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Measuring the effectiveness of a hand hygiene campaign on health care workers’ knowledge, attitudes and intention to comply with hand hygiene guidelines

March 2007

Principal Investigator: Elizabeth A. Bryce (Vancouver Coastal Health Authority)
Co-investigators: Leslie A. Forrester, Linda J. Kingsbury, Catherine Kidd (Vancouver Coastal Health Authority)

For more information about this study please contact Dr. Elizabeth Bryce.

Disclaimer

Issue

Frequent and appropriate hand washing is the most important factor in preventing and controlling infections, but compliance with this simple activity tends to be poor in health care settings. This study examined the effectiveness of a campaign to promote hand hygiene within the Vancouver Coastal Health Authority, and explored the individual, organizational and environmental factors that influence health care workers’ intent to comply with hand hygiene guidelines. The knowledge gained will be useful in the planning of future infection control initiatives.

Key findings

  • The hand hygiene campaign and research project were successful in engaging most categories of health care workers. However, there was a low level of participation by physicians.
  • Health care workers had a high level of knowledge and intent to comply with hand hygiene guidelines before and after the campaign. However, the findings also suggest that time constraints and other barriers often result in a gap between knowledge/intent and actual behaviour.
  • Barriers to optimal hand hygiene include time constraints, workload issues, inappropriate glove use, and inadequately stocked hand hygiene stations. Factors that facilitate optimal hand hygiene include visible support from the administration, the provision of additional hand hygiene supplies, and consultation with health care workers regarding the optimal placement of hand hygiene stations, particularly in clinical areas.
  • The results of a poster competition suggest that health care workers respond best to positive messages that provide a rationale for the behaviour being promoted.
  • There was an increase in the use of all hand hygiene products over the course of the campaign, likely as a result of the campaign and steps taken to make these products more accessible.

Objectives

  • To identify the individual, environmental and organizational factors that influence health care workers’ intent to comply with hand hygiene guidelines
  • To identify differences in the beliefs and attitudes that various groups of health care workers have about hand hygiene
  • To identify the factors that contribute to the success or failure of a regional campaign to promote hand hygiene

Methods

The research project used a number of techniques to assess the effectiveness of a year long hand hygiene campaign launched in fall 2005 within the Vancouver Coastal Health Authority, that targeted approximately 13,249 health care and contracted service workers. The campaign was aimed at increasing health care workers’ awareness and compliance with hand hygiene guidelines. It targeted individual, environmental and organizational factors using the following approaches:

  • Individual factors were targeted through posters, promotional items, poster contests, staff surveys and focus groups aimed at increasing awareness and intent to comply.
  • Environmental factors were addressed by increasing the number of wall mounted and portable antiseptic dispensers.
  • Organizational factors were addressed by the Senior Administration’s visible support for making hand hygiene – including increased awareness and access to hand hygiene programs – a priority issue.

The researchers collected data in the following ways:

  • Staff surveys were conducted before the campaign, mid-campaign and after the campaign ended, with questions about the effectiveness of campaign posters, knowledge of hand hygiene, intention to comply with hand hygiene guidelines, and hand hygiene product preferences, usage and accessibility.
  • Focus groups were conducted in July 2006 to explore individual, environmental and organizational factors that influence health care workers’ intent to comply with hand hygiene guidelines, as well as the effectiveness of the campaign.
  • Posters designed by staff and submitted to the poster competition were analyzed to identify how messages in the staff posters were framed and what categories of messages were used.

Results

  • Knowledge of hand hygiene outcomes and intent to comply with hand hygiene guidelines, as measured by the staff surveys, were high at the beginning of the study and did not significantly change over the course of the campaign.
  • The majority of survey respondents noticed the campaign posters, although the proportion that noticed them was lower in the middle and end of the campaign than at the beginning.
  • Effectiveness scores were calculated for ten different posters used in the campaign, based on survey responses. All ten posters scored very high. The campaign door stopper poster entitled “The Bug Stops Here” was rated the highest.
  • Over 81% of survey respondents reported that they preferred soap and water to alcohol gel.
  • Focus groups identified time constraints, workload issues and inappropriate glove use as the main barriers to compliance with hand hygiene guidelines. Focus group participants also noted the administration’s support and the provision of additional hand hygiene supplies as positive factors.
  • The content analysis of poster competition entries found that the majority of messages emphasized attaining a positive outcome as opposed to avoiding a negative outcome, and provided a strong rationale as to the importance of hand hygiene.

