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Implementation Science
Published in: Implementation Science 1/2012

Open Access 01-12-2012 | Systematic review

A systematic review of hand hygiene improvement strategies: a behavioural approach

Authors: Anita Huis, Theo van Achterberg, Marijn de Bruin, Richard Grol, Lisette Schoonhoven, Marlies Hulscher

Published in: Implementation Science | Issue 1/2012

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Abstract

Background

Many strategies have been designed and evaluated to address the problem of low hand hygiene (HH) compliance. Which of these strategies are most effective and how they work is still unclear. Here we describe frequently used improvement strategies and related determinants of behaviour change that prompt good HH behaviour to provide a better overview of the choice and content of such strategies.

Methods

Systematic searches of experimental and quasi-experimental research on HH improvement strategies were conducted in Medline, Embase, CINAHL, and Cochrane databases from January 2000 to November 2009. First, we extracted the study characteristics using the EPOC Data Collection Checklist, including study objectives, setting, study design, target population, outcome measures, description of the intervention, analysis, and results. Second, we used the Taxonomy of Behavioural Change Techniques to identify targeted determinants.

Results

We reviewed 41 studies. The most frequently addressed determinants were knowledge, awareness, action control, and facilitation of behaviour. Fewer studies addressed social influence, attitude, self-efficacy, and intention. Thirteen studies used a controlled design to measure the effects of HH improvement strategies on HH behaviour. The effectiveness of the strategies varied substantially, but most controlled studies showed positive results. The median effect size of these strategies increased from 17.6 (relative difference) addressing one determinant to 49.5 for the studies that addressed five determinants.

