Background & Objectives: Hand hygiene (HH), a fundamental action which is simple, inexpensive and most effective tool in preventing healthcare- associated infections, is at the core of infection prevention and control (IPC) program, yet hand hygiene compliance (HHC) among health care workers (HCWs) is quite low in healthcare settings and remains a lasting cause of alarm.1,2 Previous studies have shown that a multifaceted approach is critical for HHC improvement, a fact endorsed by World Health Organization.2,3,4,5 In health research, the term ‘choice architecture’ and related term ‘nudging’ are broadly applied to a range of intervention types across multiple behavioral contexts, which in recent times, are increasingly being perceived as policy strategies. 6 Nudges are choice-preserving interventions that steer people’s behavior in specific directions, while still allowing them to go their own way and thus can be easily implementable, inexpensive measures as hand hygiene interventions.7,8 Multimodal strategies have been recognized as the most effective intervention, affecting three levels: individual, interpersonal, and organizational.9,10,11 These mini-nudges, however, will not displace the traditional tools like training, regulations etc, but instead, will combine with them as potential reinforcers, since behavior can be influenced by altering the microenvironments within which people make choices (choice architecture).12 This in turn, would provide a sustainable contribution towards improving HHC to a significant extent and in turn reduce healthcare– associated infections. Aim: To assess the outcome of multimodal nudge interventions on hand hygiene compliance in healthcare workers Objective: To bring about behavioral change using nudges as interventions and in turn contribute to long- term success of these strategies to improve HHC Methods & Results: A quasi-experimental study was conducted, including a pre-intervention phase and a post-intervention phase with 226 HCWs overall, from various wards and high-risk areas of our hospital. HHC was measured using both overt and covert observations by trained personnel in pre intervention and post intervention phases. Levels of hand hygiene compliance were low in the pre-intervention phase (40.9 %) with significant improvement seen (68.4 %) in the post intervention phase, the increase after nudging interventions being statistically significant (p<0.05). Interpretation & Conclusion: If properly devised, integrated multimodal interventions based on a multilevel socioecological approach has great potential in bringing about sustained improvement in hand hygiene compliance of healthcare workers.
Healthcare-associated infections (HCAI) cause a significant healthcare burden in both high-income countries (HICs) and low-to-middle-income countries (LMICs), with an estimated prevalence of 7.6 and 10.1% of hospitalized patients, respectively.13 Hand hygiene among healthcare professionals plays a crucial role in preventing these HCAIs, yet its compliance remains quite low.1,2 Many strategies have been tried to improve the HHC of HCWs, but most effects are small to moderate, often temporary or short term.11
Healthcare systems are notoriously known for their complexity and conservative culture, making change management rather challenging. Because of its complexity, it requires more nuanced and well-thought-out interventions instead of top-down strategies, such as issuing more policy, prescribing more regulations, and introducing more stringent performance indicators.8 Thus, over the last two decades, behavioral economics and experimental psychology, in the form of nudges, has gained momentum as an innovative approach to tackle these. According to nudge theory, “supposedly irrelevant factors” in the decision context can have a substantial impact on people’s behavior, which is based on routine heuristic processes and not on careful calculation of consequences.14, 15, 16
A recent Cochrane review identified 26 studies which assessed the combinations of the following strategies: availability, education, reminders (verbal and written), performance feedback, administrating support, staff involvement and other incentives.17 These multimodal nudging strategies have proven to be effective and are distinct and complementary to more traditional tools (such as mere training or incentives).
