Hand Hygiene: the Impact of Incentive Strategies on Adherence among Healthcare Workers from a Newborn Intensive Care Unit

hygiene: the impact of incentive strategies on adherence among healthcare workers from a newborn intensive care unit. Rev Latino-am Enfermagem 2006 julho-agosto; 14(4):546-52. We carried out a before-after non-controlled intervention study to assess the impact of different handwashing strategies in health care workers at a neonatal ICU in Goiânia-Goiás, Brazil. All ethical aspects were considered. Data was collected by using a check list in order to register hand hygiene opportunities during six months. Three strategies were elaborated together with the hospital team. We observed 1358 handwashing opportunities. Incentive strategies caused a small impact on the increase of adherence to hand hygiene during and after the implementation period. However, we noticed that this increase mainly occurred after the procedures were realized. On the whole, adherence levels were similar before (62.2%) and after (61.6%) the procedures. The study showed that health care workers were more worried about individual risks. Disponível em língua portuguesa na SciELO Brasil www.scielo.br/rlae 547 INTRODUCTION Hospital infections (HI) represent an important public health problem in Brazil and the rest of the world and poses risks to the health of hospital users submitted to therapeutic or diagnostic procedures. Its prevention and control largely depend on health professionals' adherence to preventive measures (1). In 1843, Oliver Wendel Homes suggested that physicians unconsciously were the greatest cause of infectious complications in parturient women and newborns, due to the lack of hand washing. In addition, Ignaz Philipp Semmelweis established the first scientific evidence that hand washing could avoid the transmission of puerperal fever by using a solution of chlorinated water and soap for hand washing among care professionals. He managed to reduce infection numbers from 18.27% to 3.07% within two months (2). Hence, hand washing is not recent as a recommended measure for infection control. It should be done before and after patient contact, before and after using gloves, between one patient and another, between one procedure and another and in cases of pathogen transference to patients and environments, in between procedures with the same patient and after contact with blood, body fluids, secretions, excretions and contaminated articles or equipment (3-5). Despite the epidemiological importance of hand washing to prevent hospital infections, adherence to this measure has been one of the main challenges for Hospital Infection Control Commissions-HICC. This involves, among other aspects, human resources at the health institutions, their preparation and awareness (6). Hospital infections are frequently associated with health professionals' …

We carried out a before-after non-controlled intervention study to assess the impact of different handwashing strategies in health care workers at a neonatal ICU in Goiânia -Goiás, Brazil.All ethical aspects were considered.Data was collected by using a check list in order to register hand hygiene opportunities during six months.Three strategies were elaborated together with the hospital team.We observed 1358 handwashing opportunities.Incentive strategies caused a small impact on the increase of adherence to hand hygiene during and after the implementation period.However, we noticed that this increase mainly occurred after the procedures were realized.On the whole, adherence levels were similar before (62.2%) and after (61.6%) the procedures.The study showed that health care workers were more worried about individual risks.

