Hand Hygiene: Unexpected Challenges and Cutting-Edge Solutions

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Hand Hygiene: Unexpected Challenges and Cutting-Edge Solutions

Abstract

Hand washing has taken on renewed importance during the COVID-19 health crisis. Employees in the food service and health care fields have been shown to wash hands inconsistently and ineffectively, despite emphasis on heightened safety protocols and oversight by supervisors. In response, a growing number of technological devices have arisen to offer more rigorous hand hygiene solutions. This article surveys some of these options, looking at their capacity to offer more accurate handwashing, better community understanding of hand hygiene, and eco-friendly improvements on standard handwashing methods.

Main Article

In the midst of the global coronavirus pandemic, perhaps the two most easily distilled recommendations from a litany of confusing and sometimes contradictory injunctions from health professionals are: (1) Stay home, and (2) Wash hands. The latter is so ubiquitous that videos circulate the internet showing celebrities complying with CDC’s recommended 20-second duration. Children are taught to wash hands while singing the A-B-C’s. Unlike other measures such as mask-wearing or stay-at-home orders, which have proven broadly divisive (Marsh, 2020), the importance of frequent handwashing is well-known and mostly uncontroversial.

The obvious pitfall of reliance on handwashing, however, is the inability to know for certain who has done so–and done so correctly. This is true not only within one’s immediate circle of face-to-face contacts, but also among indirect contacts. Individuals may have hand-contact with food or beverages purchased in restaurants or stores. Co-workers who share the use of frequently touched surfaces like furnishings, doors, walls, curtains, and light-fixtures may increase exposure to undesired contaminations. One European study of a 200-bed hospital intensive care unit found that 25 percent of frequently touched surfaces were infected with Staphylococcus aureus at levels that could present a risk to patients (White et. al, 2008).

In addition, despite the agreement on the importance of handwashing, there remain significant problems with ensuring workplace compliance with hand hygiene protocols. This is particularly evident in the food preparation industry. A study involving 85 food handlers at a university in Kuala Lumpur, Malaysia found that despite the group’s overall decent understanding of food safety principles, 65 percent had significant detectable bacteria on their hands when swabbed, with 48 percent showing the presence of Salmonella (Lee et. al, 2017). It is noteworthy that these data did not align with the workers’ self-reported practices, with most showing a “good attitude” about hand hygiene (knowing its importance, willingness to wash hands regularly). The study demonstrates a pronounced disconnect between what behaviors individuals may know are prudent and what they will actually do, particularly when rushed or given limited oversight.

The study demonstrates a pronounced disconnect between what behaviors individuals may know are prudent and what they will actually do, particularly when rushed or given limited oversight

A similar study, which collected observational and interview data from 321 food workers in Atlanta, Georgia, found that hand washing and glove use “were more likely to occur in conjunction with food preparation than with other activities (e.g., handling dirty equipment)” (Green et. al, 2007), thus undermining efforts towards safe food preparation. Moreover, the same study showed that handwashing took a marked downturn when workers were busy. Having a sink in an observed worker’s line of sight did increase handwashing, the study found; evidently, visual reminders are needed for workers to consistently practice good hand hygiene.

A Disconnect Between Knowledge and Action

But the reasons for the breakdown between knowledge (that consistent handwashing is important for safety) and practice (actually doing it consistently and effectively) are manifold. Poor compliance with hand hygiene protocols is generally not deliberate, malicious, or even apathetic. A study showed that the reasons hospital workers reported poor compliance ranged from finding hand hygiene agents irritating to the skin, inaccessibility of hand products, needs of the patient or patient-relationship taking priority, and wearing of gloves (an insufficient substitute for regular hand hygiene). All of these reasons were more common impediments than mere “forgetfulness” (Pittet, 2000). Other complaints included being too busy, lack of “role models,” and lack of institutional support or enforcement of hand hygiene practice.

majority of people wash hands ineffectively

Even with clear knowledge of the importance of handwashing and prioritizing the actions, numerous studies have found that the majority of people wash hands ineffectively. This can include not washing long enough, washing without using the right amounts of water or hygiene agent, or insufficient rubbing and lathering actions. A study of the prevalence of handwashing practice in medical students in their third through fifth years showed that 80 to 90 percent demonstrated a “good level of knowledge” about hand hygiene. Of this group, 80 percent washed hands regularly, but “only 41.6 percent performed effective handwashing” (Aznal, 2015). This group of students was well aware of the vital role of hand hygiene in infection control, particularly within a medical setting with vulnerable patients. Yet, even their practices, though more diligent than those of the restaurant workers in other studies, fell short in efficacy the vast majority of the time. The implications of these collected data, point towards the need for multi-pronged solutions to the breakdown of hand hygiene in critical locations.

The Limits of Oversight

In some establishments, a simple solution to the hand hygiene dilemma may simply lie in increased oversight by supervisors. However, installing individuals to observe proper hand washing often yields the Hawthorne Effect–individuals altering behaviors due to an awareness of being monitored, and then reverting to natural inclinations when no longer under observation (Boyce, 2017). Technological behavior monitoring was shown to avoid this problem, showing increased hand hygiene compliance anywhere from 6.40%-54.97% according to a German study (Meng et. al, 2019), with acceptance correlated to transparency, confidentiality, and user attitude. However, disadvantages of technological solutions for behavior monitoring included cost of installation, limited data on cost-effectiveness or healthcare-related infection rates, issues relating to acceptance, and inability to monitor all stages of handwashing for efficacy (Boyce, 2017).

