Vicki Erasmus

The ACCOMPLISH study. A cluster randomised trial on the cost-effectiveness of a multicomponent intervention to improve hand hygiene compliance and reduce healthcare associated infections

BackgroundPublic health authorities have recognized lack of hand hygiene in hospitals as one of the important causes of preventable mortality and morbidity at population level. The implementation strategy ACCOMPLISH (Actively Creating COMPLIance Saving Health) targets both individual and environmental determinants of hand hygiene. This study aims to evaluate the cost-effectiveness of a multicomponent implementation strategy aimed at the reduction of healthcare associated infections in Dutch hospital care, by promotion of hand hygiene.Methods/designThe ACCOMPLISH package will be evaluated in a two-arm cluster randomised trial in 16 hospitals in the Netherlands, in one intensive care unit and one surgical ward per hospital.InterventionA multicomponent package, including e-learning, team training, introduction of electronic alcohol based hand rub dispensers and performance feedback.VariablesThe primary outcome measure will be the observed hand hygiene compliance rate, measured at baseline and after 6, 12 and 18 months; as a secondary outcome measure the prevalence of healthcare associated infections will be measured at the same time points. Process indicators of the intervention will be collected pre and post intervention. An ex-post economic evaluation of the ACCOMPLISH package from a healthcare perspective will be performed.Statistical analysisMultilevel analysis, using mixed linear modelling techniques will be conducted to assess the effect of the intervention strategy on the overall compliance rate among healthcare workers and on prevalence of healthcare associated infections. Questionnaires on process indicators will be analysed with multivariable linear regression, and will include both behavioural determinants and determinants of innovation. Cost-effectiveness will be assessed by calculating the incremental cost-effectiveness ratio, defined here as the costs for the intervention divided by the difference in prevalence of healthcare associated infections between the intervention and control group.DiscussionThis study is the first RCT to investigate the effects of a hand hygiene intervention programme on the number of healthcare associated infections, and the first to investigate the cost-effectiveness of such an intervention. In addition, if the ACCOMPLISH package proves successful in improving hand hygiene compliance and lowering the prevalence of healthcare associated infections, the package could be disseminated at (inter)national level.Trial registrationNTR2448

Behavioral and psychosocial interventions for HIV prevention in floating populations in China over the past decade: a systematic literature review and meta-analysis.

Background Floating populations have been repeatedly characterized as “the tipping point” for the HIV epidemic in China. This study aims to systematically summarize and assess the effectiveness of HIV prevention interventions in floating populations in China over the past decade. Methods We conducted a systematic search in three international databases for literature published between 2005 and 2012 with condom use as the primary outcome, and knowledge about HIV transmission and prevention and stigma towards HIV-infected individuals as secondary outcomes. The impact of interventions on changing the primary and secondary outcomes was calculated by risk difference (RD). We also performed subgroup analyses and meta-regression based on different study characteristics, using Stata 12.0, for the primary outcome. Results Sixteen studies (out of 149) involved 19 different programs and a total of 10,864 participants at entry from 11 provinces in China. The pooled effect estimate of all studies indicated that people participating in HIV-related interventions were 13% more likely to use condoms (95%CI: 0.07, 0.18), however, the effects on increasing condom use exhibited significant heterogeneity across programs (P<0.01, I 2 = 0.93). The meta-regression results suggest that interventions have been significantly less successful in changing condom use in more recent studies (β, 0.14; 95%CI: 0.01, 0.27), adjusted for sexual relationship, study design and follow-up period. Regarding the secondary outcomes, HIV-related interventions were successful at improving knowledge about HIV transmission and prevention (RD, −0.26; 95%CI: −0.36, −0.16 and RD, −0.25; 95%CI: −0.33, −0.16, respectively), and decreasing stigma (RD, 0.18; 95%CI: 0.09, 0.27). Conclusions The included studies between 2005 and 2012 indicate that HIV prevention interventions among Chinese floating populations in the past decade were only marginally effective at increasing condom use, but relatively successful at increasing HIV knowledge and decreasing stigma. To avert new infections, novel sexual risk-reduction interventions taking into account the changing socio-economic and cultural situation of Chinese floating populations are urgently needed.

