Nudging Towards Cleaner Hands: Insights from a Hospital Visitor Experiment
A field experiment at a Danish hospital utilized Behavioural Insights to significantly increase the number of visitors using hand sanitizer
With the onset of the COVID-19 pandemic, the importance of hand hygiene has been thrust into the spotlight like never before. While basic hand cleansing has long been advocated as a means of illness prevention, achieving compliance, particularly in healthcare settings, remains a challenge. Hospital-care-associated infections (HCAIs) continue to pose a significant threat to patient safety, making the need for effective hand hygiene practices all the more critical.
In a ground-breaking field experiment, iNudgeyou sought to explore the effectiveness of nudging strategies in promoting hand hygiene compliance among hospital visitors. Over 50 days, we observed the behaviour of over 46,000 visitors entering a hospital in Denmark, experimenting with various contextual features surrounding the presentation of hand sanitizer in the foyer.
Varying seemingly irrelevant features
The results were illuminating. By varying seemingly irrelevant features such as the placement and salience of hand sanitizer stations, compliance rates significantly increased from a baseline of 0.4% to as high as 19.7% (and ultimately 47.6% during the COVID-19 pandemic). In general, the integration of nudges significantly increased compliance, with certain combinations proving particularly effective.
The experiment tested 4 key nudges in 9 combinations. The four key nudges were:
- Location of hand sanitiser station (baseline placement next to reception, right after entrance to hospital foyer and right before entrance to hospital foyer)
- Pink sign labelled “sanitiser” (present vs. absent)
- Pink banner campaign advertising hand hygiene campaign (present vs. absent)
4. Assertive pink duct tape line on floor by sanitiser (present vs. absent).
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Detailed Results and Findings
While other experiments have been conducted analysing hand sanitation compliance in a similar manner, none have looked at as large a sample set as this one, nor taken into account the interaction of the different nudges at once. For these reasons, analysis of the data also revealed some detailed results and intriguing insights.
First, it is a noticeable finding that implementation of any nudge increased compliance above the baseline, which was measured at only 0.43%. Although it might be hard to fathom, this baseline level is actually not unusual compared to baselines in the many hand hygiene experiments we have conducted over the years. Thus, given the cost-effectiveness of nudges, there seems no excuse for hospitals not to apply this approach as soon as possible.
Next, the most effective combination of nudges turned out to be a scenario with the sanitiser placed before the entrance to the foyer, visibly prominent with pink signage and a duct tape line on the floor to further encourage people to perceive it as boundary requiring an action. Compliance in this case rose to 19.66%. This set-up is so easy to copy that there is no excuse not to.
The figure below shows the effects of the various combinations, including the Covid-19 observation.
Figure 1. Hand hygiene compliance (%). Percentage of people sanitizing their hands upon entering the hospital.
Third, since we had also captured data on each subject’s gender and when during the day they were visiting, compliance could also be measured along these lines. It turns out that women were more likely to be nudged into compliance as compared to men. It’s anyone’s guess as to why that might be the case. However, we speculate that there could be an increased appeal in the use of the colour pink which is the primary colour of the national female breast cancer campaign as well, but keep an eye out for our future experiments.
Finally, contrary to what other experiments has documented, time of day did not produce a statistically significant effect.
What happened when Covid-19 came along?
Shortly after we had finished the experimental protocol of the planned experiment, COVID-19 arrived on the scene. When conducting another series of hand hygiene experiments a year into the pandemic, we therefore decided to revisit the site where the most successful intervention had been implemented and measure how it performed. Over the course of 4 days, we observed almost 5,000 visitors. Unsurprisingly, data showed that compliance had skyrocketed. Scenario 10 which had achieved only 13.95% compliance prior to COVID-19 shot up to 47.6%. Interestingly, our baselines in parallel experiments did not shoot up in the same way. Hence, nudges may be conceived of as important ‘accelerants’ in efforts to create behaviour changes.
Conclusion
By implementing nudging strategies to enhance hand hygiene compliance among visitors, we can significantly reduce the risk of hospital-care-associated infections (HCAIs) and improve patient safety. The scalability and cost-effectiveness of these nudges make them invaluable tools in safeguarding public health. In particular, the results of our field experiment underscore the effectiveness of nudging strategies in promoting hand hygiene compliance among hospital visitors. By testing various contextual features surrounding the presentation of hand sanitizer, we have identified practical interventions that can be implemented to encourage cleaner hands and reduce the transmission of infections in healthcare settings. We are also proud to have published these ground-breaking results in theand as we continue to explore innovative approaches to address healthcare-associated challenges, nudging towards improved hand hygiene offers a promising pathway towards safer and healthier healthcare environments.
Reference:
Hansen, P.G., Larsen, E., Modin, A., Gundersen, C., Schilling, M. (2021) Nudging hand hygiene compliance: a large-scale field experiment on hospital visitors, Journal of Hospital Infection, 2021, ISSN 0195-6701, https://doi.org/10.1016/j.jhin.2021.09.009.
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