Innovative social and behavioural change strategies to strengthen and improve infection prevention and control – A World Health Organization first Global Patient Safety Challenge “Clean Care is Safer Care” project

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Thesis

Reference

Innovative social and behavioural change strategies to strengthen and improve infection prevention and control – A World Health Organization first Global Patient Safety Challenge “Clean Care is

Safer Care” project

LEE, Yew Fong

Abstract

Hand hygiene (HH) compliance can be improved through appropriate leadership and change agents (CAs). This study describes the influence of peer-identified change agents (PICAs) and management-selected change agents (MSCAs) for HH improvement. Based on the Diffusion of Innovation Theory, it was hypothesised that democratically identified peers will be early-adopters to improve HH through their social network. A randomised-controlled study was conducted at two wards in Malaysia. Wards were randomly assigned to PICAs or MSCAs. Outcomes were: HH compliance; HH knowledge; observations from ward tours;

perceived leadership styles of CAs; social network connectedness and communication patterns; HH leadership attributes. Both study arms experienced significant HH improvement and improved HH knowledge. PICAs led by example while MSCAs were authoritative.

Organisational culture of both wards was hierarchical. All staff preferred authoritative leadership. PICAs were not inferior to authoritative leaders, they acted as early adopters who facilitated HH improvement through role-modeling and their social network.

LEE, Yew Fong. Innovative social and behavioural change strategies to strengthen and improve infection prevention and control – A World Health Organization first Global Patient Safety Challenge “Clean Care is Safer Care” project. Thèse de doctorat : Univ. Genève, 2020, no. Sc. Bioméd. - S. Glob. 11

DOI : 10.13097/archive-ouverte/unige:150666 URN : urn:nbn:ch:unige-1506663

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Faculté de Médecine,

Département de Médecine Sociale et Préventive,

Institut de Santé Globale

Thèse préparée sous la direction du Professeur Didier PITTET

Stratégies innovantes de changement social et comportemental pour renforcer et améliorer la prévention et le contrôle des infections–Un projet du

premier Défi Mondial de Sécurité du Patient de l’Organisation mondiale de la Santé ,

« Les soins propres sont des soins plus sûrs »

Thèse

présentée à la Faculté de Médecine de l'Université de Genève

pour obtenir le grade de Docteur en Sciences Biomédicales , Mention Santé Globale par

Yew Fong LEE

de

Malaysia

Thèse n° 011

Geneva

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Faculté de Médecine,

Département de Médecine Sociale et Préventive,

Institut de Santé Globale

Thèse préparée sous la direction du Professeur Didier PITTET

Innovative social and behavioural change strategies to strengthen and improve infection prevention and control – A World Health Organization first Global

Patient Safety Challenge

“Clean Care is Safer Care” project

Thèse

présentée à la Faculté de Médecine de l'Université de Genève

pour obtenir le grade de Docteur en Sciences Biomédicales , Mention Santé Globale par

Yew Fong LEE

de

Malaysia

Thèse n° 011

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UNIVERSITY OF GENEVA, GENEVA, SWITZERLAND Thesis/ Dissertation Sheet for the degree of

Doctorate in Biomedical Sciences

Surname or Family name: LEE First name: Yew Fong

Student ID: 16-348-880

Institute: Institute of Global Health Faculty: Medicine

Title: Innovative social and behavioural change strategies to strengthen and improve infection prevention and control – A World Health Organization first Global Patient Safety Challenge “Clean Care is Safer Care” project

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Originality Statement

‘I hereby declare that this submission is my own work and to the best of my knowledge it contains no materials previously published or written by another person, or substantial proportions of materials which have been accepted for the award of any other degree or diploma at University of Geneva (UNIGE) or any other educational institute, expected where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNIGE or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project’s design and conception or in style, presentation and linguistic expression is acknowledged.’

Yew Fong LEE Date: May 2020

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Dedication

For my family

Yi Shen, Reuben and Gabriel

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Acknowledgements

Firstly, I would like to express my sincere gratitude to my supervisor Professor Dr Didier Pittet for taking me in as his student, for the continuous support of my PhD study and related research, and for his mentorship, patience, motivation, and for imparting his knowledge to me.

I would like to thank the rest of my doctoral committee members,

Professor Dr Mary-Louise McLaws, for her wise counsel and sympathetic ear, whose expertise was invaluable in the formulating of the research topic and methodology in particular. Dr Walter Zingg, for his insightful comments, reviews, and encouragement, and for providing me with tools that I needed to successfully complete my thesis. Dato’ Dr Ong Loke Meng, who was great support in deliberating over problems and findings, and for working through them with me.

My sincere thanks also goes to colleagues of the Ministry of Health, Malaysia,

Dr Wong See Yin, Dr Chua Hock Hin and Dr Suraya Amir Husin, who provided support and gave access to the hospital. Without their precious support it would not have been possible to conduct this research.

I would like to thank my family:

My late father, Lee Kah Wah, who was my life-coach. He was a firm believer of lifelong learning, who led an exemplary life full of integrity, honesty and modesty. My mother, Quek Wan Neo, for her support and love, and her willingness to provide management of

household activities, which allowed me time away to research, study and write. My husband, Wong Yi Shen, for his love, patience and support in me overcoming numerous obstacles I faced through my PhD journey. My children, Reuben Wong, who was forever interested, encouraging and always enthusiastic about my PhD studies, and Gabriel Wong, who was full of encouragement and always trusted in my ability; both of whom had provided happy distractions to rest my mind outside my research

Last but not the least, my appreciation, gratitude and love goes to

Tan Sri Dr. Jemilah binti Mahmood, for being encouraging, gracious and kind towards me

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List of Publications, Oral Communications, Poster Presentations and Other Communications Related to Thesis Topic

Published peer-reviewed papers

Paper 1

Lee YF, McLaws M-L, Ong LM, Amir Husin S, Chua HH, Wong SY, et al. Hand hygiene promotion delivered by change agents—Two attitudes, similar outcome. Infect. Control Hosp. Epidemiol. 2020;1–7.[1]

Paper 2

Lee YF, McLaws ML, Ong LM, Amir Husin S, Chua HH, Wong SY, et al. Hand hygiene - Social network analysis of peer-identified and management-selected change agents.

Antimicrob. Resist. Infect. Control 2019;8:195.[2]

Additional Paper 3

Tartari E, Fankhauser C, Masson-Roy S, Márquez-Villarreal H, Fernández Moreno I, Rodriguez Navas ML, et al. Train-the-Trainers in hand hygiene: a standardized approach to guide education in infection prevention and control. Antimicrob. Resist. Infect. Control 2019;8:206.[3]

Additional Paper 4

Loftus MJ, Guitart C, Tartari E, Stewardson AJ, Amer F, Bellissimo-Rodrigues F, et al. Hand hygiene in low- and middle-income countries: A position paper of the International Society for Infectious Diseases. Int. J. Infect. Dis. 2019;86:25–30.[4]

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Peer- reviewed journal publications

2019

1. Lee YF, Zingg W, McLaws M-L, Ong LM, Chua HH, Wong SY, et al. Factors Influencing healthcare workers’ choice of hand hygiene practices in a developing country. Antimicrob Resist Infect Control. 2019;8(1).[5]

2. Lee YF, Zingg W, McLaws M-L, Ong LM, Amir Husin S, Chua HH, et al. Social network analysis on the Influence exerted by change agents to diffuse favourable hand hygiene behaviour in a developing country. Antimicrob Resist Infect Control.