A hand hygiene intervention to decrease infections among children attending day care centers: design of a cluster randomized controlled trial

BackgroundDay care center attendance has been recognized as a risk factor for acquiring gastrointestinal and respiratory infections, which can be prevented with adequate hand hygiene (HH). Based on previous studies on environmental and sociocognitive determinants of caregivers’ compliance with HH guidelines in day care centers (DCCs), an intervention has been developed aiming to improve caregivers’ and children’s HH compliance and decrease infections among children attending DCCs. The aim of this paper is to describe the design of a cluster randomized controlled trial to evaluate the effectiveness of this intervention.Methods/designThe intervention will be evaluated in a two-arm cluster randomized controlled trial among 71 DCCs in the Netherlands. In total, 36 DCCs will receive the intervention consisting of four components: 1) HH products (dispensers and refills for paper towels, soap, alcohol-based hand sanitizer, and hand cream); 2) training to educate about the Dutch national HH guidelines; 3) two team training sessions aimed at goal setting and formulating specific HH improvement activities; and 4) reminders and cues to action (posters/stickers). Intervention DCCs will be compared to 35 control DCCs continuing usual practice. The primary outcome measure will be observed HH compliance of caregivers and children, measured at baseline and one, three, and six months after start of the intervention. The secondary outcome measure will be the incidence of gastrointestinal and respiratory infections in 600 children attending DCCs, monitored over six months by parents using a calendar to mark the days their child has diarrhea and/or a cold. Multilevel logistic regression will be performed to assess the effect of the intervention on HH compliance. Multilevel poisson regression will be performed to assess the incidence of gastrointestinal and respiratory infections in children attending DCCs.DiscussionThis is one of the first DCC intervention studies to assess HH compliance of both caregivers and children, as well as the incidence of gastrointestinal and respiratory infections in children, as outcome measures. When an effect of the intervention on improving HH compliance and/or reducing incidence of infections is shown, (inter)national dissemination of the intervention in other DCCs may be considered.Trial registrationNetherlands trial registry: NTR3000

Assessing the optimal location for alcohol-based hand rub dispensers in a patient room in an intensive care unit

BackgroundThe introduction of alcohol-based hand rub dispensers has had a positive influence on compliance of healthcare workers with the recommended guidelines for hand hygiene. However, establishing the best location for alcohol-based hand rub dispensers remains a problem, and no method is currently available to optimize the location of these devices. In this paper we describe a method to determine the optimal location for alcohol-based hand rub dispensers in patient rooms.MethodsWe composed a method that consists of a combination of qualitative and quantitative research methods. Firstly, different arrangements of dispensers were determined based on the results of two types of assessment: workflow observations and interviews with nurses and physicians. Each arrangement was then evaluated using two types of assessment: interviews with nurses and physicians and electronic measurements of the user frequency of the dispensers. This procedure was applied in a single-bed patient room on a thoracic surgery intensive care unit.ResultsThe workflow observations revealed that the activities of patient care were most often at the entrance and near the computer at the right side of the test room. Healthcare workers stated that the location of the dispenser should meet several requirements. Measurements of the frequency of use showed that the dispenser located near the computer, at the back of the room, was used less frequently than the dispenser located near the sink and the dispenser located at the entrance to the room.ConclusionThe applied method has potential for determining the optimal location for alcohol-based hand rub dispensers in a patient room. Workflow observations and the expressed preferences of healthcare workers guide the choice for the location of alcohol-based hand rub dispensers. These choices may be optimized based on measurement of the frequency of use of the dispensers.

Does Government Supervision Improve Stop-Smoking Counseling in Midwifery Practices?