INTRODUCTION
Hospital infections (HI) represent an important public health problem in Brazil and the rest of the world and poses risks to the health of hospital users submitted to therapeutic or diagnostic procedures.Its prevention and control largely depend on health professionals' adherence to preventive measures (1) .
In 1843, Oliver Wendel Homes suggested that physicians unconsciously were the greatest cause of infectious complications in parturient women and newborns, due to the lack of hand washing.In addition, Ignaz Philipp Semmelweis established the first scientific evidence that hand washing could avoid the transmission of puerperal fever by using a solution of chlorinated water and soap for hand washing among care professionals.He managed to reduce infection numbers from 18.27% to 3.07% within two months (2) .
Hence, hand washing is not recent as a recommended measure for infection control.It should be done before and after patient contact, before and after using gloves, between one patient and another, between one procedure and another and in cases of pathogen transference to patients and environments, in between procedures with the same patient and after contact with blood, body fluids, secretions, excretions and contaminated articles or equipment (3)(4)(5) .
Despite the epidemiological importance of hand washing to prevent hospital infections, adherence to this measure has been one of the main challenges for Hospital Infection Control Commissions -HICC.This involves, among other aspects, human resources at the health institutions, their preparation and awareness (6) .Hospital infections are frequently associated with health professionals' low adherence to hand washing (7)(8) .
This challenge is even greater at neonatal units, where infection processes are the main factors responsible for high morbidity and mortality during this period.In patients with an immature immune system and greater exposure to invasive procedures, it is hard to prevent and control HI.Technological advances have increased the survival of premature newborns and infants with severe diseases are the main responsibles for successful life maintenance (7) .
Literature presents different motives for low adherence to hand washing, such as lack of motivation, absence of sinks and adequate resources close to the patient, cutaneous reactions on the hands, lack of time, irresponsibility, lack of awareness about the importance of the hands in the transmission of microorganisms (8)(9) .
The use of traditional practices and teaching forms used in continuing education programs, almost always associated with punitive practices, does not manage to reach the receiver in an effective way and impairs the final result.Thus, different strategies that involve the receiver in the construction of their own professional knowledge create awareness for them to change their behavior (10) .
Learning should be relevant for the subject, who needs to get involved with ideas, feelings, and the cultural aspects of each society, with a view to becoming a social practice.The more significant the learning experience, the greater its impact will be, becoming an instrument needed to transform daily practice (11) .
This study introduced different strategies and covered a longer period than education campaigns, increasing the team's access to information about the importance of hand washing for HI control.We believe that strategies implemented on a continuous base are one of the ways to promote behavioral changes.Thus, we hope that infection control will influence the professionals' hands and awareness.
In this study, hand washing was considered as all situations in which water and soap, 70% alcohol with glycerin or gel alcohol were used.We aimed to assess the impact of using different hand washing incentive strategies among health professionals at a neonatal ITU.

METHODOLOGY
We carried out a non-controlled before-after intervention study, during which individuals, who act as their own controls, are submitted to a specific treatment (or exposure) and are compared with periods when a different treatment (or exposure) was used.No parallel group is constituted (12) .which determines on the obligatory presence of one sink for every five beds outside isolated rooms (13) .
Study participants included all professionals who voluntarily agreed to participate and worked in the three shifts of the neonatal ITU.Ten (10)  We used three intervention strategies.

Musical parodies on hand hygiene
The parodies were composed by hospital team members, including physicians, nurses, nursing auxiliaries and technicians, nutritionists, nutrition auxiliaries and laboratory technicians, as part of a contest promoted during a hand washing campaign by the CCIH/SCIH.We chose the winning songs, with lyrics and refrains that were easy to remember and well accepted melodies.
This strategy was chosen because we observed that, during an earlier hand washing campaign, professionals remembered songs more easily and, when they remembered, they immediately washed their hands and asked their colleagues to do the same.
A CD with five musical parodies was recorded by the band Mão Beleza ("Beautiful Hand"), whose members were professionals from the neonatal ITU team.All ethical aspects of copyright were respected for this recording.We received support from the UFG University Radio.
These parodies were put on the air by the hospital's radio service at least once per shift until 22:00 hours, every day of the week, during the two months of the incentive period.

Artistic information posters
Based on a study about Visual Communication in Hospital Infection Prevention (8) , we elaborated eight