HCAIs continue to burden patients, HCWs and society by increasing morbidity, mortality, absenteeism and treatment costs.11 HHC has been highlighted as the most effective measure to reduce transmission of pathogenic microorganisms and lower the incidence of HCAIs and thus HHC has become one of the key performance indicators of patient safety and quality of health services worldwide.2 Adequate hand hygiene among HCWs can prevent an estimated 15%-30% of the HAIs but compliance remains disappointingly, suboptimal.11 In complex modern health care environments, HCWs being at the front-line, are constantly exposed to stressful and time-sensitive work demands. Thus, sustaining HHC remains a challenge. The reasons for poor hand hygiene adherence may include lack of facilities, lack of staffing, increased workload, skin irritation, lack of role models, and disregard for instructions.19 In this regard, the World Health Organization has provided multiple strategies, including system change, education and training, observation and feedback, hospital reminders, and a safe hospital environment.20
Implementation science is a relatively new field in health care that focuses on the development of feasible strategies and tools that promote the adoption of effective interventions to improve the quality of care. There is often a considerable gap between experimental results for an intervention and its transformation into practice, and implementation science aims to fill this gap.21 With their seminal book titled –“Nudge: Improving decisions about health, wealth, and happiness” in 2008, behavioral economists Richard Thaler and Cass Sunstein coined the concept of nudging, which they define as: “any aspect of the choice architecture that alters people’s behavior in a predictable way without forbidding any options or significantly changing their economic incentives.”14, 15 Nudges are deliberate and small changes in the environment which exploit heuristic and automatic processes, promoting beneficial outcomes in human decision-making. In their work, Thaler and Sunstein reference two modes of thinking: the automatic system and the reflective system.14, 15 Cognitive scientist Daniel Kahneman refers to these as System 1 and System 2 respectively.17 In System 1, thinking, impressions, associations, feelings, intentions, and actions flow effortlessly and quickly. In contrast, in System 2, thinking is slow, effortful, and deliberate. In psychology, this is referred to as Dual Process Theory (DPT).14 DPT is the foundation of nudging because it explains what happens when we act unaware; yet at the same time, it provides us with the possibility to either make that action salient to ourselves, engaging System 2, or change the context so we choose something better without thinking about it, thus System 1.15 Nudging can include a wide variety of strategies, including simplification of processes, changing default options, altering physical layouts, subconscious environmental cues, timely reminders, providing performance or social norm feedback and pre-commitment strategies.
The behavior change process is multifaceted, complex and thus requires a multi-pronged approach, its effects, depending on the success of a complete simultaneous sequence of influencing factors.22 Accordingly, it is necessary to determine the most feasible, effective strategy and its influencing components to increase adherence to hand hygiene. Handwashing, as a practice, is a ritualistic behavior driven by deeply embedded, unconscious processes belonging to the non-reflective system of cognitive processing, as it involves automaticity and mental efficiency.23 Therefore, inculcating professional handwashing habits among HCWs through subconscious cues should, in theory, increase hand hygiene compliance, as conceptualized in nudge theory.
Compliance with hand hygiene among HCW is estimated to average 40% based on opportunities identified in WHO guidelines. Several meta-analyses or systematic reviews of quantitative hand hygiene research have summarized factors associated with compliance with guidelines or with efficacy of interventions.18, 24, 25, 26 Aggregate findings from these several reviews suggest that compliance rates in general improve after interventions, although potential direct or indirect causal pathways are not always clear based on the primary research studies. 24 We need to know not only the short-term effects of behavior change interventions, but whether their effects — both singly and in combination— can be sustained and if so, for how long.
Several studies showed results largely consistent with the Cochrane review findings. Two studies found performance feedback to be effective, while one study employing a mix of performance and social feedback did not. Interventions employing environmental cues were heterogenous, and only three of six studies found them to be effective. Two studies using auditory cues showed improved compliance; however, there were inconsistent results with visual cues. 10, 11, 18, 27- 29 Because of the heterogeneity of evidence, there are no meta-analyses summarizing the effect of nudge interventions on HCW hand hygiene compliance, making cost-effective assessments and implementation challenging. With the advent of digital hand hygiene auditing systems, researchers can augment future studies with high volume hand hygiene event assessments that can be performed throughout the day, and are not subject to observer bias and inaccuracies.
Future research should seek to achieve the following: develop reliable automated HHC monitoring tools, which will allow real time feedback loop; use simulated lab environments to refine study designs; expand behavioral science approaches such as environmental psychology, behavioral economics, human factors and ergonomics and financial rewards to catalyze behavior change and in particular, to sustain HHC.
Aim: To assess the outcome of multimodal nudge interventions on hand hygiene compliance in healthcare workers
Objective: To bring about behavioural change using nudges as interventions and in turn contribute to long- term success of these strategies to improve HHC
Research category and Research/Study Design: Qualitative; A quasi-experimental study including a pre-intervention phase and a post-intervention phase.
Study Area: Hand Hygiene compliance in different areas of the hospital such as wards and high- risk areas.
Study: Basic qualitative study with pre intervention and post intervention phase
Target Respondents & Age group & Gender: Both adult male and female healthcare workers of different professional categories such as Nurses, Group D workers, Consultants, Residents, Interns & Allied health personnel
PIS & ICF: Informed consent was taken from all the participants. All names were anonymized, without any personal identifiers.
Inclusion criteria: Healthcare workers who consented for the study
Exclusion criteria: Healthcare workers who did not consent for the study and those having any dermatological conditions of hands.
