The Effect of Short Messaging on Improving Nurses' Hand Hygiene Behaviors: A Randomized Controlled Trial.

<p id="p00005">Maintaining optimal hand hygiene is an important strategy for infection control and prevention. However, how to increase adherence to hand hygiene practices has been a major challenge to prevent infectious diseases and reduce hospital acquired infections (HAIs), especially in the critical period of COVID-19 epidemic regular prevention and control. There are great differences in the effectiveness between different hand hygiene behavior intervention strategies, and the best hand hygiene intervention practice is still in development and requires further investigation. In order to develop intervention strategies for health care researchers and practitioners, the current research systematically summarizes hand hygiene behavior intervention strategies from the perspective of “nudge” for the first time. Traditional hand hygiene interventions are usually based on knowledge sharing and health education, which only produce weak or modest effects on hand hygiene practices. Recent research in behavioral science provides insights for developing effective behavioral interventions to optimize hand hygiene practices by helping people form better hand hygiene habits. Traditional intervention strategies tend to rely on people’s ability to engage in rational thinking and the availability of cognitive resources, that is, encouraging people to reflect on their hand hygiene behaviors and enhance their handwashing motivation in a rational and conscious way. The influences of external environmental factors are rarely taken into account in traditional intervention strategies. Similarly, the role of personal psychological factors is often ignored, so this kind of hand hygiene intervention strategy often shows limited effectiveness and low sustainability. In addition, there are many other common obstacles such as limited accessibility of hand hygiene products, people's overconfidence in their immune system to prevent infection, inertia, and habitual forgetting. Many research results show that even if traditional intervention strategies can increase risk awareness of poor hand hygiene and enhance hand washing intention in the target population, they may not lead to effective behavior changes in hand hygiene. Inspired by the research from behavioral sciences, researchers have tried to promote experiential, unconscious, and automatically triggered hand hygiene behavior through interventions of specific psychological or external environmental factors, so as to help people overcome the gap between hand washing intention and behaviors. Based on different influential mechanisms, hand hygiene nudging strategies can be classified into four categories and nine subordinate categories, including providing decision information (simplifying information, providing feedback, and harvesting the impact of social norms), optimizing decision options (simplifying options and making original options more attractive), influencing decision structure (increasing the accessibility and visibility of favorable options), and reminding decision direction (direct reminder and environmental hint). Previous studies have shown that behavioral science-based hand hygiene interventions, in general, achieved positive effects at a fairly low cost, which are worthy of further application. However, there are still many disputes concerning ethics and effectiveness for nudging intervention. Among these disputes, the two points often mentioned are whether nudging limits the decision-makers' freedom of independent choice and damages their ability of independent choice. These two disputes may have a relatively small impact on hand hygiene promotion, and the form of nudging intervention is more easily accepted by the public, which may be due to the fact that handwashing behavior essentially has a certain degree of “injunctive norm” tendency (i.e., the vast majority of people agree with maintaining hand hygiene). In addition, previous research on hand hygiene nudging intervention also has many limitations, including low accuracy of the evaluation criteria, sustainability, and generalizability of nudging strategies. Further research is warranted to develop more effective hand hygiene nudging interventions and apply them to diverse social contexts. The effectiveness of multi-facet nudging strategies has also been confirmed in hand hygiene practices, suggesting that another future research direction is to construct a hand hygiene nudging strategy classification system similar to the Behavior Change Technique (BCT) taxonomy, so as to design multi-facet nudging strategies for promoting hand hygiene in a specific social context. Based on China's national conditions, traditional hand hygiene intervention strategies such as health education cannot be completely abandoned. This kind of comprehensive new model of “traditional intervention + nudging strategies” and the personalization and specialization of nudging intervention strategies might be the focus of hand hygiene behavior promotion intervention in the future. However, there is still a lack of hand hygiene nudging intervention in Chinese sociocultural contexts. Another direction for future research is to carry out such nudging interventions in hospitals, schools, communities, and other public places based on the theory of behavioral change, so as to contribute to the prevention and control of infectious diseases and improve public health.