RESULTS AND DISCUSSION
The permanent health team at the neonatal ITU under study consisted of 80 professionals, with the support of other external professionals from the clinical analysis laboratory, blood bank, pediatric surgery team and imagery sector.We observed sixty-nine internal and external professionals, as shown in Table 1.More than half (65.2%) of the professionals observed at the neonatal ITU were nursing team members.We know that this team is responsible for the highest percentage of direct and continuing patient care.This confirms that, at most Brazilian health institutions, the nursing team quantitatively represents this highest percentage (14) and establishes a direct We observed adherence to hand washing in 1358 procedures, totaling 180 hours across the three shifts.Only procedures observed before and after their execution were included.Table 2 presents the percentages of observations before and after the execution of procedures during the study period.We found low acceptance levels for gel or 70% alcohol with glycerin, which were used by 2.6% and 1.7%, respectively, before and after the realization of procedures.Gel alcohol is easy to use and handle; its application requires less time; the product can be placed at the patient's bedside and displays rapid antimicrobial action (15) .In spite of these facilities, health professionals at this neonatal ITU were resistant to its use, as opposed to international literature, which reports excellent adherence to the use of this alcohol solution (4) .
Table 3 shows adherence to hand washing before and after the realization of procedures, before, during and after the application of incentive strategies.Authors emphasize the importance of continuing education programs so as not to decrease their effect after some time (4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16) .In this study, incentive strategies were maintained for two months.Table 3 shows a small impact on adherence to hand hygiene during the implementation of these strategies and a decrease in adherence levels once they had ended (respectively: 22.1%, 42.4%, 35.3% of adherence before the realization of the procedures and 20.6%, 43.5%, 35.8% afterwards).Adherence levels after the strategies were higher than in the preceding period.
We observed that professionals used the information offered by the strategies.However, the stimuli led to the repetition of their action only during the intervention period, decreasing afterwards.This happened despite the implementation time of the intervention strategies, their innovative nature and the hospital professionals, mainly ICU professionals' involvement in their construction.Further  We believe that the CCIH/SCIH should promote permanent education for infection control in health institutions, in their search for means that promote more effective and long-term changes.
However, in our perspective, adherence is a voluntary and individual act that depends on each professional's decision.In this sense, it is influenced, among other factors, by care professionals' inherent complexity.We used the chi-square test to understand adherence-related factors and found a statistically significant difference only after the execution of care procedures (p= 0.001) when comparing the period before and during the application of the intervention strategies.Thus, adherence levels increased when the incentive strategies were introduced, but predominantly after the realization of the procedures.Some studies corroborate our results about higher adherence levels when incentives are used and after care procedures are realized, evidencing professionals' concern about not exposing themselves to the risk of catching a disease (9)(10)(11)(12)(13)(14)(15)(16)(17) .Table 4 lists professionals' adherence to hand washing according to the involved procedures.These figures show that adherence levels are highest after medication preparation, followed by risk of contact with secretion, such as speech and hearing science procedures, which involve oral secretion because they stimulate newborns' oral suction; aspiration; orogastric intubation and physiotherapy procedures, during which the bronchial tree is aspirated.
Hand washing after medication preparation minimizes the risk of professionals' chemical exposure to medication.However, in view of biological risk, it should be highlighted that, before medication artistic information posters, with the cooperation of a nursing academic from FEN/UFG, who represented the suggested situations with his own creations.The posters were signed by the author, mentioning the original source of the idea.We put up these posters in strategic places, such as the access control watch, located in a site all professionals had to access and on the notice board of each clinic.A timetable was set for changing the posters, which were transferred between different sites every four days, considering the changes in most hospital team members' work shifts.Phrases on hand hygieneWe chose ten phrases, elaborated by health team professionals from the study hospital on the occasion of previous hand washing campaigns promoted by the hospital's CCIH/SCIH.These phrases were disseminated by the radio service, alternating with the songs, at least once per shift during all days of the week across the two-month intervention period and written on posters with colored highlights, displayed close to the artistic information posters.Excel was used for data processing and statistical analysis, together with Epi-info 2000, version 3.2, and tables were used to present the results.The chi-square test was used, considering p< 0.05.
relation with HI prevention and control measures.The medical team also corresponds to a significant percentage, with 15 professionals (21.7%) who are continuously present, as this is an intensive therapy unit.The study unit partially attends to the requirements established in Decree MS/ GM No 3432, dated August 12 th 1998, which determines criteria for ranking Intensive Therapy Units.The unit is classified as a Type II Pediatric ITU and, what the number of health team members is concerned, an exclusive physician on duty is missing for up to ten patients or a fraction, as well as a nursing technician/auxiliary in the three shifts, considering the nine existing beds.Guaranteeing the quantitative and qualitative presence of professionals minimizes stress among team members as a result of the work overload, which may result in iatrogenic diseases.

Table 4 -
Hand hygiene adherence behavior after realization of the procedures during the study period, according to the procedure carried out.Nov/ 2003 -May/ 2004.Goiânia -GO * Multiple procedures = realization of various sequential procedures.

Table 2 -
Number and percentage of global adherence to hand hygiene before and after the realization of procedures during the study period.Goiânia -GO.