Hand hygiene in Dutch hospitals: compliance and determinants.

Today I chaired a meeting that reported and discussed the results of a comprehensive study on hand hygiene among health care workers in IC units and surgical wards in Dutch hospitals. Hand hygiene is of utmost importance in prevention of hospital acquired infections. Earlier studies suggest that hand hygiene compliance is less than optimal, to say the least, with compliance rates of about 50%.
In this age of high tech medicine, simply adhering to basic hand hygiene instructions to prevent ill health seems so obvious. But the compliance rates indicate that washing your hands when this is necessary and according to the instructions may not be that simple and straightforward.
The study that was presented included observations in Dutch hospitals to get objective assessments of hand hygiene compliance (since most compliance data are based on self reports, which may obviously be biased), and a Delphi study and a cross-sectional survey among doctors, nurses, and trainees to explore potential determinants of hand hygiene compliance and possibilities to promote better compliance.

The study was led by Dr. Ed van Beeck of the Department of Public Health, Erasmus University Medical Center (http://www.erasmusmc.nl/MAGE/), and Vicky Erasmus of the same department (http://survey.erasmusmc.nl/intern/pwp/front.php).

The study showed that observed hand hygiene compliance was even worse than expected based on self-reports. Compliance rates were below 30% overall. Especially worrying was the extremely low hand hygiene compliance before patient contacts, with hospital workers showing good hand hygiene in only a few % of the events when hand washing was needed. Somewhat better hand hygiene was observed after patient contacts, especially when the health care worker had been in contact with bodily fluid. Differences in compliance were found according to the kind of hospital investigated (small peripheral hospitals > university hospitals) and the hospital unit (surgical ward > IC unit). The observations also showed the frequency of events that require hand hygiene behavior. Basically, if appropriate hand hygiene indeed performed before or after each event that officially requires hand washing or hand alcohol, health care workers would spend a substantial part of their day ‘cleaning’ their hands. Such a time investment may just not be possible.

The exploration of potential determinants indicated that lack of knowledge of the importance of hand hygiene (among doctors only), low perceived control (i.e. most probably related to the time restraints) regarding hand hygiene practices, lack of positive descriptive norms regarding hand hygiene (among nurses only) were associated with low compliance. Furthermore, doctors were more likely to show higher compliance if they thought lack of hand hygiene could have severe health consequences for themselves, while nurses were more likely to be compliant if they perceived the potential consequences for their patients as severe.

Interventions to improve hand hygiene may include educational activities to further improve knowledge of hand hygiene recommendations, and to further stress the importance of hand hygiene practices, but should also include changes in the physical and social environments that will make compliance easier and normative.

The study was financially supported by the Netherlands Organisation for Health Research and Development, ZonMW (http://www.zonmw.nl/).

TIGO: a new national inter-institutional institute for research on aging.

We live in an aging world. Within the next decades in some countries over half of the population may be over 65 years of age, i.e. the age that for many years meant retirement.

Such an aging population faces us with many challenges, often related to health. Maybe the most striking and relevant examples are to do with the work force and health care costs. In order to maintain and ensure a large enough work force to maintain economic prosperity in an era of an aging population, people should be able to remain economically active until later age. To prevent skyrocketing costs for health care, elderly people should be encouraged to adopt and maintain healthy lifestyles to prevent or delay disease and disability to realise a further compression of morbidity in the latest phase in life. In order to enable elderly people to keep out of health care institutions as long as possible, health and care monitoring and facilitating devices such as domotics (http://en.wikipedia.org/wiki/Home_automation) solutions should be developed and tested for their true effectiveness.

These are the challenges that will be met by TIGO (http://www.ti-go.nl/home/), the Dutch national research institute for healthy aging, in which most University Medical Centers in the Netherlands, important research and health care institutes such as TNO, NIVEL and TRIMBOS, as well as key R&D departments of multinationals such as Philips and Unilever have joined forces.

Today the business plan for TIGO was presented to Mrs. Jet Bussemaker, the Dutch secretary of state for health, welfare and sports (http://www.minvws.nl/organisatie/staatssecretaris-bussemaker/) during a symposium. After a series of short keynotes the secretary of state congratulated the TIGO founders with their initiative and confirmed that the TIGO plans fitted well with her own ambitions to improve prevention and care for the elderly.

Dr. Jantine Schuit inaugurated as professor of health promotion and policy.

Last Friday Jantine Schuit gave her inaugural address as professor of health promotion and policy. Her chair is at the Department of Health Sciences of the VU university, one of the partners of the soon-to-be interfaculty EMGO Institute for Health and Care Research Institute (EMGO+) (http://www.emgo.nl/). During her presentation she argued that health promotion should be based on creating environmental opportunities for healthful behaviours and barriers for un-healthful habits, next to health education. Such environmental changes are dependent on policy initiatives at the (inter)national, regional and local levels. Prof. Schuit’s ambition is to help to narrow the gap between health scientists and health policy makers, to contribute to research on policy initiatives to promote healthful behaviour, and to develop master education on these topics. Please see http://www.ijbnpa.org/content/5/1/16 for a paper on these issues published in the International Journal of Behavioral Nutrition and Physical Activity (http://www.ijbnpa.org/).

Explaining socioeconomic status differences in health behaviors.

