Challenging Dogma - Fall 2011

Monday, December 19, 2011

Leveraging Social Sciences Theories to Improve the Public Health Approach to Handwashing Compliance – Katy Agule

Perhaps most simple, the act of handwashing causes much discussion within the hospital environment. As early as the late 19th century, Ignaz Semmelweis observed a higher mortality rate for women who had babies delivered by students and physicians at the First Clinic at the General Hospital of Vienna in comparison to those women who had babies delivered by midwives in the Second Clinic, and he attributed this difference, and the offending puerperal fever affecting the women, to “cadaverous particles” transmitted by the students and physicians. Semmelweis was then able to recommend students and physicians to clean their hands with chlorine solution between each patient, and this recommendation led to a dramatic decrease in the mortality rate. This observation and subsequent intervention represents the first evidence in favor of handwashing with an antiseptic agent. Later into the 20th century, formal written guidelines were developed by both the U.S. Public Health Service and the Center for Disease Control and Prevention. (1)
Although handwashing guidelines have been developed and disseminated to the healthcare work force, studies have shown that compliance for these suggestions are rarely followed. Mean baseline rates vary from 5 to 81%, although compliance definitions are varied (2). Compliance rates among the various roles of the healthcare work force (i.e. physician, nurse, nursing assistant, etc.) also vary, and the lack of physicians’ positive beliefs in handwashing affect compliance rates in hospitals globally (3, 4).
While it is clear more robust and convincing education is needed to increase awareness of and compliance with handwashing (5), handwashing compliance programs and interventions have not always been successful in increasing compliance rates (6, 7). Research has shown a simple addition of accessible alcohol-based hand antiseptic dispensers readily increases compliance with handwashing (6, 8), but in order to not only increase compliance rates where hand anti-septic dispensers are not available but to also advance the education of the healthcare work force, improved implementation of education and training programs is required.
Critique of the Public Health Approach to Handwashing Compliance
Even though handwashing has been established as a key step in the prevention of hospital-acquired infection, compliance rates have found to be low (7), and at this point, there has not been an intervention or program developed that successfully combats the issue at hand. The various interventions and programs developed include educational and training sessions, feedback, reminders, changing of soap, addition of “dry” rubs, and adjustment of sink facilities to include automatic sinks. Although all programs effectively increase compliance rates, these results are short-term, and no long-term solution has been found (7).
Much of handwashing compliance research has found that physician compliance rates are much lower than those of other healthcare workers (3, 4, 9, 10, 16). Among reasons for their low compliance include busy workloads, performing activities with high risks for cross-transmission, being in technical specialties, low value of hand hygiene, and low value of being a role model (4, 9). While busy workloads and technical specialties are issues of hospital organization and atmosphere, personal beliefs and attitudes are items that can be evaluated and improved. It is crucial physicians’ beliefs and attitudes are improved, as their behavior negatively impacts others working beside them (4, 11).
It is not unexpected that personal beliefs and attitudes shape physicians’ behavior. According to the Theory of Reasoned Action, decisions about health behavior are weighed according to attitudes, beliefs, and subjective norms. Two factors, outcome expectancies and social norms, are weighed depending on related factors: the strength of the value of each possible outcome and the strength of the value of each expected outcome, while the perceptions and beliefs of others and the level of importance of those peer perceptions impact the weight of the social norms (12). More specifically, three factors influence the strength of the intention of a behavior, which are the relationship of the intention and behavior according to their levels of specificity, the stability of the intention, and the person’s level of autonomy for following through with the intention (13). Physicians may have strong beliefs regarding handwashing, and as senior members of the hospital community, may place more significance on their own beliefs than the beliefs of other members of the community, who may support handwashing interventions. Erasmus et al found that physicians do find handwashing important, but did also present a perception of lack of evidence for the importance of hand hygiene in preventing cross-infection (4). It can be postulated that if physicians perceived hand hygiene as important in preventing cross-infection, handwashing compliance would increase.
Physicians’ beliefs and attitudes regarding handwashing also impact the handwashing behavior of those working with them. Erasmus et al also found nurses and medical students were impacted by negative role models. These negative role models were experienced nurses or physicians who were noncompliant with hand hygiene guidelines (4). Lankford also found that health care workers in a room with a senior medical staff person or peer who did not wash hands were significantly less likely to wash their own hands (11). From these observations, it can be postulated the negative role models that physicians and other noncompliant senior hospital staff play negatively affect the handwashing behavior of the remaining hospital staff.
The Theory of Planned Behavior, which is an improved modification of the Theory of Reasoned Action, an individual can weigh the outcome expectancies and social norms of handwashing and have the behavioral intention to follow proper hand hygiene compliance, but there might be external factors preventing their behavior. The Theory of Planned Behavior hypothesizes that perceived behavioral control, which is the degree to which someone believes they have control over whether they can take the action and the strength of that belief, affects decisions regarding health behavior (14). Consistent with this theory, those healthcare workers who work with noncompliant senior staff might have strong behavioral intention to follow proper handwashing guidelines, but may experience low perceived behavioral control to complete that action. Thus, handwashing compliance remains low throughout the hospital community. Additional research performed by McLaws et al found that negative attitudes regarding handwashing negatively impact community handwashing compliance, and concluded that community-based handwashing practices exerted a strong influence on handwashing compliance in the hospital (15). Therefore, in order to increase handwashing compliance, it would be beneficial to improve the perceived behavioral control of hospital staff by encouraging senior staff to become stronger role models.