2019;8(1).[6]

2017

3. Lee YF, Zingg W, McLaws M, Amir Husin S, Chua HH, Wong SY, et al. Hand hygiene self-assessment framework (HHSAF) survey of 23 hospitals in Sarawak, Malaysia. Antimicrob Resist Infect Control. 2017;6.[7]

4. Lee YF, Zingg W, McLaws M, Amir Husin S, Chua HH, Wong SY, et al. Are we using suitable behavioural interventions for healthcare workers’ recidivist hand hygiene behaviour? A critique of management theories. Antimicrob Resist Infect Control.

2017;6.[8]

5. Amir Husin S, Lee YF, Abd Rasid NA, Azizan A, Fajariah P, Bakhtiar NF, et al. Effect of the World Health Organization multimodal hand hygiene improvement strategies on healthcare associated infections prevalence in 14 tertiary hospitals in Malaysia.

Antimicrob Resist Infect Control. 2017;6:51–2.[9]

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Oral communications (including lectures)

2020

1. Lee YF. CDC’s Infection Prevention and Control Global Webinar Series : Practical IPC Considerations in the Fight Against COVID-19 [Internet]. In: Hand hygiene in healthcare settings in the context of COVID-19. 2020. Available from:

https://echo.unm.edu/covid-19/sessions/cdc-ipc [10]

2. Lee YF. Achieving sustainable WASH in health care. In: Adressing COVID-19 and safe, quality care for all. Geneva (Virtual): 2020. vailable from:

https://www.who.int/news-room/events/detail/2020/05/21/default-calendar/virtual- meeting-achieving-sustainable-wash-safe-health-care-facilities-in-the-2020. [11]

2019

3. Lee YF. Lecture series on Hand Hygiene. In: World Health Organization’s Multimodal Strategy for Hand Hygiene, the First Patient Safety Global Challenge workshop.

Penang, Malaysia; 2019.[12]

4. Lee YF. Global Health and Infection Prevention and Control. In: 7^th International Congress of Infection Control Association (Singapore). Singapore; 2019 [13]

5. Lee YF. Hand hygiene: Challenges and opportunities. In: 7^th International Congress of Infection Control Association (Singapore). Singapore; 2019.[14]

6. Lee YF, Zingg W, McLaws M-L, Ong LM, Amir Husin S, Chua HH, et al. Social network analysis on the Influence exerted by change agents to diffuse favourable hand hygiene behaviour in a developing country. In: 5^th International Conference of Prevention and Infection Control. Geneva, Switzerland; 2019.[15]

7. Lee YF. Lecture: Patient safety and methods for quality improvement. In: Doctor of Public Health (DrPH) programme, University Malaysia Sarawak (Session

2019/2020). Sarawak, Malaysia; 2019.[16]

8. Lee YF, Zingg W, McLaws M, Amir Husin S, Chua HH, Wong SY, et al. Using suitable social theory approaches to improve healthcare workers’ adoption of hand hygiene: a World Health Organization Collaborating Centre “Save Lives: Clean Your

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Hands” project. In: The 9^th International Congress of the Asia Pacific Society of Infection Control. Danang, Vietnam 2019.[17]

9. Lee YF. Technical guide: Monitoring & evaluating hand hygiene compliance via direct observations. In: Hand hygiene Train-the-Trainers programme. Kuala Lumpur,

Malaysia; 2019.[18]

10. Lee YF. Behavioural Innovation in infection prevention and control. In: Infection and Prevention Seminar: Breaking the Chain of Infection. Sarawak, Malaysia; 2019.[19]

2018

11. Lee YF. 2018 Society of Healthcare Epidemiology (SHEA) international

ambassadors programme. In: SHEA Spring 2018: Science guiding prevention.

Portland, USA; 2018.[20]

12. Lee YF. Technical guide: monitoring & evaluating hand hygiene compliance via direct observations. In: Infection Prevention and Control Seminar. Kuala Lumpur, Malaysia;

2018.[21]

13. Lee YF. Hand hygiene. In: Infection Prevention and Control Seminar : Prevention Starts with You. Sarawak, Malaysia; 2018.[22]

14. Lee YF. Infection prevention is everyone’s responsibility. In: Infection Prevention and Control Seminar. Penang, Malaysia; 2018.[23]

2017

15. Lee YF. Technical guide: monitoring & evaluating hand hygiene compliance via direct observations. In: Hand Hygiene Train-the-Trainers Programme. Sarawak, Malaysia:

2017.[24]

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Poster presentations

2019

1. Lee YF, Zingg W, McLaws M, Ong LM, Amir Husin S, Chua HH, et al. Factors Influencing healthcare workers’ choice of hand hygiene practices in a developing country. In: 5^th International Conference of Prevention and Infection Control. Geneva, Switzerland; 2019.[25]

2018

2. Lee YF, Zingg W, McLaws M, Amir Husin S, Chua HH, Wong SY, et al. Using social sciences to diffuse favourable hand hygiene change behaviour in a developing country. In: Lugano summer school. Lugano, Switzerland; 2018. [26]

3. Lee YF, Pittet D, Zingg W, Amir Husin S, Chua HH, Ong LM, et al. Innovations in behavioral change and patient safety to improve infection prevention and control, a World Health Organization ‘Clean Care is Safer Care’ project. In: Geneva Health Forum. Geneva, Switzerland: 2018.[27]

2017

4. Costa Pires MD, Aspevalle O, Bellissimo-Rodrigues F, Conly J, Eckmanns T, Fernades P, et al. Assessment of national infection prevention and control policies and strategies: A survey of 18 countries. In: 27^th European Congress of Clinical Microbiology & Infectious Diseases. Vienna, Austria; 2017.[28]

5. Lee YF, Zingg W, McLaws M, Amir Husin S, Chua HH, Wong SY, et al. Hand hygiene self-assessment framework (HHSAF) survey of 23 hospitals in Sarawak, Malaysia. In: 4^th International Conference on Prevention and Infection Control.

Geneva, Switzerland; 2017.[29]

6. Lee YF, Zingg W, McLaws M, Chua HH, Wong SY, Pittet D. Are we using suitable behavioural interventions for healthcare workers’ recidivist hand hygiene behaviour?

A critique of management theories. In: 4^th International Conference on Prevention and Infection Control. Geneva, Switzerland; 2017.[30]

7. Amir Husin S, Lee YF, Abd Rasid NA, Azizan A, Fajariah P, Bakhtiar NF, et al. Effect of the World Health Organization multimodal hand hygiene improvement strategies

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on healthcare associated infections prevalence in 14 tertiary hospitals in Malaysia.