Sample size: 226
As per study by Iversen et al. 11, baseline HHC is 27%. Taking this as prevalence, at 95% confidence interval and 5% absolute allowable error, sample size was calculated for proportion:
n= Zα 1-α/2 p (1-p) / d2
Z = standard normal table value for given level of significance
P = (prevalence)/ proportion
d = marginal error or precision
n = (1.96) 2 (0.16) (1 – 0.16)/ (0.05) 2 = 206
The estimated sample size is found to be 206; but during the process, additional twenty personnel were included as they showed inclination to be part of this study.
Total sample size therefore is 226
Study process:
The study was taken up as a 2- step process: a pre intervention phase and a post- intervention phase.
All the above interventions were taken up almost simultaneously and not in the above-mentioned order.
Statistical analysis: were performed using SPSS software version 28. Chi-squared test was used and Mann-Whitney test was used to determine the statistical significance of the results before and after the interventions. P values < 0.05 was considered to be statistically significant.
To take care of bias which are usually encountered during such audits, the following steps were undertaken:
Ethical Clearance: The study was undertaken after presenting to Institutional Scientific committee and Institutional Ethics Committee and obtaining the ethical clearance.
Audit details: Each observation period was for 15- 20 minutes. Most of the observations were done during day duty shift and professional category, duration, HH moments and HH followed were noted in WHO observation forms. HH opportunities and HH actions were recorded and HH adherence rate was calculated.
TABLE 1: Operational Component Details
Measure |
Detail |
Hand hygiene compliance rate |
Number of hand hygiene actions performed/ number of hand hygiene opportunities observed x 100 |
Method of observation |
Direct method |
Indications |
An indication “is the reason why hand hygiene is necessary at a given moment WHO ‘s “My five moments for hand hygiene” Moment 1: before touching a patient Moment 2: before clean/aseptic procedures Moment 3: after body fluid exposure/risk Moment 4: after touching a patient Moment 5: after touching the patient surroundings |
Opportunities |
Points in time within the care process when hand hygiene should be performed, as specified by the indications. An opportunity exists whenever at least one of the indications for hand hygiene is present and observed; however, there can be more than one indication for a single opportunity |
Actions |
Comprise the performance of hand hygiene. Each opportunity should correspond to an action of performing hand hygiene. |
Audit tools |
WHO HH monitoring tools |
Of the total 226 health care workers included in this study, 60 were Nurses, 81 consultants and 85 categorised together consisting of interns, residents and other allied health personnel. A total of 1660 HH opportunities were observed - 862 during the pre-intervention phase and 798 in the post-intervention phase (Table 2 and Table 3).
Baseline audit results overall (pre- intervention phase) showed poor HH compliance (40.9%) as compared to HHC rate of 68.4% in the post- intervention phase (Table 4). HHC among nurses was more in comparison to the other categories of healthcare workers (Table 2). Individually considering the HHC of each category during pre-intervention phase showed poorer compliance rates in all three categories of healthcare workers as compared to post intervention compliance rates. A statistically significant increase in compliance was thus evident in post intervention phase (68.4%) as compared to pre intervention phase (40.9%).
TABLE 2: Pre- intervention HH compliance in different professional categories of health care workers
Professional category |
Moments available |
HH followed |
HHC rate % |
Nurses |
440 |
209 |
47.5 |
Doctors |
294 |
98 |
33.3 |
Others |
128 |
46 |
35.9 |
Total |
862 |
353 |
40.9 |
Figure 1
TABLE 3: Post- intervention HH compliance in different professional categories of health care workers
Professional category |
Moments available |
HH followed |
HHC rate % |
Nurses |
406 |
298 |
73.4 |
Doctors |
244 |
152 |
62.3 |
Others |
148 |
96 |
64.9 |
Total |
798 |
546 |
68.4 |
Figure 2
TABLE 4: HH compliance before and after nudging interventions
Category |
Total opportunities before intervention |
Total opportunities after intervention |
HH compliance: before intervention (%) |
HH compliance: after intervention (%) |
Nurses |
440 |
406 |
47.5 |
73.4 |
Consultants |
294 |
244 |
33.3 |
62.3 |
Others |
128 |
148 |
35.9 |
64.9 |
Figure 3
Hand hygiene is considered one of the most important measures to prevent healthcare-associated infections. Since its introduction in 2008, the term “nudge” gained much attention as a viable, effective, intervention strategy for behavioral change, yet it is surprising that very few studies have been conducted on this. Our study showed improvement in hand hygiene compliance across all categories of healthcare workers. This is similar to studies where three out of four of the interventions targeting hand hygiene were successful, employing priming and environmental cueing strategies.30, 31, 32 The visual cues we used in the form of signages and posters were in local language too, which might have contributed to the improved compliance.
