported lower HHC rates. This could be attributed to the fact that nurses must respond to various unpredictable situations that could be life-threatening to the patient, and the patient’s need for immediate attention and care is put first before practicing HH. Practicing HH in an emergency could be perceived as dilatory. This could also be because the emergency department is an environment with a high density of invasive procedures that require glove usage, and there is evidence that glove usage is inversely correlated with adequate HH. [ 1 , 56 , 57 ]

An interesting finding was that nurses who indicated having a higher proportion of shift time allocated to interaction with patients and with fellow healthcare professionals reported higher HHC. More time spent with a patient could lead to more opportunities to practice HH and thus more events completed. However, this challenges the notion that the higher the demand for hygiene (the more opportunities to practice it), the lower the adherence rates. Nevertheless, the more time spent with other HCWs could result in a nurse feeling the ‘watching eyes’ effect thus leading to increased HHC. More time with the patient could also result in the nurse bonding with the patient and is thus more cognisant of practicing HH to ensure the patient’s safety.

At the individual level, one’s personal ability to manage subjectively important aspects of the professional role—such as stress management, communication skills, and being confident in one’s self as a nurse—leads to increased reporting of HHC. All the individual-level variables in the analysis could be defined as other-oriented to a degree as presumably successful stress management can lead to providing better care. The significant individual variables show other-oriented values involving care and communication as being of highest professional importance to nurses, and this orientation fosters better HH.

It has been noted in the literature that poor working conditions, increased levels of stress, and insufficient communication have a direct negative impact on the quality of nursing and have severe consequences for patients.[ 58 – 61 ] In addition, low HHC can result from fatigue or burnout. As a nurses’ shift progresses, HHC declines towards the end of the shift.[ 62 ] Continuous long shifts can lead to nurse burnout which in turn has been associated with increased HAI levels.[ 63 ] Thus, nurses who feel in control, confident in their abilities, supported, and have lower stress levels can better focus on and execute safety procedures such as HH.

Limitations

Surveys administered to HCWs are relatively inexpensive and allow for HCWs to focus and reflect on their own practices. However, self-report of infection prevention can be flawed, especially as reported HH practices and actual HH practice can differ significantly.[ 54 , 64 , 65 ] In using vignettes, we may have reduced socially desirable responses by allowing participants to report their HH practice and the practices of others through the vignette character(s) and situations.[ 65 , 66 ] This may have reduced the potential for disparity between reported and actual behaviour. Additionally, generalizability of the findings may be limited by certain characteristics of the sample, achieved through online data recruitment. This limitation was addressed by administering the survey online, which allowed for us to collect responses from a wide variety of participants located in different regions and hospitals of the United States with varying degrees of experience and specialisation.

Formative research was undertaken to assess the potential impact of several unexamined factors that could influence HH among nurses: professional role and status , social affiliation , social norms , and physical modifications to the work environment , as well as institutional factors (like safety climate). A survey questionnaire looked at how these factors influence nurses’ reported HHC and also sought to identify barriers and levers to HH. Multivariate regression modelling suggested that HHC was most likely to be a function of a hospital management’s ‘openness’, perceived performance by peers, increased interactions with patients and other staff members, and the reduction in stress, busyness, and cognitive load associated with role performance. Thus, a powerful and effective intervention focusing on nurses’ HHC should address improving communication openness, consider the impact of perceived performance by peers, increase interactions with patients and staff, and determine how to reduce the stress and cognitive load associated with role performance. Use of Behaviour Centred Design increased the informativeness of the survey tool, and could be used more widely in formative research studies.

Supporting information

Concepts and their corresponding search strings.

Acknowledgments

We are grateful to Rahul Singh for guiding the preliminary analysis of formative research results and for writing the code in R-studio for the multivariate analysis.

Abbreviations

Funding Statement

MHS and RA received financial compensation as affiliates of the London School of Hygiene and Tropical Medicine, which served as a paid consultant to GOJO Industries, Inc. for the creation and evaluation of the intervention. The funders had no role in study design, data analysis, decision to publish, or preparation of the manuscript.

Data Availability