In: 4^th International Conference on Prevention and Infection Control. Geneva, Switzerland; 2017.[31]

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Other communications

From the Desk of the Director General of Health Malaysia 2020

1. DG of Health Press by Dr. Lee Yew Fong. Essentials required in “Wartime” against Novel Coronavirus (2019- nCoV) in public areas [Internet]. 2020 [cited 2020 Mar 12];Available from: https://kpkesihatan.com/2020/02/08/essentials-required-in- wartime-against-novel-coronavirus-2019-ncov-in-public-areas [32]

Newspaper articles 2020

2. Lee Yew Fong. Essentials required in ‘war against Novel Coronavirus’’ in public areas’. Malaysia Kini. 2020 Feb 7:24.[33]

3. Lee Yew Fong. Use the correct sanitiser. The Star. 2020 Feb 18:23.[34]

2017

4. ‘Clean care is safer care’ project launched in SGH. Sunday Post. 2017 Aug 20:18.[35]

5. Project highlights the importance of hand hygiene. Borneo Post. 2017 Aug 20:21.[36]

6. Importance of hand hygiene (in Mandarin). Sin Chew Papers. 2017 Aug 17:12.[37]

7. Hand hygiene to be prioritised (in Malay). Utusan Borneo. 2017 Aug 19:45.[38]

National television

8. TV1 Malaysia National Televisyen. Hand hygiene reduces healthcare-associated infections. 2017 Aug 18.[39]

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YouTube 2019

9. Lee YF. 2019 Hand hygiene train the trainers programme, Kuala Lumpur, Malaysia.

Kuala Lumpur, Malaysian; 2019.

https://www.youtube.com/watch?v=hS6ZyiDjS4U.[40]

10. Lee YF. 2017 Hand hygiene train the trainers programme, Kuching, Sarawak.

Malaysia; 2017. https://www.youtube.com/watch?v=RZ9OABnQIk8.[41]

70^th World Health Assembly, World Health Organization 2017

11. Appointed by the Minister of Health Malaysia as an official delegate to the 70th for the World Health Organization World Health Assembly in May 2017, during which interventions were made in Committee A that are related but not limited to infection prevention and control areas, such as:

Pandemic Influenza Preparedness Framework

Global Shortage and Access to Medicines and Vaccines Global Vaccine Action Plan

Global Vector Control Response

Implementation of Global Strategy for Tuberculosis

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Abstract in English

Background: Hand hygiene occupies a unique position in the field of infection prevention and control, and is the key patient safety activity. Although hand hygiene is one of the lowest cost approaches in reducing healthcare-associated infections, compliance can be low even in high-resource countries. Hand hygiene compliance can be improved by strategies

fostering collaborative effects among healthcare workers through appropriate leadership and change agents. However, there is limited information about how change agents shape the social networks of work teams in healthcare, and how this relates to organisational culture.

The project aimed to describe the influence of peer-identified change agents (PICAs) and management-selected change agents (MSCAs) on hand hygiene behaviour, perception of their leadership style by peers, and the role of the organisational culture in the process of hand hygiene promotion through their social network. Based on the Diffusion of Innovation Theory, we hypothesised that peers who selected staff as change agents were selecting early adopters who would act as role models to improve hand hygiene compliance through their social network.

Methods: This randomised controlled study was conducted at two internal medicine wards of a public, university-affiliated, tertiary-care hospital in Malaysia, between February 2017 to March 2018, stratified in pre-, during-, and post-intervention periods. The wards were randomly assigned to either one of the two interventions, PICAs (study arm 1) or MSCAs (study arm 2), to facilitate hand hygiene promotion. Outcomes were: (1) hand hygiene compliance using direct observation by validated auditors; (2) hand hygiene knowledge; (3) observations from ward tours; (4) perceived leadership styles of PICAs and MSCAs by staff, vocalised during question and answer sessions; (5) social network connectedness and communication patterns between HCWs and change agents by applying social network analysis; and (6) hand hygiene leadership attributes obtained from HCWs in the post-

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Results: Hand hygiene compliance in study arm 1 and study arm 2 improved from 48%

(95% CI: 44–53%) to 66% (63–69%), and from 50% (44–55%) to 65% (60–69%),

respectively. Both study arms experienced significant mean percentage point improvement between the pre- to the intervention periods, and between the pre- to the post-intervention periods. Knowledge scores on hand hygiene in study arm 1 and study arm 2 improved from 60% and 63% to 98% and 93%, respectively. Ward tours revealed that all change agents performed proper hand hygiene, that democratically identified peers (PICAs) led by example and were well-liked, and that the attitude of the MSCAs was uncompromising. Staff in study arm 1 improved hand hygiene because they did not want to disappoint the efforts taken by the PICAs. Staff in study arm 2 felt pressured by the MSCAs to comply with hand hygiene to obtain good overall performance appraisals. The organisational culture of both wards was hierarchical, with little social interaction, but strong team cohesion. Position and networks of both PICAs and MSCAs were similar and generally weaker compared to the leaders who were re-nominated by HCWs in the post-intervention period. Healthcare workers on both wards perceived authoritative leadership to be the most desirable attribute for hand hygiene improvement.

Conclusion: Although the attitude of PICAs and MSCAs in terms of leadership, mode of action and perception of their task by staff were very different, or even opposed, there was no significant difference in hand hygiene improvement between the 2 study arms.

Healthcare workers preferred the existing top-down authoritative leadership structure.

However, PICAs were not inferior to authoritative leaders and acted as early adopters who facilitated the improvement of hand hygiene practices through role-modelling and their social network. This highlights the limits of applying leadership models that are not supported by

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Abstract in French

Résumé en Français

Contexte: L’hygiène des mains représente une activité clé dans le domaine de la prévention et le contrôle des infections associées aux soins, et donc dans la sécurité des patients. Bien que l’hygiène des mains soit l’une des approches les moins coûteuses pour la réduction des infections associées aux soins, l’observance à cette mesure peut être faible, même dans des pays développés. L’observance à l’hygiène des mains peut être améliorée avec des efforts collaboratifs, s’exécutant par un leadership exemplaire et l’engagement des « change agents », des soignants qui travaillent vers un changement de comportement des collaborateurs. Cependant, peu d’information est disponible sur le fonctionnement du changement de pratiques effectué par les « change agents », notamment dans le contexte de la culture organisationnelle et les réseaux sociaux des équipes. L’objective de ce projet était de décrire l’influence des « change agents » sélectionnés par les collaborateurs (CASC) et des « change agents » sélectionnés par la hiérarchie supérieure (CASH) sur l’hygiène des mains, la perception du style de leadership des « change agents » par les collaborateurs, et le rôle de la culture organisationnelle et les réseaux sociaux des soignants dans la promotion de l’hygiène des mains. S’appuyant sur la Théorie de la Diffusion d’Innovation, nous émettions l’hypothèse selon laquelle les membres du personnel désignés par leurs collaborateurs (CASC) étaient des « utilisateurs rapides » et effectuaient leur rôle en tant que ambassadeurs à l’hygiène des mains dans leur réseau social.

