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Reducing hand and glove recontamination - NU/LSHTM project

Title of PhD project / theme

Reducing hand and glove recontamination

Supervisory team

Giorgia Gon (LSHTM, Lead) giorgia.gon@lshtm.ac.uk

Chris Smith (NU) Christopher.Smith@lshtm.ac.uk

Miho Sato (NU) mihos@nagasaki-u.ac.jp

Others at LSHTM (Wendy J Graham)

Brief description of project / theme

Re-contamination of hands from unclean healthcare surfaces after hand washing or glove donning negates the value of prior hand washing with soap and water and using hand-rub. Whilst this is a potentially critical infection control limitation, this aspect of hand-hygiene behaviour has been little-studied worldwide (1,2,3,4). The study proposed here aims to understand what drives recontamination among healthcare actors; to develop pragmatic strategies and materials to support healthcare workers in this specific behaviour; and to evaluate their feasibility and acceptability. As the grant will cover a PhD student bursary, an additional aim of the study is the capacity building of the student to become a future research leader in the field of infection prevention research.  

Healthcare workers will be the main study participants; these will be any worker with clinical duties involved in touching the patients or performing clean/aseptic procedures. We will work across up to 10 hospitals overall; 4 wards in each hospital will be included, with 5 hospitals in the UK and 5 in the Gambia (possibly also hospitals in Asia such as Philippines/Japan). Providing evidence from a variety of contexts with different resources will allow us to find common solutions. We will conduct this work by using interviews and discussions with stakeholders, direct structured observation of health workers practices (using time-and-motion methods) and finally we will test various implementation strategies to reduce hand and glove recontamination.  

Specific outcomes will include a policy briefs suggesting hand hygiene improvement strategies at the local facility and ward level; at least 2 peer-review publications on the topic; various stakeholders meetings during the study and dissemination which are aimed at co-design of implementation strategies but also at raising awareness of the behaviour studies: hand and glove recontamination. Our work explores specific strategies to reduce hand and glove re-contamination which will ultimately mean better overall hand hygiene compliance e.g. through the strategic placement of handrub (5). Recontamination has been a critical underexamined topic which can account for a large proportion of low compliance to hand hygiene (1,2,3,4). Ultimately this would have an impact on reducing healthcare associated infections among patients and health workers. Healthcare-associated infections account for an estimated 15% of service-use episodes in low and middle-income countries. Reducing these infections through improved hand hygiene could bring significant economic benefits for over-burdened health services through reduced staff workload and lower treatment costs in these contexts.  

With hand hygiene being key behaviour in preventing COVID-19 transmission, this pandemic has highlighted the importance of examining the contribution of hand and glove recontamination and how to improve it. Indeed, hands and gloves have a crucial role in spreading SARS-COV2 between hands and surfaces (4). The results from this project will yield useful insights on how to limit the role of hand and glove recontamination in future epidemic of similar nature.

References:

1. Gon G, et al. Am J Infect Control. 2019;47(2):149–56.

2. Stewardson AJ, et al. In Antimicrobial Resistance and Infection Control; 2017. (Meeting Abstracts; vol. 6(Suppl 3):52).

3. Hor S, et al. BMJ Qual Saf. 2016 Nov 30;bmjqs-2016-005878.

4. Gon G, et al. Infect Control Hosp Epidemiol. 2020 Apr 6;1–2. 

5. Boog MC, et al. BMC Infect Dis. 2013 Oct 31;13:510.

Research questions and Methods

This study aims to develop a sound explanatory model of the key determinants of recontamination among healthcare actors; to select appropriate behavioural and organisational change techniques for influencing these determinants; to develop pragmatic strategies and materials for the intervention; and to evaluate their feasibility and acceptability. The key research questions include: (A) What is the hand and glove re-contamination frequency in different wards, staff cadre, facility and case-load? (B) What individual (e.g., attitudes, skills) and environmental (e.g. norms, organisation, physical) factors explain variation in this frequency? (C) What intervention strategies to promote avoiding recontamination are likely to be effective, feasible and acceptable?

To address these questions, we have selected complementary tools drawn from three main theoretical bases for improving hygiene behaviour. The Behaviour Centred Design (BCD) approach emphasizes the importance of emotional drivers (e.g. lust, nurture, disgust) and the environment in shaping hygiene behaviour.(1) This model is grounded in both evolutionary anthropology and ecological psychology and relies on in-depth, qualitative methods. The second model categorises behavioural determinants into knowledge, attitudes, norms, ability and self-regulation factors (Behavioural Change Wheel), and is based on the health belief model and the theory of planned behaviour, among others.(2) It relies on survey methods that are quantitative in nature. The third base draws on theories of organisational learning and knowledge management.(3) The importance of such a mixed-methods approach for developing sound complex interventions is widely-acknowledged.(4)

The research will be conducted in three consecutive work packages (WPs).

WP1– We will use unstructured participant observation to capture hand hygiene practices for about three weeks across up to 4 wards across the 10 study facilities. In addition, focus group discussions (FDGs) using novel participatory techniques will be conducted to identify the range of potential individual and environmental determinants driving re-contamination, to explore what surfaces healthcare workers consider safe to touch after hand hygiene is performed, and where re-contamination fits in their implicit hierarchy of work tasks. The findings from the observational work and FGDs will be used to develop an initial explanatory model of the behavioural drivers.