INTRODUCTION Smoking-cessation counseling during pregnancy is important to prevent smoking-related harm in pregnant smokers and their children. Therefore we evaluated the effects of an Inspectorates supervision programme on the provision of smoking-cessation counseling by midwifery practices in the Netherlands. The supervision programme consisted of 3 elements: A) A deadline was announced by which all practices should comply with professional norms on such counseling (2011); B) A set of randomly selected practices were assessed using a questionnaire and a personal feedback report (2010); C) Another set of randomly selected practices were assessed through a site visit and a personal feedback report (2012). METHODS Programme A was evaluated in a before-after study, Programmes B and C were evaluated in a randomized controlled trial (RCT) with only a post-intervention measurement. Primary outcome was provision of smoking-cessation counseling through a minimal-intervention strategy (V-MIS). Linear and logistic regression models were used to analyze data from 233 primary-care midwifery practices. RESULTS A) After announcement of the deadline, Dutch midwifery practices reported significantly more provision of smoking-cessation counseling. For example, the use of V-MIS increased substantially from 28% to 80%; B) In practices that were assessed with a questionnaire, the provision of counseling improved partially compared to controls; C) The provision of counseling did not differ between practices that were visited and their controls. While the training participation rate in counseling by midwifery practices did not differ between the intervention and control groups, the rate increased significantly in all practices after the start of the supervision programme. CONCLUSIONS The provision of smoking-cessation counseling improved spectacularly in Dutch midwifery practices. Despite some limitations of our study, the Inspectorates supervision programme is likely to have contributed to the improvements in provision of counseling.

Behavioral interventions to reduce HIV risk behavior for MSM and transwomen in Southeast Asia: a systematic review

ABSTRACT This systematic review aims to gain insights from existing literature from Southeast Asian countries to improve future HIV prevention programs for men who have sex with men (MSM) and transgender women (transwomen). We conducted a systematic search in six international databases for literature published prior to 1 January 2015. We included studies describing behavioral interventions targeting MSM and/or transwomen, and conducted in at least one Southeast Asian country. Five out of 575 screened studies met the inclusion criteria and reported a significant intervention effect on at least one outcome measure, that is, condom use (with casual or commercial partner), water-based lubricant use, number of sex partners, HIV prevention knowledge, or willingness to use pre-exposure prophylaxis. Peer education/outreach was the most commonly employed type of intervention in the five included studies and was usually delivered as an element of a larger intervention package, together with condom distribution and the provision of drop-in centers. Motivational interviewing was effective, while internet-based interventions appeared to be a viable platform for intervention delivery. Nevertheless, research on behavioral interventions among MSM and transwomen in Southeast Asia is limited. Future interventions should be culturally appropriate, theoretically grounded, and rigorously evaluated. Only then can we best address the HIV epidemic among MSM and transwomen in this region.

Government supervision on quality of smoking-cessation counselling in midwifery practices: a qualitative exploration

BackgroundThe Dutch Healthcare Inspectorate supervises care providers in order to improve quality of care. Recently the inspectorate assessed and promoted the use of a guideline on smoking-cessation counselling in midwifery practices. The supervision programme consisted of an announcement of the enforcement deadline for the guideline and site visits. The purpose of our qualitative study was to identify factors related to guideline adherence after the supervision programme, and investigate whether the programme had helped improve adherence.MethodsWe conducted semi-structured interviews with inspected and non-inspected midwives. Additionally, we studied documents and observed the inspection process. The sampled midwives all work in primary care midwifery practices providing care to pregnant smokers. The questions included the current provision of smoking-cessation counselling, support to the midwife in counselling, recent changes in provision of counselling, reasons for recent changes, knowledge about the supervision programme, and experiences with supervision by the inspectorate.ResultsOur results show that guideline adherence depends on several factors. Awareness and familiarity with the guideline are important, as is outcome expectancy. Additionally, motivation, guideline factors and environment factors were mentioned. Besides these previously documented factors, we found that professional collaboration also determined guideline adherence. Increased collaboration in counselling is associated with greater adherence to the guideline, such as provision of counselling and taking required training. The supervision programme helped improve stop-smoking counselling, by making midwives aware of the counselling and giving them an extrinsic motivation to provide counselling.ConclusionMotivation and environmental aspects were the most important factors related to guideline adherence, and professional environment was added as significant factor. The improved guideline adherence is partly attributable to the supervision programme.