Méthodes: Cette étude contrôlée et randomisée a été accomplie dans deux unités de service de médecine interne d’un hôpital universitaire de soins tertiaire en Malaisie. Entre février 2017 et mars 2018 trois périodes d’études (avant-intervention, intervention, post- intervention) ont été effectuées. Les deux unités ont été attribuées aléatoirement à une des deux interventions : changement de pratique facilité par CASC (bras 1), ou changement de

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pratique facilité par CAHS (bras 2). Les résultats primaires étaient : (1) l’observance à l’hygiène des mains par observation direct ; (2) la connaissance sur l’hygiène des mains, obtenu par questionnaire ; (3) interactions des soignants, observés pendant des visites dans les unités ; (4) caractéristiques de leadership de CASC et de CASH exprimés verbatim par les collaborateurs lors des sessions question-réponse ; (5) la connectivité du réseau social, ainsi que les modèles de communication entre « change agents » et collaborateurs, en appliquant l’analyse de réseau social ; (6) caractéristiques de leadership en matière d’hygiène des mains, exprimés par les collaborateurs par écrit dans la période post- intervention.

Résultats: L’observance à l’hygiène de mains a augmentés de 48% (IC 95%: 44–53%) à 66% (63–69%), et de 50% (44–55%) à 65%(60–69%) dans le bras 1 et le bras 2. Les deux bras ont connu une amélioration significative entre les périodes avant-intervention et intervention, et avant-intervention et post-intervention. Les scores de connaissance sur l’hygiène des mains se sont améliorés de 60% à 98% dans le bras 1, et de 63% à 93% dans le bras 2. Les visites dans les unités ont démontrées que tous les « change agents » effectuaient l’hygiène des mains correctement, que les comportements des CASC ont été exemplaires et bien appréciés par les collaborateurs, et que la manière de fonctionner des CASH était perçue très rigide. Les soignants dans le bras 1 ont amélioré l’hygiène des mains parce qu’ils ne voulaient pas décevoir les efforts des CASC. Les soignants dans le bras 2 ont amélioré l’hygiène des mains parce qu’ils se sont senti sous pression par les CASH. La culture organisationnelle dans les deux unités était hiérarchique, avec peu d’interaction sociale, mais avec une solide cohésion d’équipe. La position et les réseaux des CASC et des CASH étaient similaires mais généralement plus faible en comparaison avec les leaders qui ont été nominés dans la période post-intervention. Un leadership autoritaire

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Conclusion:

Bien que les attitudes des CASC et des CASH en termes de leadership, mode d’action et de perception de leur fonctionnement par les soignants étaient différentes voire opposées, il n’y avait pas de différence significative en ce qui concerne l’amélioration de l’hygiène des mains dans les deux bras. Les soignants ont préférés la hiérarchie top-down déjà en place même si en efficacité, les CASC n’étaient pas inférieurs aux CASH. Effectuant le travail principalement à travers d’être exemplaire, les CASC se positionnaient en tant que

« utilisateurs rapides » à travers du processus d’intervention, comme conçu par la Théorie de la Diffusion d’Innovation. La préférence d’un leadership autoritaire malgré l’expérience positive d’une intervention égalitaire, démontre les limites dans l’application de modèles de leadership sans tenant en compte la culture organisationnelle locale.

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1. CHAPTER ONE: General introduction

1.1: Background

The first World Health Organization (WHO) Global Patient Safety Challenge, “Clean Care is Safer Care”, was launched in 2005-2006 to focus on improving hand hygiene compliance in healthcare facilities.[42] Hand hygiene was selected because it is a low-cost practice to prevent the transmission of multidrug-resistant microorganisms and to reduce healthcare- associated infections (HAIs).[43] However, hand hygiene improvement programmes often fail because top management for infection prevention and control (IPC) do not have sufficient implementation skills.[44] Hand hygiene is driven by behaviour in a socio- economical and organisational context.[45,46] Given that hand hygiene is a behaviour- driven action, promotion should be peer-centred and multimodal. This includes leadership engagement, peer pressure, and empowering role models, opinion leaders, and

champions.[44–46] Collaborative multimodal strategies fostering good team spirit and partnership among healthcare workers (HCWs) is an important implementation strategy to drive behaviour change.[45–52] Feedback of hand hygiene compliance, even if provided on a daily basis, only is effective in settings with strong social cohesion.[52]

A role model is a person who is esteemed by his or her peers, and whose excellent behaviour becomes an accepted reference.[53] Suitability of role modelling occurs when individuals are able to relate themselves to others of the same social role and interest.[54]

Their position and their qualities make it easy for others to identify with.[53,55,56] When HCWs are identified as having qualities others admire, they may become opinion leaders that are gatekeepers of the social system who diffuses information they received within their social system. Opinion leaders act as boundary spanners, using social communication skills

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and informal social relationships; and (iii) are being perceived by others to be energetic, with insight and are innovative.[57] On the other hand, hand hygiene champions are usually well accepted, charismatic and influential leaders, or other authority figures holding a crucial component in effective infection control measures.[58,59]Champions are charismatically influential persons, perceived and accepted as authoritative leaders by their peers.[58] In an implementation, they shape organisational change through four functions: (i) protecting those involved in implementation from organisational rules and systems that may be barriers; (ii) building organisational support for new practices; (iii) facilitating the use of organisational resources for implementation; and (iv) facilitating the growth of organisational coalitions in support of the implementation.[59]

According to the Diffusion of Innovation (DOI) theory, readiness for implementation can be approximated by the duration between the exposure to the innovation and the decision to adopt it in a social system.[60] The innovation-decision period is the length of time required passing from the knowledge stage towards making a decision by the individual (or

organisation) to ‘accept or reject’ an idea. Innovators introduce the innovation or the new idea. They may or may not be part of the social system, but once peers start to adopt the innovation, implementation occurs. During implementation, four categories of adopters can be distinguished: early adopters, early majority adopters, late majority adopters, and laggards. Early adopters set the stage for subsequent adoption. They usually are well- respected peers and usually are better integrated into the social system than the innovators.

Later adopters check with the behaviour of early adopters for advice and information about the innovation in their process of considering adopting the new idea. Champions are early adopters, and, acting as positive role models and using their social network among peers, facilitate persuasion to adopt a favourable attitude towards hand hygiene by HCWs, and subsequently drive behaviour change. Early adopters are ‘role models’ because their

behaviour is not perceived as being too far ahead of the average. They decrease uncertainty

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evaluation via their wide interpersonal communication network.[60] However, identifying diffusers can be labour-intensive as there is no reliable method to identify them,[59,61]while local cultures might interfere with the actions of champions.[46]

This projects’ implementation is addressed using a sociological approach, based on the DOI theory and applying social network analysis (SNA).[60,62] Organisations are not always democratic settings, where the principles of the DOI theory apply. Leadership is not always a natural process, delivered by well-respected role models but more often a top-down

managerial approach. Social network analysis allows us to describe structural

connectedness of team networks for hand hygiene promotion. In this study, networked structures consist of individual HCWs and are referred to as nodes. Networks are visualised through ties between nodes that represent inter-relationships illustrated in a sociogram.

Healthcare workers whose behaviour are considered excellent and are admired for their professionalism are not always change agents. By understanding the relationship and partnership among different networks of HCWs, this study identified change agents that acted as role models, who diffused positive hand hygiene behaviour to early and early majority adopters, which led to reciprocation of favourable hand hygiene behaviours among potential later adopters.