Conclusions

By focussing on determinants of behaviour change, we found hidden and valuable components in HH improvement strategies. Addressing only determinants such as knowledge, awareness, action control, and facilitation is not enough to change HH behaviour. Addressing combinations of different determinants showed better results. This indicates that we should be more creative in the application of alternative improvement activities addressing determinants such as social influence, attitude, self-efficacy, or intention.
Appendix
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Literature
1.
Pittet D, Hugonnet S, Harbarth S: Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet. 2000, 356: 1307-1312. 10.1016/S0140-6736(00)02814-2.CrossRefPubMed
2.
The French Prevalence Survey Study Group: Prevalence of nosocomial infections in France: results of the nationwide survey in 1996. J Hosp Infect. 2000, 46: 186-193. 10.1053/jhin.2000.0833.CrossRef
3.
Di Pietrantoni C, Ferrara L, Lomolino G: Multicenter study of the prevalence of nosocomial infections in Italian hospitals. Infect Control Hosp Epidemiol. 2004, 25: 85-87. 10.1086/502299.CrossRef
4.
Emmerson AM, Enstone JE, Griffin M, Kelsey MC, Smyth ET: The Second National Prevalence Survey of infection in hospitals-overview of the results. J Hosp Infect. 1996, 32: 175-190. 10.1016/S0195-6701(96)90144-9.CrossRefPubMed
5.
Eriksen HM, Iversen BG, Aavitsland P: Prevalence of nosocomial infections in hospitals in Norway, 2002 and 2003. J Hosp Infect. 2005, 60: 40-45. 10.1016/j.jhin.2004.09.038.CrossRefPubMed
6.
Gikas A, Pediaditis J, Papadakis JA: Prevalence study of hospital-acquired infections in 14 Greek hospitals: planning from the local to the national surveillance level. J Hosp Infect. 2002, 50: 269-275. 10.1053/jhin.2002.1181.CrossRefPubMed
7.
Klavs I, Bufon LT, Skerl M: Prevalence of and risk factors for hospital-acquired infections in Slovenia-results of the first national survey, 2001. J Hosp Infect. 2003, 54: 149-157. 10.1016/S0195-6701(03)00112-9.CrossRefPubMed
8.
McLaws ML, Taylor PC: The Hospital Infection Standardised Surveillance (HISS) programme: analysis of a two-year pilot. J Hosp Infect. 2003, 53: 259-267. 10.1053/jhin.2002.1361.CrossRefPubMed
9.
10.
Klevens RM, Edwards JR, Richards CL: Estimating healthcare-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007, 122: 160-166.PubMedPubMedCentral
11.
Stone PW, Braccia D, Larson E: Systematic review of economic analyses of health care-associated infections. Am J Infect Control. 2005, 33: 501-509. 10.1016/j.ajic.2005.04.246.CrossRefPubMed
12.
Grol R, Grimshaw J: From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003, 362: 1225-1230. 10.1016/S0140-6736(03)14546-1.CrossRefPubMed
13.
Lautenbach E: Making healthcare safer: a critical analysis of patient safety practices. Practices to Improve Handwashing Compliance. Edited by: Shojania K, Duncan B, McDonald K, Wachter RM. 2001, MD: Agency for Healthcare Research and Quality, Rockville, 119-126.
14.
Larson E: A causal link between handwashing and risk of infection? Examination of the evidence. Infect Control Hosp Epidemiol. 1988, 9: 28-36. 10.1086/645729.CrossRefPubMed
15.
Larson EL: APIC guideline for handwashing and hand antisepsis in healthcare settings. Am J Infect Control. 1995, 23: 251-269. 10.1016/0196-6553(95)90070-5.CrossRefPubMed
16.
Teare E, Cookson B, French G: Hand washing—a modest measure with big effects. BMJ. 1999, 318: 686-10.1136/bmj.318.7185.686.CrossRef
17.
Pittet D: Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol. 2000, 21: 381-386. 10.1086/501777.CrossRefPubMed
18.
Kuzu N, Ozer F, Aydemir S, Yalcin AN, Zencir M: Compliance with hand hygiene and glove use in a university-affiliated hospital. Infect Control Hosp Epidemiol. 2005, 26: 312-315. 10.1086/502545.CrossRefPubMed
19.
Pittet D, Mourouga P, Perneger TV: Compliance with handwashing in a teaching hospital. Infection Control Program. Ann Intern Med. 1999, 130: 126-130.CrossRefPubMed
20.
Naikoba S, Hayward A: The effectiveness of interventions aimed at increasing handwashing in healthcare workers - a systematic review. J Hosp Infect. 2001, 47: 173-180. 10.1053/jhin.2000.0882.CrossRefPubMed