Existing Solutions

Several products have come on the market in order to address insufficient or poor quality handwashing in a more comprehensive manner. CleanTech™, an automated hand and footwear washing station by Colorado-based hygiene company Meritech, purports to “remove the variability of human behavior” from handwashing. In doing so, it “eliminates 99.9 percent of harmful pathogens, all while using 75 percent less water than a traditional sink”. Agro-alimentary conglomerate Roser Group offers an integrated hygiene station called SANI-ECO for factory settings, which performs an automatic rinse of employees’ hands, provides paper towels, and then sanitizes hands and shoes, only then allowing access to the production plant. And Swiss start-up Smixin offers a touch-free hand washing station suitable for schools, all while saving water.

All of these solutions support consistent, correct handwashing practices in a variety of settings–from warehouses or factories, to restaurants, to schools. They represent eco-friendly initiatives, using 60-90 percent less water than standard sinks. In addition, they support social initiatives such as increasing community conversations around hygiene.

Getting Smart and Proactive

Soapy (https://www.soapy.care/), an Israeli start-up, designed a “smart hand hygiene station” around the co-founders’ vision of diminishing the spread of hand-borne illnesses such as diarrhea in areas with limited access to clean water. Soapy’s product, CleanMachine™, seeks to further change the game by offering the world’s first AI-enhanced smart washing station. In addition to taking the guess-work out of handwashing and saving water, Soapy’s smart-sink generates data not only on users as a group, but on individual users; the “Wash AI” technology uses a case-specific sequence audit to ensure that individual users wash hands properly, generating a “real-time handwashing quality report” for each user. For restaurants, health care facilities, and even schools, the utility of this cannot be understated. Having data on the users’ handwashing practices allows the management of these establishments to utilize both broad and targeted interventions. Soapy’s goals are to improve hand-washing efficacy, troubleshoot any problems that inhibit regular handwashing practice, provide instruction to those who may need it, and ensure across-the-board compliance with safe hand-hygiene protocols.

Looking Forward

With restaurants, schools, gyms, and other establishments beginning to “open up” as coronavirus lockdowns are lifted, the importance of ensuring that all workers wash hands
regularly and effectively is of paramount importance. This is particularly vital in food preparation and health care settings, but also in schools, fitness facilities, and all types of community centers. Soapy’s AI-enhanced handwashing station can be part of a comprehensive solution to hand-borne illnesses, including coronavirus, norovirus, diarrhea, flus, and illness-causing bacteria such as Methicillin-resistant Staphylococcus aureus and Salmonella. A truly robust and effective strategy would include not only the availability of smart-sinks, but also opportunities for easy utilization within the workplace, guidance and support from supervisors, and continued efforts to foster hand-hygiene safety awareness in an impactful and empowering manner. These solutions may be time-consuming and require consideration on the part of business owners, proprietors, and administrators. However, in our efforts to tame the coronavirus pandemic and stave off subsequent outbreaks, it’s unlikely that they have ever been more important than they are now.

References

Aznal, Sulaiha. (2015). The Lack Of Effective Hand Washing Practice Despite High Level Of Knowledge And Awareness In Medical Students Of Clinical Years. International e-Journal of Science, Medicine & Education. 4(2), 18-26. https://doi.org/10.13140/RG.2.1.1457.3926.

Boyce, John M. (2017). Electronic monitoring in combination with direct observation as a means to significantly improve hand hygiene compliance. American Journal of Infection Control. 45(5), 528-535. https://doi.org/10.1016/j.ajic.2016.11.029

Green, L. R., Radke, V., Mason, R., Bushnell, L., Reimann, D. W., Mack, J. C., Motsinger, M. D., Stigger, T., & Selman, C. A. (2007). Factors Related to Food Worker Hand Hygiene Practices. Journal of Food Protection. 70(3): 661–666. doi: https://doi.org/10.4315/0362-028X-70.3.661

Lee, H. K., Abdul Halim, H., Thong, K. L., & Chai, L. C. (2017). Assessment of Food Safety Knowledge, Attitude, Self-Reported Practices, and Microbiological Hand Hygiene of Food Handlers. International Journal of Environmental Research and Public Health. 14(1), 55. https://doi.org/10.3390/ijerph14010055

Marsh, Calum. (2020, April 13). The facemask has become covid-19’s most unlikely controversy. National Post. https://nationalpost.com/life/covid-19-face-masks

Meng, M., Sorber, M., Herzog, A., Igel, C., & Kugler, C. (2019). Technological innovations in infection control: A rapid review of the acceptance of behavior monitoring systems and their contribution to the improvement of hand hygiene. American Journal of Infection Control. 47(4), 439-447. https://doi.org/10.1016/j.ajic.2018.10.012

Pittet, D. (2000). Improving Compliance With Hand Hygiene in Hospitals. Infection Control & Hospital Epidemiology, 21(6), 381-386. https://doi:10.1086/501777

White, L. F., Dancer, S. J., Robertson, C., & McDonald, J. (2008). Are hygiene standards useful in assessing infection risk? American Journal of Infection Control. 36(5), 381-384. https://doi.org/10.1016/j.ajic.2007.10.015

LAST UPDATED: January 28, 2021

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Ilana Garon is a writer and editor specializing in health tech and education topics. She received her BA from Barnard College, MA from City College of New York, and MFA from Sarah Lawrence College. Prior to writing full time, she taught high school English in the Bronx and then was a full-time professor in the English department at Nashville State Community College. In the health tech sphere, Ilana is one of the social media managers for Prime Health CO (an innovation tank in Colorado) and a staff writer for the Sharp Index and Healthcare Scene. Her education writing has appeared in The Guardian, Education Week, Education Next, Dissent Magazine, and Huffington Post. Her nonfiction memoir, "Why Do Only White People Get Abducted by Aliens?": Teaching Lessons from the Bronx was released by Skyhorse Publishing in 2013 and re-released in 2015. Ilana is married to an active duty army officer; she and her family move regularly, but are currently stationed outside Kansas City.

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