1.2: Rationale for this research

Why do we need hand hygiene compliance?

Healthcare-associated infections caused by the bacteria Staphylococcus aureus (S. aureus) is responsible for the majority of surgical site infections[63,64] and skin and soft tissue infections.[65,66] A proportion of S. aureus that has developed resistance to a marker

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infections are of concern because these are more commonly associated with elderly hospitalised patients whose health may already be compromised.[65,66] Outbreaks of HAI due to HA-MRSA result in increased length of stay, and they are associated with both morbidity and mortality. [67] Successful efforts to reduce MRSA transmission in hospitalised patients included hand hygiene improvement. [47,68–71] The Geneva programme on hand hygiene linked hand hygiene compliance with a significant reduction in MRSA infection rates by 60%.[47] It included the availability of alcohol-based hand rub (ABHR) at the point of care, posters, and clinical leadership to facilitate compliance with hand hygiene. The WHO first Global Patient Safety Challenge “Clean Care is Safer Care” is based on this seminal Geneva programme.

How successful have the hand hygiene compliance interventions been?

Each year, hundreds of millions of patients are affected by HAIs, with a higher risk in developing countries.[72,73] Hand hygiene is one of the most cost-effective measures in reducing HAIs but compliance is generally low, even in high-income countries.[74]Although HCWs know about hand hygiene practices, many have not developed a favourable attitude towards it.[74]

Between 2000 and 2004, an Australian study reported before-patient contact hand hygiene compliance ranged from 25%-67% while after-patient contact ranged from 27%-70%.[75]

The wards were most commonly in the older-style Nightingale ward arrangement, where a single sink was located outside the entrance to a six-bedded ward with sinks up to 30 metres from the point of patient care.[75] HCWs were subsequently relocated to a new hospital where sinks were no more than five metres from the point of care with a sink located within a four-bedded ward and located outside each room. Yet, increased numbers and locations of sinks did not result in significant improvement hand hygiene compliance for either before- patient contacts (13% -47%) or after-patient contact (23%-72%) 10 months later, after

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completion of relocation.[75] Larson (the ‘Washington programme’) utilised organisational cultural change as the focus for improving hand hygiene compliance (both soap and water washing and ABHR).[69] Pivotal to the Washington programme was HCWs’ active

involvement and clinical “buy-in” exemplified by staff leading the intervention through staff- led meetings, staff designed posters, and an overt involvement of senior administrative and senior clinical staff. The success of this programme over seven months was an increase in hand hygiene compliance with a concomitant decrease in transmission of other important HAIs, MRSA, and vancomycin-resistant enterococci.[69] To test these two international successful strategies, Washington[69] and the Geneva programmes[47] with a control study arm (consisting only of ABHR provision without leadership) a study was carried out in an Australian hospital that examined the effect of environmental changes on hand hygiene compliance.[76] The Washington programme[69] was launched by senior hospital executive and senior clinicians with ongoing reinforcement of the importance of the programme

through weekly ward tours, with the aim of providing visible support for the intervention.

The introduction of ABHR alone did not improve compliance (p=0.238).[76] However, the Washington programme that was staff-centred and supported by medical leadership achieved a 48% (p<0.001) improvement in compliance that was sustained over two years.[76] The Geneva programme failed to induce a significant increase in hand hygiene compliance in three wards without clinical leadership while the ward with strong clinical leadership achieved a 56% (p<0.001) improvement. [76]

Hand hygiene promotion needs leadership and should be peer-centred.[69,76] The trial of both Washington[69] and Geneva[47] programme has demonstrated that the introduction of the ABHR product alone is not effective without strong clinical leadership.[76] Senior

clinicians were used as leaders in the Washington study arm of the trial[76] while strong

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undertake the practice but is not the most influential factor for compliance.[77] The most influential predictor of intention to comply for nursing staff was simply their perception that physicians and senior administration officers expected them to comply.[77]The facilitation of compliance is therefore not simply related to effort but is highly dependent on leadership to alter behaviour. The Washington programme[69] encourages staff at all levels to get involved while the Geneva programme[47] uses the influence of strong leadership. Yet, the common approach most often used when choosing a clinical leader for patient safety initiatives has been to select the most senior clinician. The weakness in this method is that not all senior and respected leaders exert influence.

Why sound intervention strategies have fallen short?

The DOI theory seeks to outline how and why new ideas and practices are adopted over time. Those who introduce new ideas and the readiness of those to adopt or not these new ideas are said to belong to one of five categories of adopters: innovators, early adopters, early majority adopters, late majority adopters, and laggards. Innovators are those first individuals who rapidly adopt the target behaviour.[60] They either develop new ideas or require a shorter innovation-decision period possibly because they have more favourable attitudes towards new ideas, embrace new ideas, utilise technically accurate sources about innovations, and place higher credibility in these sources than the average individual within their social, professional group or organisational ‘system’. Innovators may not be respected by other members of their system but they still play an important role in the diffusion process by launching new ideas.

Early adopters have a shorter innovation-decision period than later adopters and adopt early because they become aware of the new required behaviour or idea sooner than others within their system. This group has the highest number of opinion leaders in their system and also serve as ‘role models’. Potential adopters look towards early adopters as “the

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individual to check with”, for advice and information about the innovation before adopting the new idea. They are respected and are considered the embodiment of successful and

discrete use of new ideas. In order to continue to be held in high esteem by their colleagues, early adopters decrease uncertainty about a new idea by adopting it and then convey a subjective evaluation of it to their peers via their interpersonal communication network. The early majority adopts the new idea just before the average member of the system but after the early adopters. This group interacts with their peers but does not hold the position of opinion leaders. This group usually consists of one third (34%) of the entire system. Their position between early adopters and late majority adopters provides an important

interconnectedness in the system’s interpersonal communication network. They may take some time until completely adopting the new idea, but once done, they implement the idea deliberately; however, they rarely lead the way within their system for any new idea or practice. The late majority adopters will eventually be influenced to adopt the innovation only after the average member of the system. Like the early majority adopters, these members make up one third (34%) of the five adopters categories. The late majority adopters approach innovations with scepticism and caution. This group observes the results of innovations and will not adopt the innovation until most members of their system have done so and emerging peer pressure is necessary to motivate adoption. The reason for their later adoption is that they may not have the conceptualisation of the earlier adopters and

uncertainty must be removed before this group feels safe to adopt the innovation. Laggards are the last to adopt (if ever) and are almost never opinion leaders. They are isolated in their system and their decision-making is based on previous practice, as their point of reference is the past. They are suspicious of change agents and view resistance as entirely rationale.

They require certainty that the new innovation will not fail before they can adopt it.