Conclusions

The researchers conclude that the social marketing approach of the campaign was successful, as evidenced by the excellent response to surveys, poster contests and promotional items. Organizational factors, such as management support, and environmental factors, such as accessibility to hand hygiene products, were the areas most positively affected by the initiative. Health care workers’ knowledge and intent to comply were already high at the beginning of the campaign and remained unchanged.

Based on the results, the researchers conclude that hand hygiene promotion should focus less on individual attitudes and beliefs and more on organizational and environmental factors, such as implementing clear policies and directives, and improving the accessibility of hand hygiene products and resources, in consultation with health care workers.

Future directions

The results of the project will be used to inform future interventions aimed at increasing compliance with hand hygiene guidelines. Future efforts may include new ways to target physicians, patients and visitors more effectively, considering different kinds of poster messaging, and having “poster holidays” to prevent tolerance to campaign messaging. The results of the project also point to the need for further research on how best to engage hard-to-reach populations such as physicians, how to address the issue of inappropriate glove use that was raised by focus group participants, and exploring why health care workers prefer soap and water despite its being more time consuming than alcohol based products.

Publications and Presentations

The campaign was featured in the following issues of the “Current” Magazine (Current is the official newsletter of Vancouver Coastal Health Authority):

  • September 2005 (Vol. 3, No. 8) – VCH Promotes its Infection Control Hand Hygiene Campaign Clean Hands for Life™.
  • October 2005 (Vol. 3, No. 9) – Clean Hands for Life™
  • November 2005 (Vol. 3, No. 2) – Good Hand Hygiene Supports Infection Control.
  • February 2006 (Vol. 4, No. 2) -- Clean Hands for Life™ Poster Contest Winners Announced.
  • July/August 2006 (Vol. 4, No. 7) – The Power is in Your Hands: Portable Hand Rub Dispensers Increase Hand Hygiene and tips for Keeping Your Hands Clean.
  • July/August 2006 (Vol. 4, No. 7) -- Clean Hands for Life™ Campaign and Staff Recognized for Good Infection Control Practice.

The campaign was also featured in “Spotlight”. Spotlight features weekly highlights on the Vancouver Coastal Health Authority intranet site.

  • October 17, 2005 -- Clean Hands for Life™ Campaign.
  • January 24, 2006 -- Clean Hands for Life™ Poster Contest Winners Announced.

Presentations

  • “Clean Hands for Life™”. Oral presentation at the Hand Hygiene Consensus Building Workshop, Toronto, Ontario, March 1, 2006.
  • “Social Marketing Contributes to the Success of a Regional Hand Hygiene Campaign” poster presentation at CHICA National Education Conference, London, Ontario, May 9, 2006.
  • “Measuring the Effectiveness of a Regional Hand Hygiene Campaign on Healthcare Workers’ Knowledge, Attitudes and Intention to Comply with Hand Hygiene Guidelines” oral presentation at the 2nd International Infection Control Conference, Hong Kong, June 18, 2006.
  • “Clean Hands for Life™: Evaluating the Effectiveness of a Regional Hand Hygiene Campaign” poster presentation at Halifax 6: The Canadian Healthcare Safety Symposium, Vancouver, BC, October 19, 2006.
  • “Clean Hands for Life™” Innovation in Poster Presentation” poster presentation at the BC Ministry of Health
  • “Innovations in Health Care Best Practices Forum, Vancouver, BC, June 1, 2007.
  • “Clean Hands for Life™. Oral presentation at the CHICA BC Annual Education Day, Vancouver, BC, October 26, 2007.