Inclusion of Real-Time Hand Hygiene Observation and Feedback in a Multimodal Hand Hygiene Improvement Strategy in Low-Resource Settings

This quality improvement study uses a novel data collection and visualization tool to audit hand hygiene adherence before and after training among health care workers in low-resource settings at 2 hospitals in Nigeria.


Introduction
Health care-associated infections (HAIs) are a leading concern for patient safety and are associated with prolonged hospital stays, long-term morbidity, increased resistance levels in pathogenic bacteria, higher costs for hospitals and patients, and higher mortality. 1 In resource-limited settings, the prevalence of HAIs is estimated to be more than 2-fold the prevalence in Europe (15.5 per 100 patients vs 7.1 per 100 patients). 2 In these contexts, HAIs are also problematic because, as a high proportion of medical care is provided in inpatient departments, antimicrobial-resistant pathogens are highly prevalent, and many patients are particularly susceptible to HAIs (especially neonates and patients who are malnourished, have numerous complex comorbidities, or require surgical care). 3 Acquisition of an HAI occurs primarily through contact with contaminated hands of transiently colonized health care workers (HCWs) or from contaminated environmental surfaces. 4 Therefore, hand hygiene for HCWs is the primary method to reduce the spread of HAIs. Unfortunately, hand hygiene adherence rates in HCWs remain low globally. [5][6][7] To improve hand hygiene adherence, the World Health Organization (WHO) recommends implementing a multimodal approach to strengthening hand hygiene in health care. 8 This improvement strategy focuses on increasing awareness and adherence of HCWs following the 5 Moments for Hand Hygiene, 8 which has proven successful in reducing HAIs in numerous countries. [9][10][11][12] However, in low-resource contexts (including humanitarian hospitals), there are implementation challenges to increasing HCWs' adherence. Most hospitals in these contexts lack the appropriate infrastructure and resources to facilitate hand hygiene (eg, insufficient space between beds, crowding of patients), and staff and family caretakers are not trained in appropriate hand hygiene measures and sometimes lack knowledge of the consequences of poor adherence. 3,13 In humanitarian hospitals, routine audits to measure hand hygiene adherence are infrequent. 3 Thus, in the absence of simple monitoring tools for hand hygiene, the long-term sustainability and feasibility of hand hygiene strengthening measures are at risk. In higher-resource settings, the current criterion standard for measuring hand hygiene adherence is direct observations of HCWs and performance feedback. 8,14 Médecins Sans Frontières (MSF) is a medical humanitarian organization that works in diverse health care settings, including outpatient clinics and hospitals. Médecins Sans Frontières' current infection prevention and control policy focuses, standardizes, and simplifies high-impact infection prevention and control interventions (ie, hand hygiene, cleaning and disinfection, and transmissionbased precautions) so that all HCWs are able to understand and prioritize these interventions. 15,16 For hand hygiene, this includes infrastructure adjustments (eg, more space between beds, availability of clean water and alcohol-based hand sanitizer [ABHS]), training and education for all HCWs, establishing evaluation and feedback mechanisms for adherence, and posters and staff meeting reminders about the importance of the 5 Moments for Hand Hygiene. As part of improving the evaluation and feedback for hand hygiene adherence, we developed and piloted the use of opensource software on mobile devices and interactive analytical dashboards for the collection and visualization of hand hygiene adherence data in 2 MSF-supported hospitals in northwest Nigeria after hand hygiene strengthening activities. We describe our experiences with the multimodal approach and with the adherence monitoring tools.

Context
The pilot study was conducted from April 23 to May 25, 2018 in 2 hospitals in northwest Nigeria supported by MSF: (1) Anka General Hospital (AGH), Anka, Nigeria, where MSF works with the Nigerian Federal Ministry of Health in the pediatric ward, the inpatient therapeutic feeding center, and the isolation ward, and (2) Noma Children's Hospital (NCH), Sokoto, Nigeria, where MSF and the Ministry of Health work in preoperative and postoperative wards that care for patients with noma. 17 The HCWs employed at these sites are a mix of MSF and Ministry of Health employees (ie, nurses, physicians, guards, hygienists, and health promoters). Qualitative data were analyzed throughout data collection and used for immediate feedback to staff. A more formal analysis of the data was conducted during October 2018.

Hand Hygiene Strengthening Intervention
We implemented infrastructure improvements, educational discussions with HCWs, and a training of trainers (TOT) with supervisory staff at both hospitals. 18 The infrastructure improvements focused on increasing the availability and accessibility of ABHS at most patients' beds and in clinical areas. The educational discussions aimed to train HCWs on the rationale, importance, and correct technique of hand hygiene and to understand their existing knowledge, attitudes, and practices about it. The educational discussions were facilitated with different HCW groups using a topic guide that was designed by the study team and included information from previously published hand hygiene topic guides. 19,20 It covered the following aspects: knowledge about the 5 Moments for Hand Hygiene, perception of importance and adherence, barriers (including infrastructure), and perception and need for feedback of adherence measurements (eAppendix in the Supplement).
The TOT was conducted as an interactive workshop and covered (1) the MSF infection prevention and control policy, (2) the importance of hand hygiene to prevent HAIs and transmission of multi-drug-resistant bacteria, (3) descriptions and practice of the multimodal strategy and correct hand hygiene techniques, and (4) how to conduct adherence monitoring and feedback. Participants in the TOT were a combination of health promoters, nursing supervisors, nursing activity managers, and water and sanitation supervisors from the hospitals. After the TOT, participants were tasked to provide cascade training to HCWs in each of the wards they were responsible for at the start of their shifts.

