October 4, 2019
By: Lindsay Denny, Global Water 2020
Photo Credit: WaterAid/Tom Greenwood
It’s a familiar scenario. A trainer runs a training on hand hygiene for nurses. Good practice is modeled, copied by participants. Nurses return to their work. Hand hygiene compliance marginally increases, only to return to baseline a few months later. Rinse, repeat.
Capacity building has become the go-to of development programs across low- and middle-income countries. There is a prevailing assumption that knowledge is lacking. However, training (and the holy grail of trainings – the training of trainers) is only one kind of behavior change intervention. In the case of handwashing practices among clinicians, increased knowledge of handwashing has limited impact on practice. Why then do we continue to overemphasize this one element when it hasn’t produced positive results?
If we understand behavior based on the COM-B framework, we see that capacities, motivations, and opportunities all interact to affect behavior (Michie, 2011). So, if increased knowledge through trainings alone isn’t the solution, there must be other drivers involved. What else should we be considering? The thoughts below are compiled from my facility visits and discussions with clinicians across Africa, Asia and Latin America:
1. Enabling environment
To state the obvious, practicing proper handwashing relies on the availability of soap and running water or alcohol-based hand rub (ABHR). The 2019 JMP baseline report on WASH in healthcare facilities found that 1 in 6 healthcare facilities globally had no hygiene services (JMP, 2019).
Basic access is just one facet of the enabling environment – the quantity and location of hand hygiene facilities can also drive behaviors. Johns Hopkins University found in Ethiopia a ratio of 1 sink to 74 nurses (PMA2020). Meanwhile, I have visited hundreds of wards where the sink is inconveniently located for healthcare workers to access while providing care. A sink 50 meters down the hall and around the corner will not encourage consistent handwashing. A sink located where a healthcare worker will need to re-contaminate his hands by opening the door to get to the patient also does not support patient safety.
We seem to forget that clinicians are human too, and their behaviors are influenced similarly. While handwashing benefits both doctor and patient, there could be a myriad of conscious, habitual and unconscious reasons that prevent them from doing so. Given the frequency at which they need to wash their hands, they may have strong preferences about the kind of hand hygiene materials that they use. Do they prefer ABHR to soap and water? Does ABHR cause their hands to dry out and thus they use it infrequently? Is liquid soap preferred to bar soap? We need to know answers to these questions. If we, practitioners and policymakers, do not take their preferences into consideration when formulating lists of supplies, we are hindering our efforts to ensure good practice.
A key question we should be asking is who bears the cost of the hand hygiene materials. If soap is consistently disappearing from the facility, healthcare workers may bring their own. The same can be said about ABHR, which can be an expensive investment when you are using it as much as healthcare workers should be. If a healthcare worker is spending her own money on hand hygiene supplies, then she may want to conserve it and may be unlikely to share with her coworkers. Could this impact the frequency at which she washes her hands? What situations would she deem worthy of clean hands and which situations might it be OK to forgo the practice? If the facility bears the cost, it is thus important to work with facilities and the broader health system to ensure hand hygiene materials are budgeted for and readily available as needed.
4. Attitudes, Motivators and Culture
Minimal research has been conducted around what are the prevailing attitudes and motivators related to handwashing among healthcare workers in LMICs. In 2016, my team at Emory University surveyed 300 clinicians at hospitals in Cambodia. A quarter of respondents said it was acceptable to go between patients without washing hands. These attitudes give us a glimpse into why we found hand hygiene compliance to be around 35% when knowledge was high. Meanwhile, what do we know about what motivates individual nurses, midwives and doctors to wash their hands? Does the use of nudges see an increase in hand hygiene compliance in healthcare facility settings in LMICs? Finally, is there a culture of cleanliness within the facility? The tone set by management and leadership can impact the behaviors of the rest of the staff. What does it say to interns that the senior physician doesn’t wash his hands between patients? Cleanliness champions, particularly among the leadership, can lead to a shift in the facility culture and expectations. Ultimately, attitudes, motivations, and culture can override knowledge.
Whether its peer pressure, oversight from a supervisor, or regular reminders from leadership about expected behaviors, we all do better at following the rules when some kind of accountability mechanism is in place. This could take the form of routine monitoring of hand hygiene accompanied by recognition of good performance and/or corrective action for poor performance. Or perhaps morning staff meetings include daily reminders and demonstrations of hand hygiene, while posters above sinks urge staff to wash at the 5 Key Moments.
Changing and maintaining behaviors is hard work. It’s why WHO recommends a multimodal strategy to improve hand hygiene – system change, training and education, observation and feedback, reminders in the workplace, and creating a safety culture. But even with a more robust approach, it is clear we do not fully understand the drivers of handwashing among clinicians in LMICs and the impact various interventions may have. We have a responsibility to not take the easy way out and develop interventions that consider more than just gaps in knowledge.
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