BackgroundImproving hand hygiene in hospitals is the most efficient method to prevent healthcare-associated infections. The hand hygiene behavior of hospital patients and visitors is not well-researched, although they pose a risk for the transmission of pathogens. Therefore, the present study had three aims: (1) Finding a suitable theoretical model to explain patients’ and visitors’ hand hygiene practice; (2) Identifying important predictors for their hand hygiene behavior; and (3) Comparing the essential determinants of hand hygiene behavior between healthcare professionals from the literature to our non-professional sample.MethodsIn total N = 1,605 patients and visitors were surveyed on their hand hygiene practice in hospitals. The employed questionnaires were based on three theoretical models: a) the Theory of Planned Behavior (TPB); b) the Health Action Process Approach (HAPA); and c) the Theoretical Domains Framework (TDF). Structural equation modeling was used to analyze the data. To compare our results to the determinants of healthcare workers’ hand hygiene behavior, we searched for studies that used one of the three theoretical models.ResultsAmong patients, 52% of the variance in the hand hygiene behavior was accounted for by the TDF domains, 44% by a modified HAPA model, and 40% by the TPB factors. Among visitors, these figures were 59%, 37%, and 55%, respectively. Two clusters of variables surfaced as being essential determinants of behavior: self-regulatory processes and social influence processes. The critical determinants for healthcare professionals’ hand hygiene reported in the literature were similar to the findings from our non-professional sample.ConclusionsThe TDF was identified as the most suitable model to explain patients’ and visitors’ hand hygiene practices. Patients and visitors should be included in existing behavior change intervention strategies. Newly planned interventions should focus on targeting self-regulatory and social influence processes to improve effectiveness.

Hand hygiene is one effort to reduce the risk of Healthcare-Associated Infections (HAIs). Nurses' compliance with hand hygiene is still low. The study aimed to analyze the influence of perceived subjective norms on nurses' hand hygiene behavior through intention as an intervening variable. The type of study is observational analytic with a cross-sectional design. The sample was nurses at Hospital X in Jember Regency (116 respondents) using a total sampling technique. The results show that most of the respondents were aged 26 – 35 years (52.59%), male (56.03%), had a diploma (43.97%), and had a working period of 1 – 5 years (39.66%). Model analysis showed the model fit with good predictive relevance (SRMR = 0.090; NFI = 0.851; Q2 = 0.608). Perceived subjective norms and intentions could explain hand hygiene behavior by 74.6% (R2 = 0.746; f2 = 0.146). Perceived subjective norms positively affected hand hygiene behavior directly (p = 0.001) and indirectly through intention (p = 0.001). Perceived subjective norms can increase nurses' hand hygiene intentions and compliance. Leaders of health institutions can improve the nurses' perceived subjective norms through regular monitoring and evaluation to increase hand hygiene intentions and behavior and reduce the risk of HAIs and patient mortality.

Only a few studies have examined the long-term trends of hand and oral hygiene, especially among adolescents. To investigate the 15-year trends in frequency of handwashing and toothbrushing and examine the factors associated with hand and oral hygiene, particularly during the COVID-19 pandemic. This cross-sectional study, performed from January 1, 2008, to December 31, 2022, used general population-based data from 963 644 individuals in a national representative survey (Korea Youth Risk Behavior Web-based Survey [KYRBS]). COVID-19 pandemic. Trends in hand and oral hygiene practices were measured by how frequently adolescents washed their hands and whether they fulfilled the recommended guidelines for toothbrushing. An interrupted time series analysis using linear and logistic regression models was performed to assess any associations with the COVID-19 pandemic. Hand and oral hygiene behaviors before and during the pandemic in each sociodemographic subgroup were also compared. In the 963 644 adolescents (495 697 [51.4%] male; mean [range] age, 15.01 [12-18] years) who participated in the KYRBS from 2008 to 2022, a 73.3% (95% CI, 59.4%-97.4%; P < .001) immediate increase was seen in overall hand hygiene behavior at the onset of the COVID-19 pandemic compared with the prepandemic period, with a sustained decrease thereafter (β = -0.018; 95% CI, -0.022 to -0.015; P < .001). Meanwhile, no immediate increase was observed in terms of overall oral hygiene behavior (0.1%; 95% CI, -0.9% to 1.1%; P = .82); however, there was a sustained decrease during the pandemic (β = -0.018; 95% CI, -0.020 to -0.016; P < .001). Older age, female sex, nonsmoking status, alcohol use, low household economic level, and poor school performance were significantly associated with poor hand hygiene during the pandemic. In this cross-sectional study of South Korean adolescents, an increase in the prevalence of hand hygiene was observed during the early pandemic; however, this prevalence decreased over time. Meanwhile, the decrease in the prevalence of oral hygiene was more pronounced during the pandemic. This study recommends stronger guidelines for adolescent health coaches, such as teachers or public health advisers, regarding hygiene behaviors, even after the COVID-19 pandemic ends.