21.
Gould DJ, Moralejo D, Drey N, Chudleigh JH: Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev. 2011, CD005186-Review
22.
23.
Grimshaw JM, Thomas RE, MacLennan G: Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004, 8: iii-iv.CrossRefPubMed
24.
Pittet D: The Lowbury lecture: behaviour in infection control. J Hosp Infect. 2004, 58: 1-13. 10.1016/j.jhin.2004.06.002.CrossRefPubMed
25.
van Achterberg T, Schoonhoven L, Grol R: Nursing implementation science: how evidence-based nursing requires evidence-based implementation. J Nurs Scholarsh. 2008, 40: 302-310. 10.1111/j.1547-5069.2008.00243.x.CrossRefPubMed
26.
de Bruin M, Viechtbauer W, Hospers HJ, Schaalma HP, Kok G: Standard care quality determines treatment outcomes in control groups of HAART-adherence intervention studies: implications for the interpretation and comparison of intervention effects. Health Psychol. 2009, 28: 668-674.CrossRefPubMed
27.
Abraham C, Michie S: A taxonomy of behavior change techniques used in interventions. Health Psychol. 2008, 27: 379-387.CrossRefPubMed
28.
Bartholomew LK, Parcel GS, Kok G: Intervention mapping: a process for developing theory- and evidence-based health education programs. Health Educ Behav. 1998, 25: 545-563. 10.1177/109019819802500502.CrossRefPubMed
29.
van Achterberg T, Huisman-de Waal GG, Ketelaar NA, Oostendorp RA, Jacobs JE, Wollersheim HC: How to promote healthy behaviours in patients? An overview of evidence for behaviour change techniques. Health Promot Int. 2011, 26 (2): 148-162. 10.1093/heapro/daq050.CrossRefPubMed
30.
Anderson LA, Sharpe PA: Improving patient and provider communication: a synthesis and review of communication Interventions. Patient Educ Couns. 1991, 17: 99-134. 10.1016/0738-3991(91)90014-V.CrossRef
31.
32.
Duerink DO, Farida H, Nagelkerke NJD: Preventing nosocomial infections: improving compliance with standard precautions in an Indonesian teaching hospital. J Hosp Infect. 2006, 64: 36-43. 10.1016/j.jhin.2006.03.017.CrossRefPubMed
33.
Harbarth S, Pittet D, Grady L: Interventional study to evaluate the impact of an alcohol-based hand gel in improving hand hygiene compliance. Pediatr Infect Dis J. 2002, 21: 489-495. 10.1097/00006454-200206000-00002.CrossRefPubMed
34.
Lam BCC, Lee J, Lau YL: Hand hygiene practices in a neonatal intensive care unit: A multimodal intervention and impact on nosocomial infection. Pediatrics. 2004, 114: 565-571. 10.1542/peds.2004-1107.CrossRef
35.
Larson EL, Bryan JL, Adler LM, Blane C: A multifaceted approach to changing handwashing behavior. Am J Infect Control. 1997, 25: 3-10. 10.1016/S0196-6553(97)90046-8.CrossRefPubMed
36.
Zerr DM, Allpress AL, Heath J, Bornemann R, Bennett E: Decreasing hospital-associated rotavirus infection: A multidisciplinary hand hygiene campaign in a children’s hospital. Pediatr Infect Dis J. 2005, 24: 397-403. 10.1097/01.inf.0000160944.14878.2b.CrossRefPubMed
37.
Moongtui W, Gauthier DK, Turner JG: Using peer feedback to improve handwashing and glove usage among Thai healthcare workers. Am J Infect Control. 2000, 28: 365-369. 10.1067/mic.2000.107885.CrossRefPubMed
38.
Golan Y, Doron S, Griffith J: The impact of gown-use requirement on hand hygiene compliance. Clin Infect Dis. 2006, 42: 370-376. 10.1086/498906.CrossRefPubMed
39.
Khatib M, Jamaleddine G, Abdallah A, Ibrahim Y: Hand washing and use of gloves while managing patients receiving mechanical ventilation in the ICU. Chest. 1999, 116: 172-175. 10.1378/chest.116.1.172.CrossRefPubMed
40.
Brock V: The impact of performance feedback on handwashing behaviors PhD thesis. 2002, Birmingham: University of Alabama
41.
van de Mortel T, Bourke R, Fillipi L: Maximising handwashing rates in the critical care unit through yearly performance feedback. Aust Crit Care. 2000, 13: 91-95. 10.1016/S1036-7314(00)70630-8.CrossRefPubMed
42.
Earl ML, Jackson MM, Rickman LS: Improved rates of compliance with hand antisepsis guidelines: a three-phase observational study. Am J Nurs. 2001, 101: 26-33.CrossRefPubMed
43.