Other than negative attitudes, beliefs, and perceived control, external factors also contribute to handwashing noncompliance. Research has found high workloads contribute to lower handwashing compliance (3, 9, 10, 17). Pittet et al noted that perceived busyness, assumedly from a high workload, substantially reduces handwashing compliance (3). Jang et al also found handwashing compliance was affected by other environmental factors, including unreliable access to alcohol hand rub, skin damage due to frequent handwashing, lack of improved technology, and lack of clean equipment (10). Lastly, the research of Erasmus et al found the “hospital culture” encourages poor handwashing compliance, in that it is acceptable for senior staff to deviate from guidelines, which frustrates other hospital staff (4). Clearly, external factors can have a significant impact on hand hygiene adherence.
The impact of external factors in the hospital community on handwashing compliance can be explained by the ecological perspective. The ecological perspective theorizes there is interaction and interdependence of factors across multiple levels, including physical and socio-cultural environments, known as multiple levels of influence and reciprocal causation respectively (18). There are five levels that influence health-related behaviors: intrapersonal or individual factors; interpersonal factors; institutional or organizational factors; community factors; and public policy factors (19). According to this theory, a high intensity work environment and a busy workload would influence individuals as institutional or organizational factors. These factors constrain handwashing compliance even though it is a recommended behavior.
Although proper handwashing adherence has been known to prevent hospital acquired infections, handwashing compliance rates remain low. Many versions of hand hygiene interventions have been developed and implemented, but few provide long-term solutions (7). Among the various issues found during hand hygiene adherence research include: physician’s negative attitudes and beliefs regarding handwashing, the lack of positive role modeling by senior staff, lack of perceived behavioral control, high intensity workloads, and other external factors. In order to improve handwashing compliance, these issues must be addressed and then improved interventions can be developed.
Proposal of Improved Public Health Approach to Handwashing Compliance
Many handwashing adherence programs have been developed and attempted at various organizations across the world. These programs include but are not limited to: educational and training sessions, feedback, reminders, changing of soap, addition of “dry” rubs, and adjustment of sink facilities to include automatic sinks (7). With the aim of improved handwashing compliance, concerns deriving from previous programs must be addressed.
First, many physicians have reported negative attitudes and beliefs regarding handwashing, including a lack of belief that hand hygiene does actually prevent cross-contamination (4). In actuality, there has been abundant research presented regarding the benefits of handwashing adherence and its success at preventing hospital-acquired infections (5). Physicians’ beliefs and attitudes must be improved in order to increase handwashing compliance, as physicians’ feedback has a far-reaching impact throughout hospitals. Research has also shown that the value of personal protection is an important indication of handwashing compliance (10).
In accordance with the Health Belief Model, the value of person protection can be used to improve handwashing compliance. The Health Belief Model states that health seeking behavior and other health behavior is motivated by four factors: perceived susceptibility, perceived severity, perceived benefits of an action, and perceived barriers to taking that action (14). To leverage this theory, the various pieces of data can be compiled to leverage the value of personal protection to improve handwashing compliance. For example, colorful and attractive signs can be posted in restrooms, corridors, near handwashing sinks and patient doors, to remind physicians and other healthcare workers to wash their hands before and after patient contact. Hospital-acquired infection data before and after handwashing compliance interventions can provide proof of the severity of the issue and increase the perceived benefits of an action, while various ailments one could develop can be noted to increase perceived susceptibility.
The lack of positive role models is a second cause of low handwashing compliance. Research has shown the physicians do not agree they act as role models to other staff (10), and nurses and other staff have claimed the presence of noncompliant experienced nurses or physicians as a reason for their own noncompliance (4). In regards to handwashing compliance, Erasmus et al noted “positive role models are essential to breaking the cycle” (4). It is critical physicians are encouraged to become positive role models.
Social Cognitive Theory can be applied to encourage physicians to become positive role models. According to Social Cognitive Theory, three factors, self-efficacy, goals, and outcome expectancies, all affect the possibility that a person will change their behavior. A concept of Social Cognitive Theory, observational learning or modeling, implies that behavioral acquisition occurs by watching the actions and outcomes of others’ behavior (18). Regarding the issue of promoting positive role models within the hospital, physicians who already perform high handwashing compliance and have positive beliefs and attitudes toward handwashing can be recruited to strongly exaggerate and display their role as a positive role model in their department, in order to show the benefits and effect of being a positive role model. If possible, these recruited physicians can also be positively reinforced, thus applying a second concept of Social Cognitive Theory, using rewards and positive feedback. By utilizing positive observational learning and reinforcements, those physicians performing low handwashing compliance should be encouraged to act as better role models for those around them.