Study of the Intervention
We conducted a prospective multicenter quality improvement study that evaluated an intervention for improving hand hygiene adherence among HCWs. We piloted the use of novel electronic data collection, analysis, and visualization tools for feasibility and ease of use in this lower-resource context. Infrastructure improvements and some training for hand hygiene were performed prior to implementation of this pilot study. For the study, we performed preintervention adherence measurement first, then educational group discussions second, TOT for supervisory staff third, and postintervention adherence measurement last. Discussion participants were sampled purposively, and all participants provided their verbal informed consent to participate in the discussion and for the discussion to be recorded and disseminated. Discussions were transcribed in English by a native English speaker. No data collection was performed during the TOTs. This pilot study fulfilled the

Measures Qualitative Measures
The educational discussions were conducted in English by 1 of us (B.v.D.) with the support of a Hausalanguage translator. Groups were composed of HCWs with similar roles, and each discussion lasted 1 hour. In AGH, we conducted 3 educational discussions: 1 with health promoters, 1 with members of the infection prevention and control committee (including nurse ward supervisors, nurses, physicians, nutrition assistants, and laboratory technicians), and 1 with guards and hygiene officers.
In NCH, we also conducted 3 educational discussions: 1 with nurses, 1 with ward assistants, and 1 with physicians.

Quantitative Measures
Hand hygiene observation data were collected using KoBoCollect (KoBoToolbox), an open-source and free mobile data collection application. 21 We designed a form in KoBoCollect called the Hand Hygiene Observation Tool (HHOT) (Figure 1). The form was uploaded onto mobile phones with Android operating systems (Alphabet) in AGH and tablets with Android operating systems in NCH.
Each observer had participated in the TOT and was trained for approximately 10 minutes on how to use the tool, followed by a supervised observation period. Trained observers recorded data for each directly observed hand hygiene opportunity of HCW staff in the facility. A hand hygiene opportunity was defined as any of the 5 moments defined in the 5 Moments for Hand Hygiene: (1) before patient contact, (2) before an aseptic or clean task, (3) after bodily fluid exposure risk, (4) after patient contact, and (5) after contact with patient surroundings. 22 At each opportunity, the observer recorded in the HHOT the number of opportunities for hand hygiene observed for each participant, the HCW role (eg, physician, nurse), and which hand hygiene action they performed. Actions recorded included handwashing with water and soap, hand disinfection with ABHS, wearing gloves, or no action performed. A correct technique was considered as one in which handwashing or ABHS were performed according to WHO protocol. Wearing gloves without either the use of ABHS or handwashing prior to donning gloves was considered incorrect. We defined an adherent hand hygiene opportunity as one that had been conducted correctly. Completed forms were uploaded to a centralized MSF-managed KoBoToolbox server each time the phone or tablet connected to a Wi-Fi signal. The HHOT was used in both preintervention and postintervention measurements.
We conducted preintervention and postintervention hand hygiene adherence direct observations. At least 200 opportunities (per ward, hospital, or role) are needed to obtain reliable results on hand hygiene adherence. 22 Thus, 200 hand hygiene opportunities were observed in each hospital before the intervention and again after the intervention. 23 Observations in AGH were conducted in the inpatient therapeutic feeding center and pediatric ward, whereas observations in In AGH, we conducted the preintervention observations, the implementation of the intervention, and the postintervention measurements within the same week. However, in NCH, we conducted the preintervention measurements and the implementation of the intervention within the same week, and the postintervention measurements were completed within 2 weeks after the TOT.

Statistical Analysis Qualitative Measures
A simple deductive approach was used to analyze the content of educational discussions (performed by A.L., N.G., and S.K.). This involved reading and rereading the transcriptions and identifying common themes and patterns that emerged in line with the themes highlighted in the topic guide.
We also allowed new themes to emerge from the data and cross-checked findings among 3 of us (A.L., N.G., and S.K.) to enhance validity.

Quantitative Measures
Hand hygiene adherence was defined as the number of correctly performed hand hygiene actions divided by the number of total hand hygiene opportunities observed. 22 We measured the adherence at the ward and hospital level and stratified by role level within each hospital.
Using the KoboCollect application programming interface, a set of clearly defined methods for allowing the communication of data among different applications and platforms, we connected data from the KoboToolbox server to Power BI (Microsoft Corp), a partially proprietary online platform for automated data analysis with an interactive visualization display (dashboard). The application programming interface was used to populate Power BI, and the dashboard was refreshed daily. To evaluate whether the intervention was associated with hand hygiene adherence, we compared preintervention with postintervention adherence rates and calculated 2-tailed χ 2 and their respective P values to determine significance of the difference. Statistical significance was set at less than .05. These analyses were conducted using Stata statistical software version 15 (StataCorp). praying. Most medical HCWs (ie, nurses and physicians) reported that they should perform hand hygiene before touching a patient, after bodily fluid exposure, and after touching a patient. However, the moments before an aseptic procedure and after touching a patient's surroundings were not frequently mentioned. Gloves were mentioned often as a method of hand hygiene, and there was confusion around when one should use gloves compared with washing one's hands or using ABHS.