Giannitsioti E, Athanasia S, Antoniadou A: Does a bed rail system of alcohol-based handrub antiseptic improve compliance of healthcare workers with hand hygiene? Results from a pilot study. Am J Infect Control. 2009, 37: 160-163. 10.1016/j.ajic.2008.04.252.CrossRefPubMed
44.
Haas JPL: Impact of wearable alcohol gel dispensers on hand hygiene in an emergency department. Acad Emerg Med. 2008, 15: 393-396. 10.1111/j.1553-2712.2008.00045.x.CrossRefPubMed
45.
Larson EL, Albrecht S, O’Keefe M: Hand hygiene behavior in a pediatric emergency department and a pediatric intensive care unit: comparison of use of 2 dispenser systems. Am J Crit Care. 2005, 14: 304-311.PubMed
46.
Whitby M, McLaws ML: Handwashing in healthcare workers: accessibility of sink location does not improve compliance. J Hosp Infect. 2004, 58: 247-253. 10.1016/j.jhin.2004.07.024.CrossRefPubMed
47.
Dorsey ST, Cydulka RK, Emerman CL: Is handwashing teachable? Failure to improve handwashing behavior in an urban emergency department. Acad Emerg Med. 1996, 3: 360-365. 10.1111/j.1553-2712.1996.tb03451.x.CrossRefPubMed
48.
Slota M, Green M, Farley A, Janosky J, Carcillo J: The role of gown and glove isolation and strict handwashing in the reduction of nosocomial infection in children with solid organ transplantation. Crit Care Med. 2001, 29: 405-412. 10.1097/00003246-200102000-00034.CrossRefPubMed
49.
Larson E, McGeer A, Quraishi ZA: Effect of an automated sink on handwashing practices and attitudes in high-risk units. Infect Control Hosp Epidemiol. 1991, 12: 422-428. 10.1086/646372.CrossRefPubMed
50.
van de Mortel T, Heyman L: Performance feedback increases the incidence of handwashing by staff following patient contact in intensive care. Aust Crit Care. 1995, 8: 8-13.CrossRefPubMed
51.
Howard DP, Williams C, Sen S: A simple effective clean practice protocol significantly improves hand decontamination and infection control measures in the acute surgical setting. Infection. 2009, 37: 34-38. 10.1007/s15010-008-8005-3.CrossRefPubMed
52.
Sharek PJ, Benitz WE, Abel NJ, Freeburn MJ, Mayer ML, Bergman DA: Effect of an evidence-based hand washing policy on hand washing rates and false-positive coagulase negative staphylococcus blood and cerebrospinal fluid culture rates in a level III NICU. J Perinatol. 2002, 22: 137-143. 10.1038/sj.jp.7210661.CrossRefPubMed
53.
Mayer JA, Dubbert PM, Miller M, Burkett PA, Chapman SW: Increasing handwashing in an intensive care unit. Infect Control. 1986, 7: 259-262.PubMed
54.
Raju TN, Kobler C: Improving handwashing habits in the newborn nurseries. Am J Med Sci. 1991, 302: 355-358. 10.1097/00000441-199112000-00006.CrossRefPubMed
55.
Huang J, Jiang D, Wang X: Changing knowledge, behavior, and practice related to universal precautions among hospital nurses in China. J Contin Educ Nurs. 2002, 33: 217-224.PubMed
56.
Rupp ME, Fitzgerald T, Puumala S: Prospective, controlled, cross-over trial of alcohol-based hand gel in critical care units. Infect Control Hosp Epidemiol. 2008, 29: 8-15. 10.1086/524333.CrossRefPubMed
57.
Santana SL, Furtado GH, Coutinho AP, Medeiros EA: Assessment of healthcare professionals’ adherence to hand hygiene after alcohol-based hand rub introduction at an intensive care unit in Sao Paulo, Brazil. Infect Control Hosp Epidemiol. 2007, 28: 365-367. 10.1086/510791.CrossRefPubMed
58.
Raskind CH, Worley S, Vinski J, Goldfarb J: Hand hygiene compliance rates after an educational intervention in a neonatal intensive care unit. Infect Control Hosp Epidemiol. 2007, 28: 1096-1098. 10.1086/519933.CrossRefPubMed
59.
Creedon SA: Healthcare workers’ hand decontamination practices: an Irish study. Clin Nurs Res. 2006, 15: 6-26. 10.1177/1054773805282445.CrossRefPubMed
60.
Picheansathian W, Pearson A, Suchaxaya P: The effectiveness of a promotion programme on hand hygiene compliance and nosocomial infections in a neonatal intensive care unit. Int J Nurs Pract. 2008, 14: 315-321. 10.1111/j.1440-172X.2008.00699.x.CrossRefPubMed
61.
Berg DE, Hershow RC, Ramirez CA, Weinstein RA: Control of nosocomial infections in an intensive care unit in Guatemala City. Clin Infect Dis. 1995, 21: 588-593. 10.1093/clinids/21.3.588.CrossRefPubMed
62.
Muto CA, Sistrom MG, Farr BM: Hand hygiene rates unaffected by installation of dispensers of a rapidly acting hand antiseptic. Am J Infect Control. 2000, 28: 273-276. 10.1067/mic.2000.103242.CrossRefPubMed