Today Carlijn Kamphuis defended her thesis entitled ‘Explaining socioeconomic inequalities in health behaviors: The role of environmental factors’.
Inequalities in health according to income, level of education or other socio-economic status indicators have and are being observed across the world. Poorer and less educated people live shorter lives and have higher risk for a range of diseases and health threats. This is also true in a rather egalitarian country like the Netherlands.
One of the reasons why people from lower socioeconomic status groups are less healthy is the fact that these people on average live less healthy lives. Smoking prevalence, lack of physical activity and un-healthful dietary habits are more prevalent. The next question , of course, is to try to find out why that is the case. This is what Carlijn Kamphuis set out to explore in her doctoral thesis research: why do we find socioeconomic differences in physical activity and dietary habits? Her hypothesis was that contextual, or environmental factors, rather than personal factors are the main determinants. More explicitly, she especially explored whether neighbourhood physical environmental factors were important, i.e. the availability and accessibility of opportunities to be physically active and eat a healthful diet.
The thesis contains a series of papers that have been published in different international scientific journals, including two systematic reviews, qualitative research and quantitative analyses of data from the Globe study.
The results indicate that neighbourhood factors do explain only a small proportion of socioeconomic inequalities in health behaviors. It appears that individual cognitions such as attitudes and intentions, and social environmental factors, such as social modelling and support are more important.

For further reading:

• http://www.ncbi.nlm.nih.gov/pubmed/18791047?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum


• http://www.ncbi.nlm.nih.gov/pubmed/18182936?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum


• http://www.ncbi.nlm.nih.gov/pubmed/17010219?ordinalpos=8&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum


• http://www.ncbi.nlm.nih.gov/pubmed/17381942?ordinalpos=7&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum


• http://www.ncbi.nlm.nih.gov/pubmed/16815073?ordinalpos=9&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
  

Dietary guidelines and the obesity epidemic

In a recent issue of the American Journal of Preventive Medicine (2008;34:234-240; http://www.ncbi.nlm.nih.gov/pubmed/18312812?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum) Paul Marantz, Elisabeth Bird and Michael Alderman from the Department of Epidemiology and Population Health of the Einstein College of Medicine, New York, published a paper in which they call for higher standards for dietary guidelines. Their paper argues that dietary guidelines are often based on indirect and sometimes weak evidence, that resulting guidelines may cause harm instead of health benefits, and that dietary guidelines may better be avoided if not based on adequate evidence. They use the fat reduction guideline as an example. In the 1980s and 90s dietary recommendations in most countries included recommendations to reduce dietary fat intake to less than 30 or 35 percent of total energy intake. The authors argue that this recommendation was not based on firm evidence (i.e. total fat is not an issue, type of fat is more important) and that the recommendation has issued changes in peoples diets and in food production and innovation towards less fat, but also towards more sugar and other carbohydrates, leading to higher calorie intakes, and thus possibly contributing to the obesity epidemic. A comment on their paper by Steven Woolf and Marion Nestle was published in the same issue (http://www.ncbi.nlm.nih.gov/pubmed/18312816?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus).

Local produce and the 100 mile diet

'Normal' farming, with the use of loads of fertilizer, long transport distances from farms to food industry to retail to consumers causes lots of wasted energy and leaves a huge carbon foodprint. I reported here earlier on the 100 mile diet, initiated by Alisa Smith and J.B. MacKinnon, i.e. "local eating for global change" (http://100milediet.org/). The 100 mile diet may be much easier for more people when 'skycraper framing' is applied: vertical farming right in the middle of urban areas.

Vertical framing is a possible means to grow grains, fruits and vegetables and fruits, raise poultry and pork, use their waste as fertilizer, and use city waste water for irrigation. A vertical farm could potentially reduce the fossil-fuel use and emissions associated with farming. Year round growth and harvesting could be possible, and consumers could get real fresh, organic produce near their city homes.

Vertical or skycraper farming (http://www.sciam.com/article.cfm?id=growing-vertical-skyscraper-farming or http://en.wikipedia.org/wiki/Vertical_farming), i.e. a multi-storey building with integrated crop and animal farming, is one of the ideas for Earth 3.0 (http://www.sciam.com/article.cfm?id=introducing-earth-3-point-0), as described in the September 2008 issue of Scientific American. In these Earth 3.0 terms, Earth 1.0 was the earth that existed for billions of years untill well into the 18th century. Earth 2.0 came into existence with the industrial revolution leading to enourmous tehnological achievements and health benefits resulting in longlevity and prosperity for at least the richer part of the world.

Earth 3.0 should combine the prosperity of Earth 2.0 for all with the sustainability of Earth 1.0. With a large majority of the world population living in cities within the next few decades, vertical farming may contribute to a more sustainable and healthy food producion chain.

The technology for vertical farming does exist and the idea has received quite a bit of media attention lately (see http://www.verticalfarm.com/Default.aspx).

Literature and medicine

Last Thursday I attended a symposium on 'addiction'. This symposium in the literature and medicine series focussed on the role of addiction in literature, in poetry, fiction, song lirics et cetera (see http://www.vu.nl/nl/nieuws-agenda/nieuws/2008/jul-sep/expositie-aan-de-ketting-verslaving-en-afkicken.asp). With bright, funny, insightful and sharp contributions of Armand Girbes ( http://armandgirbes.com/), Aafke de Groot, Jelly Brouwers, Arko Oderwald, Stefan Brijs and a musical intermezzo of Rick de Leeuw and Jan Hautekiet, it was a great afternoon. The symposium also introduced the book "Aan de Ketting" ('Chained') on addiction in literature edited by Arko Oderwald, Koos Neuvel and Willem van Tilburg.

Some citations: 'The desire for a cigarette is the desire itself" (Rutger Kopland), and "Addiction is a sanctuary without a roof" (Jelly Brouwers)