Nudging hand hygiene compliance: a large-scale field experiment on hospital visitors

Background: Hospital-care-associated infections (HCAIs) represent the most frequent adverse event during care delivery, affecting hundreds of millions of patients around the world. Implementing and ensuring conformity to standard precautions, particularly best hand hygiene practices, is regarded as one of the most important and cheapest strategies for preventing HCAIs. However, despite consistent efforts at increasing conformity to standard hand hygiene practices at hospitals, research has repeatedly documented low conformity levels amongst staff, patients and visitors alike. Aim: The behavioural sciences have documented the potential of adjusting seemingly irrelevant contextual features in order to 'nudge' people to conform to desirable behaviours such as hand hygiene compliance (HHC). In this field experiment we investigate the effect on HHC amongst visitors upon entry of a hospital by varying such features. Methods: Over 50 days, we observed the HHC of a total of 46,435 hospital visitors upon their entry to the hospital in a field experimental design covering eight variations over the salience, placement and assertion of the hand sanitizer in the foyer, including the presence of the yearly national HHC campaign and a follow up during the COVID-19 pandemic. Findings: Our experiment found that varying seemingly irrelevant features increased HHC from a baseline of 0.4%-19.7% (47.6% during COVID-19). The experiment also found that the national HHC-campaign had no direct statistically significant effect on HHC. Conclusion: Varying seemingly irrelevant contextual features provides an effective, generic, cheap and easy to scale approach to increasing HHC relative to sanitizing one's hands at hospitals. (c) 2021 The Authors. Published by Elsevier Ltd on behalf of The Healthcare Infection Society. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).