The cultivation of hand hygiene behavior among school-age children is an important way to prevent the spread of diseases and ensure children’s health. However, traditional health education methods lack personalized programs tailored to each child, which cannot effectively improve their hand hygiene awareness and behavior. In response to this issue, the study combines multi-objective particle swarm optimization algorithm to provide personalized hand hygiene behavior development recommendations for school-age children, improving their hand hygiene awareness and behavioral level. The study adopted multi-objective particle swarm optimization algorithm and convolutional neural network, combined with the personalized needs of school-age children and the goal of cultivating hand hygiene behavior, and proposed a health education plan based on intelligent recommendation algorithm. Through deep learning, match the hand hygiene needs of school-age children with corresponding health education plans to achieve personalized recommendations. The average accuracy of the health education recommendation plan for hand hygiene behavior cultivation of school-age children based on multi-objective particle swarm optimization algorithm reaches 99.07%. Meanwhile, after introducing convolutional neural networks, the feature matching error between the recommended scheme and school-age children ranges from 10-1 to 10-2. After testing, the designed algorithm performs more stably and has less fluctuations under different sparsity conditions. Health education solutions based on intelligent recommendation algorithms can provide personalized solutions for school-age children, effectively cultivate their hand hygiene behavior, and meet various health needs.

Hand Hygiene Behaviors Monitored by an Electronic System in the Intensive Care Unit

Background: Many investigations into the determinants of hand hygiene (HH) behaviour have explored only individual predictors or were designed according to arguably overly simplistic models of behaviour. Consequently, important influences on HH behaviour, including habit and emotion, are sometimes neglected. This study is the first to employ the Theory of Interpersonal Behaviour as a comprehensive model for understanding the determinants of HH behaviour. Method: A self-report questionnaire was conducted with staff from two large UK veterinary referral practices. Participants ( n = 75) reported their HH behaviour and responded to statements rating the importance of social norms, self-protection, patient protection, time pressures, access to equipment, habit and disgust, to their HH behaviour. Results: Regression analysis showed that, overall, determinants explained 46% of variance ( p &lt; .001) in self-reported HH behaviour, with time constraints being the strongest predictor ( β = −.47, p &lt; .001) followed by difficulty finding equipment ( β = −.21, p = .05). Discussion: Time constraints may be the most important influence on HH adherence among the determinants investigated. Future researchers should consider employing theoretical models to aid a more comprehensive understanding of the psychology underlying HH adherence and HH interventions.

BackgroundThe hand hygiene (HH) behaviour of the general public and its effect on illnesses are issues of growing importance. Gender is associated with HH behaviour. HH efficiency is a combination of washing efficiency and hand drying, but information about the knowledge level and HH behaviour of the general public is relatively limited. The findings of this cross-sectional study can substantially contribute to the understanding on the knowledge gap and public behaviour towards HH, thereby providing information on gender-specific health promotion activities and campaigns to improve HH compliance.MethodsAn epidemiological investigation by using a cross-sectional study design on the general public was conducted either via an online platform (SurveyMonkey) or paper-and-pen methods. The hand-washing and -drying questionnaire was used for data collection.ResultsA total of 815 valid questionnaires were collected. Majority of the respondents can differentiate the diseases that can or cannot be transmitted with poor HH, but the HH knowledge of the respondents was relatively inadequate. The female respondents had a significantly better HH knowledge than male respondents. The multiple regression analysis results also indicated that females had a significantly higher knowledge score by 0.288 towards HH than males after adjusting for age and education level. Although the majority of the respondents indicated that they performed hand cleaning under different specific situations, they admitted only using water instead of washing their hands with soap. More males than females dried their hands on their own clothing, whereas more females dried their hands through air evaporation. The average time of using warm hand dryers was generally inadequate amongst the respondents.ConclusionsBeing a female, middle-aged and having tertiary education level are protective factors to improve HH knowledge. Misconceptions related to the concepts associated with HH were noted amongst the public. Self-reported practice on hand drying methods indicated that additional education was needed. The findings of this study can provide information on gender-specific health promotion activities and creative campaigns to achieve sustained improvement in HH practices.