Children’s hand hygiene behaviour and available facilities: an observational study in Dutch day care centres

BACKGROUND Children attending day care centres are at increased risk of infectious diseases, in particular gastrointestinal and respiratory infections. Hand hygiene of both caregivers and children is an effective prevention measure. This study examined hand hygiene behaviour of children attending day care centres, and describes hygiene facilities at day care centres. METHODS Data were collected at 115 Dutch day care centres, among 2318 children cared for by 231 caregivers (August to October 2010). Childrens hand hygiene behaviour was observed and data on hand hygiene facilities of the day care centres collected by direct unobtrusive observation. National guidelines indicate hand hygiene is required before eating, after toilet use and after playing outside. RESULTS Among 1930 observed hand hygiene opportunities for children, overall adherence to hand hygiene guidelines was 31% (95% CI: 29-33%). Adherence after both toilet use and playing outside was 48%. Hands were less frequently washed before eating, where guideline adherence was 15%. In 38% of the playrooms there was no soap within reach of children and 17% had no towel facilities. In over 40% of the playrooms, appropriate hand hygiene facilities for children were lacking. CONCLUSION Adequate hand washing facilities were available for children in only half of the participating day care centres in our study and children washed their hands in only 15-48% of the occasions defined by official guidelines. More attention is needed to hand hygiene of children attending day care centres in the prevention of infectious diseases.

A Quantitative Exploration of Health Care Workers Opinions and Attitudestowards HIV-Infected Co-Workers and Patients in Beijing, China

This study examines underlying stigmatizing opinions and attitudes of health care workers (HCWs) that may drive discrimination towards HIV-infected co-workers and patients in the workplace. Socio-demographics, opinions regarding managing HIV-infected co-workers, and attitudes regarding working with HIV-infected patients were measured using a self-administered anonymous questionnaire in a sample of 392 HCWs (113 doctors, 236 nurses and 43 technicians) in Beijing. Participants perceived a high risk of HIV transmission in both co-worker and HCW-patient relationships. Half of participants agreed that HCWs should routinely and mandatorily receive HIV-tests, HIV-infected co-workers should disclose their diagnosis to relevant parties, and should be restricted from performing invasive procedures. Most of participants feel disgusted by patients infected through sexual contact, and believed that HCWs have the right to refuse to care for infected patients, and that those patients should be treated only in designated hospitals. Almost all participants intended to avoid performing invasive clinical procedures or nursing services for HIV-infected patients. Nurses had significantly more stigmatizing attitudes towards HIV-infected patients than doctors and technicians. The identified rigid opinions on managing HIV-infected co-workers, together with stigmatizing attitudes towards HIV-infected persons, underscores an urgent need for interventions to prevent discriminatory practices in health care settings.

Improving hand hygiene compliance in hospitals by design

markdownabstractEssential in reducing hospital-acquired infections is adequate hand hygiene (HH) among healthcare workers (HCWs). International studies show, however, that HH guidelines are adhered to in less than 50% of required times. Research into HH behavior has shown that self-reported compliance is often higher than observed compliance, which seems to indicate that HCWs are unaware of their HH behavior. In addition, because of its frequency, HH behavior could be considered an automatic (or subconscious) behavior. Therefore, a (temporary) shift from the subconscious to the conscious could be a solution to change current HH behavior and create new habits. These insights formed the points of departure of the design project described here, which aimed to develop an alcohol-based hand rub (ABHR) dispenser to stimulate HCWs to better adhere to the international guidelines of HH. In order to increase the chance of success of the new dispenser, a participatory design approach was applied, meaning that all stakeholders of the dispenser (nurses, physicians, infection control practitioners, housekeeping) were actively involved in the different phases of the development process. The development process of the new dispenser consisted of 5 phases: analysis, idea finding (identifying promising design directions), and 3 idea iterations. Interim ideas were evaluated using functional 3-dimensional prototypes and the results applied to further develop the final concept. Methods of user research included observations and individual and focus group interviews.