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Does Self Protection Drive Hand Hygiene Behaviour in Healthcare?

October 15, 2013

WHO 5 Moments of Hand HygieneThe WHO 5 Moments are evidence based, user-centred guidelines designed to direct hand hygiene at specific points during Patient care to prevent cross-transmission.  Their use can prevent both the spread of infection between individuals (exogenous) and prevent infection caused by an individual’s own microorganisms (endogenous).   Implementation and use across a range of global settings supports the efficacy of such a multimodal approach to hand hygiene promotion.

What is of particular interest, from an intervention design point of view, is the potential the WHO 5 Moments provides for a deeper exploration of WHEN hand hygiene is being performed, and crucially, when it is being missed.  Because, perhaps, not all hand hygiene is the same…

Examining measured hand hygiene rates using the WHO 5 Moments, for example from the Australian National Hand Hygiene Initiative (Grayson et al., 2011), we can see hand hygiene compliance at 12.6% lower before Patient contact (Moment 1) than after Patient contact (Moment 4). And this finding is not in isolation.  A systematic review by Erasmus et al. (2010) found 35 studies reporting compliance rates  before and after Patient contact, with a median compliance rate of 21% found for “Before” as opposed to a much higher median of 47% found for “After”.

So what does this mean? 

In terms of behaviour it suggests that healthcare professionals are less likely to be performing hand hygiene before attending to their Patient, with all the related cross-contamination risk that this may imply.  However, upon completion of an interaction with a Patient the healthcare professional is more likely to then perform hand hygiene. 


As promotion and education of the WHO 5 Moments has been significant, and successful, it has been suggested that underlying behavioural drivers may explain differing rates of hand hygiene relating to specific moments of Patient care.  Self-protection has been noted as a strong motivator for hand hygiene in doctors, over and above the need to prevent cross-contamination (e.g. Erasmus et al., 2009). This may explain why hand hygiene is seen more frequently AFTER Patient contact, when a perceived risk to the healthcare professional drives the behaviour, whereas BEFORE Patient contact requires a driver stemming from a desire to prevent potential contamination reaching the Patient. 

Such drivers may also explain why WHO 5 Moment driven studies often show poor levels of hand hygiene compliance for Moment 5 - After Touching Patient surroundings (e.g. Rossini et al.,2013, in press; Grayson et al., 2011).

Work currently being undertaken within an NHS setting (Dawson, 2013 – in preparation) indicates that this moment is perceived by healthcare professionals as the one most likely to be “dropped” when other pressures mount.  Conversely, Moment 2 (Before Clean/Aseptic Procedure) and Moment 3 (After Body Fluid exposure risk) were perceived as those which would “always be done”.

Such perceptions link to the ‘Hierarchy of Risk’ phenomenon discussed by Whitby et al. (2006) in formation of their Inherent and Elective theory of hand hygiene behaviour. This theory suggests that the concept of ‘dirtiness’ is key to driving hand hygiene behaviour, activities which do not trigger a ‘dirty’ perception are less likely to lead to hand hygiene.  My current research explores how this theory may link with the WHO 5 Moments, and therefore enable us to explore further what drives hand hygiene at each of the individual moments.

This is an exciting new field to explore; data is currently sparse, and mixed. Examples of differing results from studies at #ICPIC2013 showed the need for more reporting with regard to research methods if data is to be collated going forwards.  However, the WHO 5 Moments provides a perfect framework to conceptualise different types of hand hygiene. This can then be used to communicate directly back to those providing front-line medical care to Patients, highlighting areas where performance is strong, and where improvements are possible.

Interestingly, there is also the potential for technology developers to aid with this more specialised field of hand hygiene measurement and feedback. 

Innovations which provide monitoring aligned to the WHO 5 Moments enable healthcare professionals to generate feedback on their hand hygiene performance. This is achieved through the use of statistically validated benchmark algorithms, allowing feedback to be both very reliable and validated. Such innovations provide a robust general overview of hand hygiene compliance, though currently they cannot specify rates of compliance or hand hygiene events for each WHO moment individually.

Systems that are able to perform monitoring at individual WHO moment level (e.g. by use of badges worn by healthcare professions) appear only able to measure and provide feedback on WHO Moments 1, 4 and 5.  Currently Moments 2 and 3 appear impossible to detect, due to the need for prediction (e.g. Moment 2 - knowing a clean/aseptic procedure is about to occur) and specific risk perception (e.g. Moment 3 - the presence of a body fluid exposure risk). Measurement of Moment 2 or 3 cannot be based purely on the detection of movement within a specified area.

Arguably then, an ideal solution would be a system which would allow monitoring of all WHO 5 Moments, with the additional specificity to provide feedback on hand hygiene events at each moment individually.  This certainly provides a major challenge going forwards. As Moments 1 and 5 appear to generate particularly low levels of compliance, it may be of benefit to begin focus here. 

Any tool, technical or manual, which can provide data on hand hygiene has the potential to be of benefit, but only if the data produced is meaningful.  The use of data regarding performance (individual, unit, organisation) at each of the WHO 5 Moments - with a growing understanding that likelihood of hand hygiene at these moments is not equal - has great potential for education and training. 

Where we are aware that hand hygiene is less likely, because it is not driven by self-protection or concepts of dirtiness, we perhaps need to examine performance data more closely, and be more innovative in our intervention design.  It may be time to re-envisage hand hygiene compliance measurement. Stop setting targets based on percentages, and instead think about what specific behaviours we really want, and need, to encourage.  It’s not just hand hygiene, it’s hand hygiene WHEN.


About Carolyn Dawson, BSc, MA


Carolyn DawsonCarolyn Dawson is a doctoral researcher at Warwick University exploring healthcare hand hygiene, the potential role of technology and influences of human behavior. Her research explores the challenges faced by healthcare staff in performing hand hygiene and the potential role of technology according to the WHO 5 Moments.  You can gain more insights into Carolyn's doctoral research by visiting her "Exploring Hand Hygiene" blog or following @CHD05 on Twitter. 



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