Using the theory of planned behaviour to explain hand hygiene among nurses in Hong Kong during COVID-19

Although hand hygiene (HH) is widely accepted as the most effective measure for preventing cross-infection in healthcare setting, overall compliance remains poor among health care workers (HCWs). The last 30 years have demonstrated a growing interest in many interventions determining effective strategies to enhance HH compliance. Based on those evidences, the World Health Organization guidelines on hand hygiene [1] have recommended multifaceted interventions as the most effective and sustainable tools to increase HH compliance, which consist of five components: system change, including availability of alcohol-based handrub at the point of patient; education of healthcare professionals; monitoring of HH practices and performance feedback; reminders in the workplace; and the creation of a HH safety culture [1]. Recently, many researches investigating factor associated with HH compliance have paid attention to behavioral aspects of HH compliance for more-pronounced and sustainable effect. The assumption that an individual's perceptions have a strong effect on each one's behavior brought about cognitive models [2], which may give an insight into HH behavior. A report [3] already stated 20 years ago that infection control field should learn from the behavioral science to achieve compliance of HCWs. Some models from psychology have been applied to evaluate predictors of health behavior [4]. HCW's behavior can be stratified into individual (intrapersonal), interpersonal, and community level [2]. Intrapersonal factors include individual's knowledge, attitudes, and belief and interpersonal factors include interpersonal process as like a group pressure. Community factors indicate networks and norms [2]. In particular, the specific from pressure on individual's behavior have been called as social network effects or peer effect [5]. The effect of role model for colleagues on HH compliance has already showed importance in a few quantitative [6] and qualitative researches [7]. A recent study [5] identified that the presence and proximity of other HCWs was associated with increased HH adherence and, more interestingly, the adherence increased the more as other HCWs became more crowded. Lee et al. [8] have assessed the improvement of HH compliance and the change of perceptions: intention, knowledge, motivation regarding HH in HCWs in a tertiary teaching hospital in South Korea from 2009 to 2012, where HH promotion programs including poster campaign, monitoring and feedback, and education have been actively conducted. Overall adherence with HH has dramatically increased during the period regardless of professional status or medical specialty. Lee et al. [8] focused on the perception change regarding HH as associated factor of enhanced adherence of HH. However, as the often-cited drawbacks to many intervention studies regarding HH is an independent causal relationship, this research is in danger of making the same mistake. While we can assess the change of perceptions of HCWs and the improvement of HH compliance, we cannot deduce an independent causality between the two facts, since they performed monitoring and performance feedback as well as education with special attentions to perceptions of being a role model for other colleagues. Similarly, Pittet et al. [9] identified awareness of being observed, the belief of being a role model, positive attitudes toward HH as associated cognitive factors of HH adherence. However they coupled observed each HCW's adherence to HH with each one's perceptions and demographic characteristics and conducted multivariate regression analysis for examining independent associated factors. Nevertheless, it is noteworthy that current study by Lee et al. [8] demonstrated astonishing improvement in adherence and in perception and attitude regarding HH during a short period through promotion programs. Although alcohol-based hand disinfectants had already been available since 2004, authors noted this single intervention did not enhance the HH compliance. Furthermore, while knowledge about HH indication and awareness of being observed was not significantly improved between 2009 and 2012, positive attitude toward HH promotion was sharply increased. HH promotion programs including education emphasizing role model could reinforce the positive attitude/perception in HCWs in a positive feedback manner. The inability to motivate HCWs' compliance with only some guidelines indicates that behavior regarding HH is a complex phenomenon [10]. Future HH promotion should consider not only expansion of physical facility like alcohol-based handrub or reminder, but also the dynamics of behavioral change based on the understanding of factors influencing HH cognition and behavior. Multi-level and multidisciplinary strategies regarding behavioral determinants would show great promise for achieving sustainable improvement in HCWs' HH.