JAMA Network Open | Infectious Diseases
The barriers to performing hand hygiene highlighted by HCWs were ABHS being unavailable or not easily accessible in clinical areas, absence of both water and soap at handwashing stations, and large patient loads and thus lack of time to perform hand hygiene between patients (Table 1). Several participants mentioned that we should include patients and caretakers in hand hygiene training sessions. The ABHS was also mentioned as a deterrent because people felt that they needed to wash their hands after having used it owing to their hands feeling dirty (Table 1). Finally, the need for reminders, posters throughout the hospital, and more training sessions for all staff levels that work in the hospital was mentioned in most groups.
Overall, hand hygiene adherence increased from 32.4% before the intervention to 57.4% after the intervention. Lowest overall postintervention adherence occurred before patient contact (53.1% postintervention periods (P < .001). The increase in adherence was also seen in each of the 5 moments. After the intervention, the lowest adherence rates were for the moments before aseptic  (Table 2).

Discussion
Our results suggest that the implemented multimodal hand hygiene improvement strategy can be successful in increasing HCW hand hygiene adherence, as demonstrated in these 2 hospitals in Nigeria. Additionally, we were able to successfully develop and use an open-source mobile data collection tool to perform hand hygiene observations and create an automated dashboard to support data display and analysis as well as feedback to HCW staff. These tools are useful for further extrapolation in different MSF settings but can also be easily replicated by other organizations in low-resource settings. Also, our study contributes to the lack of research around hand hygiene adherence in these contexts. 24 We observed that hand hygiene adherence differed between nurses and physicians.
Particularly, the decrease in postintervention adherence in the physician group at NCH was concerning. This specific group of HCWs may benefit from a more targeted training on hand hygiene.
We also observed that the 5 Moments for Hand Hygiene (particularly after touching a patient's surroundings) were inconsistently understood by the groups of HCWs. These differences in knowledge and adherence with regard to hand hygiene among different HCWs are well documented. [25][26][27] The differences in adherence observed between AGH and NCH might have been This was a pilot evaluation of the HHOT. However, the findings have direct applications to routine activities focusing on improving hand hygiene in health care settings. The HHOT is free and can easily be adopted (and adapted) to any health care setting to monitor hand hygiene adherence.
The HHOT allows for more discrete and faster adherence observations, decreases use of paper, eliminates the need for data entry, and could improve data quality. Although the HHOT should only be used by a trained observer, it is easy to use and teach and works well for adherence monitoring in low-resource settings. Also, the dashboard allows quick analysis of data by ward, HCW role, and the 5 moments, thus facilitating the rapid identification of low adherence. This information can be used to rapidly target interventions and educational efforts for HCW groups or specific hand hygiene moments. The version of PowerBI used by MSF is a paid version, but a simplified free version also exists. Even so, data collected in the HHOT can easily be shared with any free or open-source data analytics system or program to generate automated, real-time, data visualization dashboards (eg, MSF's Github dashboard [https://github.com/MSF-UK/MSF-Dashboard]). The only costs associated with customizing an electronic dashboard would be from development work.

Limitations
Our intervention and pilot study had some limitations. The educational discussions were useful in starting a dialogue about hand hygiene with staff in the 2 hospitals; however, researcher time was limited, and the duration of the sessions was too short to serve as a qualitative investigation regarding perceptions and barriers to hand hygiene and as a teaching opportunity to increase awareness and adherence. However, the topic guide served as a useful tool for future interventions and as a starting point for future dialogues with HCWs. It is currently being further developed for use as a teaching tool (rather than a research tool) for health care facilities to address hand hygiene in an interactive manner. This was a pilot study with a quasi-experimental design (ie, without a control group) that was conducted within a short time. As such, the results cannot be extrapolated to other settings and may not be representative of possible improvements in hand hygiene adherence in AGH or NCH for the longer term. After the pilot of the HHOT, monthly adherence measurements have continued as part of the multimodal strengthening initiatives in both hospitals. We are aware that without ongoing efforts and investments in hand hygiene, it is likely that adherence rates will decrease through time in both hospitals. The HHOT relies on direct observations of hand hygiene adherence, which, despite being the criterion standard, 14,22 is inherently subject to the Hawthorne effect. 33 We tried to limit this bias by using a mobile device for observations (which could suggest that the observer was looking at his or her smartphone rather than observing the participant). In both hospitals, preintervention and postintervention observations were conducted by 2 different observers, which may have altered the way in which adherence was judged. This was minimized by