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Models using clinical leadership to effect widespread change implicitly assumes that leaders also act as role models. Diffusion of Innovation can explain the differences in the success of the Washington[69] and the Geneva programmes[47] and the replicates of these protocols [71,76] that achieve significant but albeit small improvements. In accordance with the DOI, the designer and implementer of the Geneva programme [47] could be described as both innovators and early adopters. Hence, his/her influence reported in the seminal paper[47]

may have been in principle as a result of the early majority complying as this group accounts for a third of any system. The designer of the Washington programme [69]attempted to utilise all levels of staff including the innovator and the early adopters to develop and implement the programme and finally, the early majority as the programme design stresses the whole of system involvement. It is unlikely that the Washington programme succeeded in involving late majority adopters and laggards in the design and implementation stages. The identification of the appropriate clinical leaders in both of these protocols according to the DOI must be selected within the specific healthcare profession as HCWs cannot be considered a homogenous group for patient safety activities, rather medical staff look to each other for leadership.[78]For example, had the choice of leadership in the replicate studies [71,76] utilised the DOI approach of selecting and educating the well-liked early adopters in the system, who would then lead the behaviour change with an overt focus on the physician group to influence the nursing staff,[79] the percentage point improvement in hand hygiene may have been larger.

Why selecting leaders using Diffusers of Innovation method is superior?

Broadly, five methods are commonly used to select a leader: (i) leader selects him/herself as the role model; (ii) those who develop the innovation/intervention programme select the leader; (iii) the members in the system recruit participants (not leaders) who in turn each recruit new participants (namely, snowball method); (iv) identified members in the system select the leader; and (v) all the members of the system select the leader. The limitation of

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the influence of leaders selected using approaches (i) and (ii) include potential for members of the system believing the leader may have a different (and perhaps harmful) agenda from the other members, the leader having limited knowledge of the members’ needs or that the leader has insufficient knowledge of the innovation. The snowballing effect of enrolling participants within the system avoids the selection bias of the first two methods. This is an excellent method for easily communicated messages. However, if the innovation is complex or the individuals cannot communicate the innovation effectively the flow-on effect of the correct message may be lost or damaged and the dynamics of the snowball method are temporary. The fourth method overcomes the disadvantages of methods (i) to (iii) and is the common method utilised in clinical leadership. The disadvantage of this method is that the effectiveness of the innovation is highly dependent on the selected leader who may not be well-liked or respected by his/her members of the system. Allowing all members of the system to select a leader is democratic, increases the likelihood of a well-liked adopter who is believed to be trustworthy being selected, and overcomes most of the disadvantages common to methods (i) to (iv). An additional advantage of method (v) is that a number of leaders can be selected for training and the members within e.g. healthcare professionals can select a leader from their own group or from other healthcare professional groups. The selected leader(s) instructed in the innovation can then communicate the intervention to the membership of the system. In accordance with the DOI, members of the system are asked to nominate those members whom they would go to for advice about an issue within the paradigm of the innovation (for example, medical/nursing practice or healthcare career advice). According to the Rogers and Cartano (1962) technique, leaders are chosen by the frequency of the members in their system nominating them.[80] The effect of the selected leader (or leaders) may simply work through their direct social network of communication or passive communication where the innovation is an overt behaviour (such as hand hygiene).

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What is the relevance of social network concepts in hand hygiene promotion?

The focus of this thesis is the transmission of information within social networks for hand hygiene promotion. Social network analysis has been applied to similar fields.[81–85] A recent systematic review and meta-analysis demonstrated that many health behaviours are shaped by influences of social networks.[86] Social norms, key individuals, and the type of innovation shapes a person’s intention to adopt a behaviour within this social network. Social norms are the typical behaviour inside a social network, they characterize the scope of passable behaviour and set the standard for behaviour in the social network.[60]

Interpersonal communication channels are most influential in persuading other individuals in a social network to accept new practice behaviour.[60] However, for diffusers to perform as social communicators, they should not violate the norms within their social system.

Generally, SNA is based on the social network made up of individuals, organisations, or entities called ‘nodes’, which are tied or connected by one or more specific types of interdependency.[87] Nodes are the individual actors within the network and ties are the relationships between actors.[87,88] Identification and examination of key actors or nodes within healthcare networks are critical, they are defined by their position within the overall structure of the network and are important in the network function. Key actors and nodes are central individuals in a network who are the most connected or interact with the most other people, [89] they are described as ‘opinion leaders’ [80,90,91] Opinion leaders occupy key positions identified by their centrality score in SNA. Such influence is derived from their technical competence, social accessibility, and conformity to social norms.[60,80,92] When early adopters act as opinion leaders to translate an innovation for the remainder of the network, they become change agents for diffusion to accelerate.[60]

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1.3: Thesis objectives

(i) To test two leadership principles in work teams on hand hygiene compliance: (a) influence of peer-identified change agents (PICAs) in which peers, acting as early adopters according to the DOI theory, facilitate hand hygiene improvement and sustainability by role modelling;

and (b) influence of management-selected change agents (MSCAs) who are expected to carry out top-down leadership where hand hygiene improvement is enforced by staff formally appointed by management.

(ii) To describe the perception of different change agents’ leadership styles by peers, their ability to shape team dynamics, and the role of organisation culture in this process.

1.4: Hypothesis

We hypothesised that PICAs will be regarded as early adopters and role models whose influence shall facilitate the adoption and reciprocation of good hand hygiene, outperforming MSCAs who will have less impact on hand hygiene promotion (measured by percentage point improvement in hand hygiene compliance).

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2. CHAPTER 2: Methodological contributions 2.1: Settings

Study collaborations

This was a collaborative project between the Malaysian Ministry of Health, the WHO

Collaborating Centre on Patient Safety at the University of Geneva Hospital (HUG), Geneva, Switzerland, and the University of New South Wales in Sydney, Australia. This study was conducted in Sarawak General Hospital (SGH), a university-affiliated tertiary care teaching hospital in Kuching, Sarawak, Malaysia.

Geography, demographics and local governance

Malaysia is an upper-middle income country located in Southeast Asia.[93] Sarawak is the largest state in Malaysia located on the northwest Borneo Island, and has a land area of 124,450km^2, with a reported population of 2.8 million in 2018.[94] Kuching is the largest city and the economic centre in Sarawak with a total population of 325,132.[95] The head of state is known as the Governor and head of the government is the Chief Ministry. The state is divided into 12 divisions with a total of 40 districts within and accounts for 8.7% of

Malaysia’s total population.[95] Uniquely, although Malaysia is a fundamentalist Islamic country,[96] Sarawak has the highest percentage of Christians and has the most diverse population in Malaysia, with more than 40 sub-ethnic groups, each having their distinct dialect, lifestyle, and culture. There is also the existence of the Native Courts in Sarawak, a state legal institution created under the Native Courts Ordinance (1992) that originated from the Court of Datu established by Sir Rajah Charles Brooke in the late 1860s.[97]

Sarawak’s Health Profile

The total expenditure on health as a percentage of GDP was reported in 2017 to be 4.55%

for the year 2015.[98] There are 23 public hospitals and special medical institutions in

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Sarawak. The total number of hospital beds (public and private) per 1,000 people for the whole of Malaysia is 1.8 in 2012,[99] and 1.5 in 2013[95] for Sarawak. The nurse to population ratio for Malaysia in 2017 was 1:309,[98] while the doctor to population ratio for Malaysia in 2016 was 1:632,[98] but only 1:1,184[100] for Sarawak with only one Infectious Disease physician for the entire state during the study duration.