BackgroundDuring the first wave of the COVID-19 pandemic, social distancing and hand hygiene have been the primary means of reducing transmission in the absence of effective treatments or vaccines, but understanding of their determinants is limited. This study aimed to investigate knowledge and socio-cognitive perceptions, and their associations with such protective behaviours, in UK university students.MethodsA cross-sectional online survey of 293 students was undertaken on 13 May 2020. Survey questions addressed demographics, knowledge of the disease and effectiveness of the protective measures, risk perception, socio-cognitive perceptions (e.g. attitude, social support, and self-efficacy), habit, time factors and trust, as well as the hand hygiene and social distancing behaviours. Multiple linear regression was used to identify the strongest associations of potential determinants with behaviour.ResultsParticipants reported high levels of social distancing with 88.9% answering “Mostly” or “Always” for every activity, but only 42.0% reporting the same for all hand hygiene activities. Knowledge of the effectiveness of each activity in preventing transmission was high, with 90.7% and 93.5% respectively identifying at least 7 of 8 hand hygiene or 9 of 10 social distancing activities correctly. Habit (β = 0.39, p = 0.001) and time factors (β = 0.28, p = 0.001) were the greatest contributors to unique variance in hand hygiene behaviour, followed by ethnicity (β = − 0.13, p = 0.014) and risk perception (β = 0.13, p = 0.016). For social distancing behaviour, the determinants were self-efficacy (β = 0.25, p < 0.001), perceived advantages (β = 0.15, p = 0.022), trust in policy (β = 0.14, p = 0.026) and gender (β = − 0.14, p = 0.016). Regression models explained 40% hand hygiene and 25% social distancing variance.ConclusionsThis study indicated that communications about effectiveness of hand hygiene and social distancing behaviours had been effective in terms of knowledge acquisition. However, in the light of likely second waves of COVID-19, attention to maintaining social distancing behaviour and improving hand hygiene behaviour may need to address more difficult areas of changing habits, overcoming time factors and building trust, as well as interventions to increase self-efficacy and address risk perception concerns.

Objective: The study aimed to estimate the prevalence and correlates of oral hygiene (OH) and hand hygiene (HH) behavior among school adolescents in three Caribbean countries. Method: In all, 7476 school adolescents (median age 14 years) from the Dominican Republic, Suriname, and Trinidad and Tobago responded to the cross-sectional Global School-Based Student Health Survey (GSHS) in 2016–2017. Results: The prevalence of poor OH (tooth brushing < 2 times/day) was 16.9%, poor HH (not always before meals) was 68.2%, poor HH (not always after toilet) was 28.4%, and poor HH (not always with soap) was 52.7%. In the adjusted logistic regression analysis, current cannabis use, inadequate fruit and vegetable intake, poor mental health, and low parental support increased the odds for poor OH. Rarely or sometimes experiencing hunger, trouble from alcohol use, inadequate fruit and vegetable intake, poor mental health, and low parental support were associated with poor HH (before meals and/or after the toilet, and/or with soap). Conclusion: The survey showed poor OH and HH behavior practices. Several sociodemographic factors, health risk behaviors, poor mental health, and low parental support were associated with poor OH and/or HH behavior that can assist with tailoring OH and HH health promotion.

Original Article Factors affecting hand hygiene behavior among health care workers of intensive care units in teaching hospitals in Korea: importance of cultural and situational barriers 2 In Intensive Care Units (ICUs), where severely ill patients are treated, importance of reducing Hospital Acquired Infection (HAI) cannot be overstated. One of the sim-plest and most effective actions against HAI is proper hand hygiene (HH) behavior of Health Care Workers (HCWs). However, compliance varies across different cultures and different job types of HCWs (physicians, residents and nurses). This study aims to understand determinants of HH behavior by HCWs’ job types in Korea. Quali-tative analysis was performed based on Reasoned Action Approach style interviews with staff physicians, residents and nurses across 7 teaching hospitals. We found that all HCWs strongly believe HH is important in reducing HAI. There were, how-ever, job type-specific HH behavior modifying factors; staff physicians stated feeling pressure to be HH behavior role model. Residents identified Quality Improvement team that measured compliance as a facilitator; a notable barrier for residents was senior physicians not washing their hands, because they were afraid of appearing impudent to their seniors. Nurses designated their chief nurse as a key referent. All participants mentioned heavy workload and lack of access to alcohol-based sanitizer as situational barriers, and sore and dry hand as deterrents to HH compliance. Key wordsPatient safety, Hand Hygiene, Hospital acquired infec-tion, Intensive Care Unit (ICU), Safety culture, Rea-soned action approach