A third factor negatively impacting handwashing compliance is the effect of external factors on handwashing. Inaccessibility to alcohol hand rub, lack of improved hospital technology, numerous sources of microorganism transmission, poor equipment handling, risk of transmission associated with visitors, and lack of hospital initiatives have all been cited as external factors contributing to low handwashing compliance (10). Many, if not all, of these factors can be improved using a toolbox of social science theories.
According Everett Rogers, the Diffusion of Innovation theory is the process in which individuals adopt a new idea, product, practice, or philosophy. For most situations, only an initial few are open to the new idea and adopt its use, but as the word is spread, additional individuals adopt the idea which leads to the development of a critical mass, and saturation is eventually achieved (20). Utilizing this theory can improve hospital initiatives to assist with handwashing adherence by employing accountability from the top of hospital organizations. It has been reported that a few hospital organizations have made hand hygiene an annual organizational goal, first by setting a compliance goal and offering a monetary incentive to each employee when the goal was attained (21). If enough hospitals employ this method and create a culture of accountability, it can be assumed with positive publicity, the importance of handwashing compliance and proper hospital initiatives to support the campaign will reach a saturation point. Once at saturation point, it is hoped handwashing compliance will increase on a long-term basis.
Improved health initiatives related to handwashing adherence can also be improved using agenda-setting theory. According to agenda-setting theory, media dictates the public agenda, and any issues that are brought through the media agenda to the public agenda will be brought to the policy agenda (22). Thus, hospital administrators can work with the media to increase the awareness of handwashing adherence. Increased media outreach, combined with stronger hospital initiatives, can assist in raising the awareness of the importance of handwashing adherence.
Healthcare workers had also noted the risk of transmission associated with visitors as a reason for a lack of compliance (10). In order to combat this risk and improve compliance among hospital visitors, marketing and advertising theory can be employed, using an idea of what people actually want, and then packaging your product to fulfill that want (23, 24). Advertising theory assumes the advertisement has three factors: promise, core values, and support (24). In order to employ marketing and advertising theory to the issue of lack of handwashing compliance among hospital visitors, a promise must first be chosen. To be most influential for this issue, the chosen promise could be that loved ones go home from the hospital healthy and happy. For hospital visitors, this is a promise that will appeal to their core values, the second part of advertising theory, of family and love. Finally, the three most effective ways to support promises should be employed: visual images, stories, and music. It would be most effective to recruit a former patient and their loved ones to share a story regarding their hospital visit and the effect of proper handwashing. This story will demonstrate to the viewer that proper handwashing is important for healthy hospital stays, and as theorized by the law of small numbers, one story of one person is more impactful that showing many stories (25). Thus, the one story chosen must have great significance regarding both a healthy hospital stay and proper handwashing. Other information, visual images, and upbeat music can only strengthen the message of the video.
Numerous sources of microorganism transmission and poor equipment handling were also found to be sources of low handwashing compliance, but it was noted that these beliefs tended to be based on incorrect assumptions (10). To combat these assumptions, in-service programs reviewing the hand hygiene guidelines would serve as useful reminders for all healthcare workers.
Another issue noted by healthcare workers is inaccessibility to alcohol handrub (10). Research has shown that increased accessibility to alcohol handrub increases handwashing compliance (6, 26), and it would be clearly beneficial to introduce alcohol handrub throughout more hospitals. According to the Illusion of Control theory, individuals have a distorted sense of the extent they control their fate or events that happen to them, and it is particularly distorted when they have ownership (25). From this theory, it can be postulated that distributing alcohol handrub to healthcare workers will only benefit handwashing compliance because the workers would then have a higher sense of control of their behavior, and thus perform hand hygiene procedures for an increased number of opportunities.
Much research has been done regarding the reasons for low handwashing compliance, and the issues include physicians’ negative beliefs and attitudes regarding handwashing, lack of positive role models, and external organizational factors (3, 4, 6, 7, 9-11).
Although many handwashing intervention programs have been implemented across the world, many of these programs do not aim to resolve the underlying factors that contribute to low handwashing adherence. With the employment of several social science theories, these factors can become combated, and an improved handwashing intervention approach can be designed, using multiple methods and programs.
This multi-method approach can include educational in-service programs, outreach campaigns to the media, influential and inspiring videos for hospital information monitors, improved hospital initiatives, and increased accessibility to alcohol handrub, with room for many more types of programs.
As proper hand hygiene is widely known to prevent hospital-acquired infections, it is hoped handwashing compliance among healthcare workers can improve throughout the world. Although a mighty goal, if singular hospitals or organizations can take the first step in promoting hand hygiene at home, the global health organization community will improve.
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2. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51 (No. RR-16): 22

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18. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Rockville, MD: National Cancer Institute, 2005.

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21. Greising C. Accountability at the top. Trustee October 2010.

22. Siegal M. Social and Behavioral Sciences of Public Health lecture, 3 November 2011.

23. Siegel M. Social and Behavioral Sciences of Public Health lecture, 27 October 2011.

24. Siegel M. Social and Behavioral Sciences of Public Health lecture, 20 October 2011.

25. Siegel M. Social and Behavioral Sciences of Public Health lecture, 1 December 2011.

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