Sarawak General Hospital

At SGH, two internal medical wards, one male and one female (study arm 1, study arm 2), were selected for this project because the staff and head of the medical department were interested, commitmentted, and receptive towards initiatives that improve hand hygiene behaviour. Each ward had 42 official beds but would take up to eight additional beds, if necessary. The nurse-to-doctor ratios of the male and female wards were 69:6 and 64:5, respectively, with no overlap of staff between the two wards. Almost one-third of the nurses were male (19/69) in the male ward. There was only one male nurse in the female ward (1/64). There were five male doctors in the male ward and three male doctors in the female ward.

The nurse-to-patient ratio was 1:2 in both wards. During the intervention period, the number of patient-days was 2,242 days for the male ward and 2,348 days for the female ward. The delivered healthcare and workload in both wards were similar, which consisted of a mixed internal medicine adult patient population with acute and chronic diseases. In the case of overflow in the intensive care unit, some patients underwent ventilation in both wards.

Malaysia’s commitment towards “Clean care is Safer Care”

In 2006, Malaysia pledged commitment to the WHO First Global Patient Safety Challenge

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of resources on hand hygiene in its public healthcare facilities using the WHO Self- Assessment Framework (HHSAF).[49,101–103] In 2011, 2013, 2015, and 2017, the total HHSAF scored for SGH were 445, 465, 470, and 472.5 respectively, attaining an ‘advanced hand hygiene level’. [29,101] For 2013, 2015 and 2017, the total HHSAF leadership scores for SGH were 18, 20, and 17, respectively, which translates to ‘high-level leadership support’

for hand hygiene promotion. [29,101]

2.2: Study Design

Timeline

The project was conducted from February 2017 to March 2018. The study was stratified into pre-, during, and post-intervention periods of 48-56 days for each period.

In February 2017, hospital administration, the infectious disease physician, the head of the medical department, infection control nurses (ICNs), and hospital and ward matrons were engaged in the project. A Train-the-Trainers hand hygiene workshop with validation of the hand hygiene auditors was organised prior to the pre-intervention period.[3] The pre- intervention period started in May 2017, followed by the intervention period in September 2017, and the post- intervention period in January 2018. Pre-, during, and post-intervention period for study arm 1 had 48, 5 and 56 study days, and study arm 2 had 49, 51 and 56 days (week-days, and week-ends) respectively; school and public holidays were excluded.

The pre-intervention period on both wards acted as the control.

Interventions

Nomination of change agents:

Two different strategies to identify change agents were tested. Before the pre-intervention period, staff from both wards anonymously nominated and ranked 10 peers to become their

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change agents for hand hygiene promotion. The wards were then randomly allocated to either study arm 1 or study arm 2 by flipping a coin. To reduce bias, no information on randomisation was revealed.

Change agents in study arm 1 (PICAs) were with the highest numbers of nominations by their peers. Peer-identified change agents were hypothesised to be early adopters acting as role models, and whose hand hygiene compliance practice will positively impact on the behaviour of their peers.

During the pre-intervention period, change agents in study arm 2 (MSCAs) were selected by senior management. Senior management refers to members of the medical and nursing boards of the department. On average, MSCAs were 12 years older than the PICAs, and their working experience three times longer. We hypothesised that MSCAs have less impact on hand hygiene compliance of the peers compared to PICAs.

To conceal the wards from knowing their allocation to one or the other study arm, all change agents were told that they were selected by senior management. In total six change agents, five nurses, and one doctor were selected per study arm based on the nurse-to-physician ratio. This was to assure that at least one change agent would be present on any study day.

To be eligible for selection as a change agent, nurses and doctors had to have worked in the ward for at least six months, were not planned to leave the ward until the end of the study, and did not have skin intolerance to the use of ABHRs.

Responsibilities of Change Agents

Before the pre-intervention period, all change agents attended a local hand hygiene Train-

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active intervention. During the intervention period, both PICAs and MSCAs were given the task to promote hand hygiene in their work teams during the intervention period by

encouraging peers to perform hand hygiene, giving feedback, and offering correction or congratulation on missed or observed hand hygiene opportunities.

Initial one-week (seven days) follow-up

Change agents were scheduled to work in their usual participating ward. During their work shift, they were randomly paired with a trained hand hygiene auditor, either an ICN or the principal investigator (PI) to receive overt education, praises, and/or correction on hand hygiene practices together with the other ward staff. These sessions lasted 20 minutes and took place daily for seven days.

The initial seven days feedback of the change agents’ practice by a trained auditor consisted of more than the current auditing practice without immediate individual feedback. For change agents or HCWs who displayed inappropriate elective hand hygiene behaviour with

perceived ‘clean’ contacts, the ICN or PI used the opportunity to overtly educate them about the differences between socially accepted elective hand hygiene practices in the community and mandatory compliance before contact with a patient.

Subsequent seven weeks (49 days) follow-up

Subsequently, the PI followed-up with all change agents once a week via voice calls, reminding them of their responsibilities and to receive feedback regarding their roles and responsibilities.

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2.3: Data Collection

Outcomes

Hand hygiene compliance

Hand Hygiene compliance of both study arms was measured by direct hand hygiene observations in the pre-, during, and post- intervention period using the WHO methodology.

[104] A minimum of one but no more than two observation sessions per day were performed in each study arm, and all three study periods. The auditors were randomly scheduled using online randomisation software.[105] Each session lasted no longer than 30 minutes, allowing observing 12-15 hand hygiene opportunities. The nurse-to-doctor ratio of observed staff was 3:1.[106]

Hand hygiene audits were a Ministry of Health commitment and audit schedules were endorsed by the local Sarawak State Health Department. Weekday audit assignments were announced weekly, on Friday mornings for the following week. On the other hand, weekend and public holiday audit schedules were separately announced at least two weeks before the start of each audit period.

Hand hygiene knowledge

All auditors, change agents, and ward staff of the two selected wards were tested using WHO’s “Hand Hygiene Knowledge Questionnaire for Healthcare Workers” (revised 2009 edition).[107] Knowledge questionnaires were performed once in the pre-intervention period and three times during the intervention period. Amelioration of knowledge was carried out on staff that did not score 100% (additional training was offered for staff scoring below 100%).

Those that did not score 100% in the 4th assessment had to undergo the 5th assessment.

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Observations from ward tours

During the intervention period, the PI conducted a total of 16 sessions of ward tours, eight sessions for each study arm. Each session was conducted once a week, on a random weekday for 20 minutes (total 320 minutes), anytime between 08:00 to 17:00, to observed initiatives taken by change agents to improve hand hygiene compliance and interactions between change agents and ward staff. The PI observed ward activities and visual information that was related to hand hygiene and received feedback from ward staff regarding this project when approached. Field notes were written and used as data based on feedback received and observations made.