Background: The ongoing novel coronavirus (COVID-19) global pandemic has resulted in significant levels of morbidity and mortality worldwide, particularly among the elderly and immuno-suppressed groups. Although adequate hand hygiene (HH) behaviour and compliance is widely accepted as being the most effective self-protective measure in preventing the spread of diseases like COVID-19, previous research suggests that normal hand hygiene compliance is poor, but generally improves during a disease pandemic. This research aimed to evaluate the hand hygiene behaviour and compliance of the general public in the initial weeks of the COVID-19 pandemic in Northern Ireland (NI). Methods: This cross-sectional study involved the use of infrared-imaging cameras to observe the hand hygiene behaviour and compliance of the general public when using one set of male and female public restrooms. Results: The findings of this study indicated that the level of hand hygiene compliance of the general public was poor in the initial weeks, with 82.93% overall not washing their hands adequately. Conclusions: Inadequate HH behaviour and compliance may have added significantly to the rapid rate of spread of COVID-19 in the initial weeks of the pandemic in NI. Current public health campaigns do not appear, based on this study, to have the desired impact and may need to be reviewed or re-enforced in order to achieve the levels of hand hygiene compliance required to slow the spread of COVID-19 and other communicable diseases in the future.

The adoption of protective behaviors represents a crucial measure to counter the spread of infectious diseases. The development of effective behavior change techniques therefore emerged as a public health priority during the COVID-19 pandemic, but randomized controlled trials (RCTs) testing such interventions during the pandemic were scarce. We conducted a Multiphase Optimization Strategy to develop, optimize, and evaluate a smartphone app, Soapp+, to promote hand hygiene during the COVID-19 pandemic. This RCT aims to evaluate the efficacy of the Soapp+ app (intervention group) targeting motivation and habit compared to a simplified version of the app mainly delivering hand hygiene information (active control group). We hypothesize that, compared to the control group, the intervention group will show greater improvements in hand hygiene behavior and behavioral determinants post intervention and at a 6-month follow-up. We conducted an RCT from March 2022 to April 2023, recruiting 193 adults living in Switzerland online. Following baseline assessment, the intervention lasted 32 days, followed by a postintervention assessment and a 6-month follow-up. The primary outcome was the change in hand hygiene behavior from pre- to postintervention and preintervention to follow-up. Hand hygiene was assessed with electronic diaries. The intervention group received content incorporating various behavior change techniques designed to address key motivational and volitional determinants of hand hygiene behavior (eg, skills, knowledge, intention, attitudes toward hand hygiene, risk perception, outcome expectancies, self-efficacy, action planning, coping planning, action control, habit). In contrast, the active control group was exposed to behavior change techniques targeting only a subset of these determinants (ie, skills, knowledge, and intention). The delivery of the intervention content was fully automated. Group differences were tested using an intention-to-treat approach with the nonparametric Wilcoxon rank sum test. Of the 193 randomized participants, 146 completed the first hand hygiene diary preintervention and were included in the main analysis. The mean age was 41 (SD 17) years, and 69.2% (n=101) were women. The main analysis revealed significant superiority of the intervention compared to controls in the change in hand hygiene pre-post intervention (W=2034; P<.04; effect size r=0.17) and between preintervention and follow-up (W=2005; P<.03; effect size r=0.18). Regarding behavioral determinants, the change in coping planning pre-post intervention (W=3840; P=.03, effect size r=0.16) was significantly greater in the intervention group using Soapp+ compared to controls. Soapp+ was developed through a rigorous experimental method during the ongoing COVID-19 pandemic. The RCT provided evidence for the efficacy of Soapp+ to promote hand hygiene in the context of a pandemic. ClinicalTrials.gov NCT04830761; https://clinicaltrials.gov/study/NCT04830761.