In our study, compliance was better in nurses than other professionals. Consultant doctors had the lowest baseline compliance but seemed to be very responsive to the intervention and reached almost same compliance levels as the nurses similar to few other studies.11,12 In one study, the nurses receiving individual performance feedback demonstrated the best performance in all the different room types.11 However our study did not focus on giving feedback exclusively to nurses; instead, was given to all HCWs, though feedback to consultants was not given freely as with other professionals. The reasons interfering with this being seniority, hierarchy and ‘know-it-all’ attitude and mannerisms of some of the doctors.
This notwithstanding, a reason for the improvements observed could be the reduction in cognitive biases. When HAIs manifest several days after exposure, HCWs do not encounter the consequences of poor hand hygiene and they could consider their risk of causing infections negligible. When being reminded about the importance of good hand hygiene through performance feedback and via other nudges in the moment, some of these cognitive barriers are removed.11All but one of these” multi-nudging” studies had a positive result.8, 10. 24, 29 Of all nudges, 84% resulted in statistically positive results.8 As an overarching method, nudges are an attractive implementable intervention as they can be applied to a wide array of problems arising from behaviour and are often easy to deliver and low cost.7
The ideal approach to monitoring HH compliance is not clear; each has numerous advantages and limitations, the optimal “threshold” for HH compliance to improve clinical outcomes not being well understood. Although direct observation is considered the gold standard, it suffers from many important limitations that limit its generalizability. The accuracy and reliability of each approach is not well understood. Multimodal interventions incorporate different components, including some of those advocated by WHO. The ideal components of multimodal campaigns remain to be established, and it is still unclear whether multimodal interventions are superior to single interventions.18 The combination of several intervention strategies, on the one hand, seems to increase the possibility that an intervention is effective, but on the other hand, makes it hard to determine exactly which elements make an intervention successful.
Similarly, in our study, though overall increase in compliance rate was evident post these nudging interventions, the exact extent to which each of these individually had an effect remains unclear. Also since this was a short-term study, whether the effects of these nudges will still have a positive reinforcing effect on HCWs after a certain amount of time has elapsed, has not been ascertained. Apparently, even in convenient conditions of information and incentives, people may still fail to pursue beneficial actions, because choices do not usually arise as the logical consequences of stable preferences and beliefs.9
Yet, this approach certainly supports the theory of multimodal strategy put forth by WHO and though just a small step, it needs to be followed upon, to get further insights and reach conclusions.
Insights into the quirks and limitations of human rationality can help us improve decision outcomes by the design of suitable nudges, non-coercive and typically small changes of the choice context that exploits inherent tendencies of agents in order to promote desirable outcomes.9
Remember - Nudges are not meant to displace more traditional tools to promote beneficial behavior (training, regulations), but instead to complement them.
Many organizations have provided guidelines to promote hand hygiene in healthcare settings but those issued by WHO are the most comprehensive. The multimodal package of interventions recommended (ABHR, education, reminders, performance feedback, and managerial support) are applicable to all settings and implementation should therefore be encouraged. However, the WHO intervention will need to be adapted to meet local needs and available resources, which was done by us for our present study. If properly devised, integrated multimodal interventions based on a multilevel socioecological approach has great potential in bringing about sustained improvement in hand hygiene compliance of healthcare workers, which would in turn lead to decreased incidence of health care associated- infections.
Pitfalls of direct observation; lack of orientation/ sensitization in some doctors along with skepticism, short duration of study period and lack of adequate manpower and resources to study effects of individual interventions.
Recommendations:
“If I continue to do what I have always done, then I’m going to get what I’ve always got”. -Forsyth & Eifert
Results obtained will change only when there is a change in the system and the process of behavior change always starts with awareness!
In this regard, incorporating behavioral approach as one of the multimodal intervention strategies to improve hand hygiene compliance is highly recommended since this is easy to implement, sustainable and cost- effective.
Conflict of interest: Nil
Acknowledgements: I express my sincere thanks to Dr. Nalini A. R, Director & Quality Manager, THS Super speciality hospital, Tumakuru, Karnataka for her immense support.
I would like to thank all the health personnel who contributed for the audits.