WP2– We will conduct time-and-motion observation of healthcare workers practices during two key hand hygiene moments a) before clean/aseptic procedures and b) before touching the patient – these are moments where re-contamination presents highest patient-risk. We will try and conceal the study purpose from health workers during this structured observation by suggesting the observation is about all around quality of care and not specific to hand hygiene. This should minimise the Hawthorne effect. Initial observational data will be discarded in view of the Hawthorne effect.(5) Observation will be performed across the different wards in all study hospitals – with at least 100 hand hygiene opportunities observed at each ward based on our initial sample size calculations. We will also collect information during the observation on contextual level factors such as availability of handrub. We will develop a survey questionnaire to capture the key variables in the initial explanatory model, drawing on validated questionnaires and developing new scales where necessary. The survey will be conducted among all health workers observed working in the 10 facilities (~200 health workers in total). Health workers will complete the questionnaire after the observation is carried out.  Regression analyses and structural equation models will be used to identify the key drivers or predictors of hand hygiene practices among birth attendants and mothers.

WP3– For the key determinants identified in WP2, we will examine theory and literature to identify those most amenable to change and thus targets for intervention. Drawing on insights from WP1 & WP2 and our earlier needs assessment, we anticipate developing a multi-level intervention, utilizing Behavioural and Organisational Change Techniques to target individuals (such as knowledge, motivation, reminders to activate norms/goals), social norms, and organisational behaviour (such as altering the physical environment or policies). A feature of the study is the intended co-production of intervention materials with the target groups. The intervention material will be pre-tested among the target groups to evaluate their acceptability as well as the feasibility of implementation. Possible example of behaviour change strategies to be tested include: repositioning of hand hygiene items e.g. gloves pack evidence sharing on relative surface contamination;(6,7) and innovative ways of teaching the concept of “patient zone” in hand hygiene.

  1. Aunger R, Curtis V. A Guide to Behaviour Centred Design, DRAFT. 2016; Available from: https://blogs.lshtm.ac.uk/envhealthgroup/files/2015/04/Guide-to-Behavio…
  2. Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science. 2011;6:42.
  3. Grol RP t. m., Bosch MC, Hulscher ME j. l., Eccles MP, Wensing M. Planning and Studying Improvement in Patient Care: The Use of Theoretical Perspectives. Milbank Quarterly. 2007;85(1):93–138.
  4. Craig P, Dieppe P, Macintyre Sally, Michie S, Nazareth Irwin, Petticrew Mark. Developing and evaluating complex interventions: new guidance. Available from: http://www.mrc.ac.uk/documents/pdf/complex-interventions-guidance/
  5. McCambridge J, Witton J, Elbourne DR. Systematic review of the Hawthorne effect: New concepts are needed to study research participation effects. J Clin Epidemiol. 2014 Mar;67(3):267–77.
  6. Dancer SJ, White L, Robertson C (2008) Monitoring environmental cleanliness on two surgical wards. Int J Environ Health Research 18: 357-364.
  7. Adams CE, Smith J, Robertson C, Watson V, Dancer SJ. (2017) Examining the relationship between surface bioburden and frequently touched sites in Intensive Care. J Hosp Infect 95(1):76-80.

The role of LSHTM and NU in this collaborative project

The supervisors from LSHTM and NU will offer monthly or biweekly meetings to the student to concentrate on the technical aspects of the PhD, in addition to regular weekly catch calls to ensure the smooth study progression. Currently, there is an online system in which the supervisors and student log in their meetings (frequency, content) which allows LSHTM to monitor whether the student is supported in an appropriate way.

In addition, the student will be supported by a PhD Advisory committee that will be recruited based on the needs that arise during the PhD and that will complement the supervisor skills. Preliminary academics that will be contacted for this will be Associated Professor Alex Aiken with expertise in clinical microbiology and infection prevention and control, Assistant Professor Loveday Penn-Kekana with expertise in qualitative methods, and Professor Simon Cousens with expertise in statistical methods.

Finally, the student will have access to a research degree coordinator within the department which she/he will have regular meetings throughout her/his degree to ensure she/he is on track and she supported in the appropriate way by her supervisors and the institution.

Particular prior educational requirements for a student undertaking this project

We will recruit a student with a background in epidemiology and therefore we expect a master degree which included quantitative skills.

Skills we expect a student to develop/acquire whilst pursuing this project

We will recruit a student with a background in epidemiology and therefore we expect a certain degree of quantitative skills.

Dependently on their level however, we will recommend the student to take the following quantitative modules: Statistical Methods in Epidemiology, Advanced Statistical Methods in Epidemiology.

Given that the PhD will also include qualitative methods, dependently on the familiarity of the student with such methods, we will encourage her/him to take the module entitled Principles of Social Research.

Outside of the available and free modules offered within LSHTM, we would hope to enrol the student in a short course available at University College London entitled “Introduction to Behaviour Change” with experts in the field of behaviour change like Professor Susan Michie who has a track record in health workers behaviour change.