Perceived leadership style

In the post-intervention period, six question and answer (Q&A) sessions were conducted for each study arm with no repeats, to explore the opinion of ward staff towards PICAs and MSCAs. The sessions were conducted over six days in mixed languages, English and Malaysian, with a maximum of 10 randomly allocated participants per session, in total, 57 and 55 ward staff in study arm 1 and study arm 2, respectively. A local IPC expert facilitated the Q&A sessions using a semi-structured interview guide that addressed five areas of leadership attributes: attitude, self-confidence, approachability, team role, and decision- making capacities.[45,108] At the beginning of each Q&A session, written informed consent was obtained from all participants, and ground rules were set to address privacy and

confidentiality concerns. All sessions were audio-recorded, transcribed verbatim and translated into English. The PI was present during all sessions for note taking. In addition, the participants’ re-nominated five peers (nurses only) they preferred as leaders for hand hygiene promotion. Doctors did not participate in this exercise. They also listed and ranked (as free text) three main leadership qualities they considered important for hand hygiene promotion.

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Social network connectedness

The social network of the wards was analysed from questionnaires administered at the end of each Q& A session conducted in the post-intervention period, where participants re- nominated five peers (nurses only) whom they believed would have been good hand hygiene leaders with regards to the recent hand hygiene intervention that took place. To maintain confidentiality and discretion, individual identification codes were given to the nominators. Nomination data was analysed using NodeXL Pro software (Social Media Foundation, Belmont, CA, USA [109] to produce sociograms and graph metrics illustrated the nomination relationship based on perceived leadership characteristics exhibited during the intervention period.

Preferred hand hygiene leadership attributes

Participants listed and ranked (as free text) three main leadership qualities they considered important for hand hygiene promotion at the end of each Q& A session conducted in the post-intervention period.

Training and validation

Data on hand hygiene compliance were collected by nine ICN auditors and the PI. The ICN auditors together with the change agents, attended a local hand hygiene Train-the-Trainers programme in Kuching, Sarawak, organised by the HUG team[3] before the intervention period. The PI was trained and validated at HUG in Geneva. The objective of the locally conducted Train-the-Trainers programme was to increase knowledge about the WHO hand hygiene auditing methodology based on the WHO five- moments of hand hygiene and to address misconceptions about hand hygiene practices.

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hygiene actions at different time slots of each video and in the written scenarios. Inter-rater reliability between all nine observers was calculated using the Fleiss Kappa-test against gold standard answers provided by HUG.[110]

2.4: Data Analysis

(i) Hand hygiene compliance

On weekdays, data were entered at 1.00 pm of the audit day to a Microsoft Excel

spreadsheet on designated computers, located in the clinical research centre of the SGH.

Data entry was performed on the next working day if the audit sessions fell on a weekend or public holiday. Calculation error was minimised with the daily hand hygiene compliance rate being auto calculated in Microsoft Excel and verified by another auditor against the WHO

“Hand Hygiene Observation- Basic Compliance Calculation” form.[107]

Hand hygiene compliance was calculated if a minimum of 12 observed hand hygiene opportunities were achieved.[111] For median and mean hand hygiene compliance calculations, one day equalled one data point.[112–114] Hand Hygiene compliance data were calculated[115] and collected [116] in accordance with the WHO “Hand Hygiene Observation” form[107] and presented on a Microsoft Excel run chart that performs at roughly 95% confidence interval (95%CI).[117] The Wilcoxon ranksum test was used to calculate mean differences of hand hygiene compliance within study arms (pre-intervention to intervention; pre-intervention to post-intervention), and between study arms (intervention and post-intervention periods). Statistical analysis was performed using STATA version 14.0 (Stata Corporation, College Station, Texas, USA).

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(ii) Hand hygiene knowledge assessment

Each correct answer was given one point, and each incorrect answer was given zero points.

Overall scores of each individual were expressed in percentage correct.

(iii) Observations from ward tours

Field notes were captured during ward tours through a cultural lens. Data were thematically analysed into two main categories; (i) Interactions between change agents and peers; (ii) Interactions between peers.

(iv) Question and answer sessions

The Q&A sessions aimed to explore common subthemes that emerged according to the five areas of leadership attitudes that were asked without the imposition of pre-determined premises. The audio recordings were transcribed verbatim and translated to English. The transcripts were checked against the audio recordings prior to analysis. Similar subthemes were identified through an iterative process for verification and clustered to reduce

redundancy. In addition to the use of field notes and audio recordings, member check was conducted by reflecting dominant answers at the end of each session for clarification and further comments.

(v) Social network analysis

Social networks were examined in three dimensions: a) visual measures; b) whole network measures; c) individual measures.

a) Visual measures

Sociograms mapped networks between the nominators and nominees, it visualised the

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represented a ‘node’ and the lines between each node described the personal network of HCWs and the relational distance within this network.

b) Whole network measures

The structural characteristics of the entire network were measured to explain the overall relationship structure and relationship patterns of the HCWs within each ward.

Density measures the total number of relational ties (relationships or interactions) present between individuals, divided by the total number of possible relational ties (relationships or interactions) between individuals within the network.[118,119] This is used to

explain the portion of potential network connections that are actual connections.[120]

Geodesic distance measures the shortest route or pathway between two individuals and the extend (range) of their connections within the network. The distance is reported as an average and maximum distance between individuals.[118,121] This is used to explain the cohesiveness of the ward network seeking hand hygiene leadership by looking at the distance and number of ties between HCWs.

Reciprocity measures the relationship strength evident when staff reciprocates by

nominating each other (individuals nominating each other). [91,122] Nomination networks can be asymmetrical: staff x nominates y but staff y might not reciprocate to nominate staff x. This is used to explain whether individual HCWs who were the source of hand hygiene leadership also received advice from the individual HCWs who nominated them. Vertical hierarchies have low reciprocity (little nominations between individuals), while horizontal hierarchies have high reciprocity (many nominations between individuals).

Innovative social and behavioural change strategies to strengthen and improve infection prevention and control – A World Health Organization first Global Patient Safety Challenge “Clean Care is Safer Care” project

Thesis

Reference

Innovative social and behavioural change strategies to strengthen and improve infection prevention and control – A World Health Organization first Global Patient Safety Challenge “Clean Care is

Safer Care” project

Stratégies innovantes de changement social et comportemental pour renforcer et améliorer la prévention et le contrôle des infections–Un projet du

premier Défi Mondial de Sécurité du Patient de l’Organisation mondiale de la Santé ,

« Les soins propres sont des soins plus sûrs »

Innovative social and behavioural change strategies to strengthen and improve infection prevention and control – A World Health Organization first Global

Patient Safety Challenge

“Clean Care is Safer Care” project

UNIVERSITY OF GENEVA, GENEVA, SWITZERLAND Thesis/ Dissertation Sheet for the degree of

Doctorate in Biomedical Sciences

CONTENTS

Originality Statement

Dedication

Acknowledgements

List of Publications, Oral Communications, Poster Presentations and Other Communications Related to Thesis Topic

Published peer-reviewed papers

Peer- reviewed journal publications

Oral communications (including lectures)

Poster presentations

Other communications

Abstract in English

Abstract in French

Résumé en Français

1. CHAPTER ONE: General introduction

1.1: Background

1.2: Rationale for this research

1.3: Thesis objectives

1.4: Hypothesis

2. CHAPTER 2: Methodological contributions 2.1: Settings

2.2: Study Design

2.3: Data Collection

2.4: Data Analysis