63.
Marra AR, D’Arco C, Bravim BA: Controlled trial measuring the effect of a feedback intervention on hand hygiene compliance in a step-down unit. Infect Control Hosp Epidemiol. 2008, 29: 730-735. 10.1086/590122.CrossRefPubMed
64.
Conly JM, Hill S, Ross J, Lertzman J, Louie TJ: Handwashing practices in an intensive care unit: the effects of an educational program and its relationship to infection rates. Am J Infect Control. 1989, 17: 330-339. 10.1016/0196-6553(89)90002-3.CrossRefPubMed
65.
Simmons B, Bryant J, Neiman K, Spencer L, Arheart K: The role of handwashing in prevention of endemic intensive care unit infections. Infect Control Hosp Epidemiol. 1990, 11: 589-594. 10.1086/646100.CrossRefPubMed
66.
Eldridge NE, Woods SS, Bonello RS: Using the six sigma process to implement the Centers for Disease Control and Prevention guideline for hand hygiene in 4 intensive care units. J Gen Intern Med. 2006, 21 (suppl 2): 35-42.CrossRef
67.
Trick WE, Vernon MO, Welbel SF: Multicenter intervention program to increase adherence to hand hygiene recommendations and glove use and to reduce the incidence of antimicrobial resistance. Infect Control Hosp Epidemiol. 2007, 28: 42-49. 10.1086/510809.CrossRefPubMed
68.
Won SP, Chou HC, Hsieh WS: Handwashing program for the prevention of nosocomial infections in a neonatal intensive care unit. Infect Control Hosp Epidemiol. 2004, 25: 742-746. 10.1086/502470.CrossRefPubMed
69.
Gould D, Chamberlain A: The use of a ward-based educational teaching package to enhance nurses’ compliance with infection control procedures. J Clin Nurs. 1997, 6: 55-67. 10.1111/j.1365-2702.1997.tb00284.x.CrossRefPubMed
70.
Larson EL, Early E, Cloonan P, Sugrue S, Parides M: An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behav Med. 2000, 26: 14-22. 10.1080/08964280009595749.CrossRefPubMed
71.
Brown SM, Lubimova AV, Khrustalyeva NM: Use of an alcohol-based hand rub and quality improvement interventions to improve hand hygiene in a Russian neonatal intensive care unit. Infect Control Hosp Epidemiol. 2003, 24: 172-179. 10.1086/502186.CrossRefPubMed
72.
Bosch M, Faber MJ, Cruijsberg J: Effectiveness of patient care teams and the role of clinical expertise and coordination: a literature review. Med Care Res Rev. 2009, 66 (suppl 6): 5-35.CrossRef
73.
Grol R, Wensing M: Improving patient care: the implementation of change in clinical practice. Effective implementation: a model. Edited by: Grol R, Wensing M, Eccles M. 2005, London: Elsevier, 94-108. 197–206
74.
Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA: Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. The Cochrane Effective Practice and Organization of Care Review Group. BMJ. 1998, 317: 465-468. 10.1136/bmj.317.7156.465.CrossRefPubMedPubMedCentral
75.
Grimshaw J, Eccles M, Thomas R: Toward evidence-based quality improvement: evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966–1998. J Gen Intern Med. 2006, 21 (suppl 2): 14-20.
76.
Huis A, Schoonhoven L, Grol R, Borm G, Adang E, Hulscher M: Helping hands: A cluster randomised trial to evaluate the effectiveness of two different strategies for promoting hand hygiene in hospital nurses. Implement Sci. 2011, 6: 101-10.1186/1748-5908-6-101.CrossRefPubMedPubMedCentral
77.
Strecher VJ, Seijts GH, Kok GJ, Latham GP, Glasgow R, DeVellis B: Goal setting as a strategy for health behavior change. Health Educ Q. 1995, 22: 190-200. 10.1177/109019819502200207.CrossRefPubMed
78.
Carroll C, Patterson M, Wood S, Booth A, Rick J, Balain S: A conceptual framework for implementation fidelity. Implement Sci. 2007, 2: 40-10.1186/1748-5908-2-40.CrossRefPubMedPubMedCentral
Metadata
Title
A systematic review of hand hygiene improvement strategies: a behavioural approach
Authors
Anita Huis
Theo van Achterberg
Marijn de Bruin
Richard Grol
Lisette Schoonhoven
Marlies Hulscher
Publication date
01-12-2012
Publisher
BioMed Central
Published in
Implementation Science / Issue 1/2012
Electronic ISSN: 1748-5908
DOI
https://doi.org/10.1186/1748-5908-7-92

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