Train-the-Trainers in hand hygiene: a standardized approach to guide education in infection prevention and control

Healthcare-associated infections (HAIs) are associated with long-term morbidity, prolonged length of hospital stay, financial losses for hospitals and patients and higher mortality [1, 2]. Hand hygiene is a core infection prevention and control (IPC) strategy with a high impact for the prevention of HAIs and for limiting the spread of antimicrobial resistance [3, 4].

There is substantial heterogeneity in hand hygiene education among IPC professionals worldwide [5]. Countries face many challenges that prevent the participation of healthcare workers (HCWs) in educational programmes, including the lack of available trained professionals and financial constraints [6, 7].

There is a recognized global, unmet need for well-trained hand hygiene observers [8]. The standardization of observations is limited by the lack of formal core competencies and certification for IPC professionals. Insufficient training of hand hygiene observers results in interpersonal differences and over or underestimation of compliance rates, limiting comparability [8‐10]. A recent systematic review found that there is a large heterogeneity in the methodology used in studies claiming to use the direct observation method. In fact, studies referring to this method used various observation schemes: the World Health Organization (WHO) tools (45%), own institutions’ tool (24%), a WHO-modified tool (21%) and a minority did not even mention the observation method used [9].

Education and training is recommended as a core component for effective IPC programmes by the WHO [10‐12]. Simulation-based training of HCWs in a practical, bedside and hands-on approach has shown to improve hand hygiene compliance and lower HAIs [13‐17].

To support countries with the capacity building for training IPC professionals, the Infection Prevention and Control programme and WHO Collaborating Centre on Patient Safety (IPC/WCC) at the University of Geneva Hospitals and Faculty of Medicine, Switzerland, developed a TTT course in hand hygiene based on the Geneva hand hygiene promotion strategy at the origin of the WHO multimodal strategy [4, 18]. The potentially positive impact of hand hygiene training on improved knowledge of IPC practitioners was first described in a pioneering TTT pilot event organised by the IPC/WCC in Brazil in 2015 [19]. This course was then modified to become more interactive following feedback from course participants and became the TTT model described in this paper.

Globally, capacity building of HCWs has the potential for enhancing networking and collaboration among professionals and for sustaining improvement. The TTT approach aims to reach larger audiences through subsequent training led by former course participants themselves. There is no prior publication that describes a formal course for training IPC practitioners in hand hygiene including training of auditors in hand hygiene compliance monitoring using direct observation methods.

We describe a standardized approach to hand hygiene training using a “Train-the-Trainers” (TTT) course for IPC professionals and evaluate its impact on participants knowledge in six countries.

Between June 2016 and January 2018 the IPC/WCC held seven TTT courses in five middle-income countries (Iran, Malaysia, Mexico, South Africa and Thailand) and one high-income country (Spain). Fifteen TTT courses were then organized by previous course participants between 2017 and 2019 (Fig. 1). Here we describe the results from the initial seven courses (from June 2016 to Jan 2018).

A total of 305 IPC professionals completed the TTT programme. There was no withdrawal from the course. However, eight participants did not complete the pre-course questionnaire and six participants did not complete the post- course questionnaire due to logistical reasons (i.e. arriving late at the course venue or having to leave earlier). They were excluded from the analysis because we were not able to compare the participants’ knowledge acquisition before and after.

The average number of IPC professionals participating in a TTT course was 43, ranging from 21 to 81. Malaysia had the highest number of course attendees (n = 81) with participants from all 13 states and 2 federal territories in the country and 4 from Singapore. Thailand had participants (n = 53) from 11 different provinces; Jalisco (Mexico) had participants (n = 49) from 4 different cities within the State and Puebla (Mexico) had participants (n = 35) from 4 different States: Queretaro, Puebla, Jalisco and Mexico City. Iran had participants (n = 36) from 10 different cities in the country. South Africa had participants (n = 30) from 15 different (mostly English) speaking countries in Africa (Cameroon, Democratic Republic of Congo, Egypt, Ethiopia, Kenya, Liberia, Malawi, Namibia, Nigeria, Rwanda, Senegal, Sierra Leone, South Africa, Uganda, and Zimbabwe). Spain had participants (n = 21) coming mainly from Madrid and Barcelona. In total, participants from more than 20 countries were trained.

The majority of participants were nurses (n = 196; 64.2%), while physicians (n = 53; 17.3%) and other professionals (epidemiologists, quality assurance professionals and hospital managers (n = 56; 18.3%) were included.

Most participants came from HCFs that engaged in the annual global WHO campaign ‘SAVE LIVES: Clean Your Hands’ and celebrated the 5th of May World Hand Hygiene Day (https://​www.​who.​int/​gpsc/​5may/​registration_​update/​en/​) (Spain 100%; South Africa 67%; Puebla (Mexico) 69%; Jalisco (Mexico) 75%; Malaysia 85%; Iran 73%; Thailand 33%).

The great majority of participants reported to have completed the Hand Hygiene Self-Assessment Framework (HHSAF)

(https://​www.​who.​int/​gpsc/​country_​work/​hhsa_​framework_​October_​2010.​pdf): Spain 100%, South Africa 66.6%, Puebla (Mexico) 57.1%, Malaysia 85% and Iran 66.6%; but less frequently in Jalisco (Mexico) 44.9% and Thailand 45.2%.

Overall, we observed a significant improvement in knowledge of TTT programme participants across countries and regions (Fig. 2). This improvement was statistically significant (P < 0.05) in all countries between the pre- and post- phases (Table 1). Puebla (Mexico) had the largest improvement between the pre- and post-TTT course phases (22.3%). This was followed by Malaysia (21.2%), Mexico (Jalisco) (20.2%), Thailand (18.8%), South Africa (18.3%), Iran (17.5%) and Spain (9.7%). Spain had the highest pre- and post- overall scores. Thailand had the lowest pre- and post- overall scores.

The launch of a hand hygiene simulation-based educational programme resulted in a significant increase in participants knowledge for all HCWs in a range of countries worldwide as measured by a pre-post questionnaire.

This is the first report on a worldwide TTT programme on key principles for best practices in hand hygiene showing a positive effect on knowledge. Despite the diverse context of languages, healthcare systems, educational background, resources and cultures, our study demonstrates the feasibility of a TTT educational model based on the WHO Multimodal Hand Hygiene Improvement Strategy [23] in different healthcare settings around the world. Our results expand and strengthen the findings from the first pioneering TTT event organised by the IPC/WCC in Brazil in 2015 [19]. Bellissimo-Rodrigues et al. [19] reported that an intensive 3-day TTT course in hand hygiene increased the knowledge of IPC professionals (n = 33) from 77.0% in the pre- to 89.7% in the post-training phase (P < 0.001). They have made available all the video recorded presentations in Portuguese and in English and these received a lot of attention (https://​brasil.​aesculap-academy.​com/​). The successful results from the first TTT in Brazil encouraged the replication of 25 hand hygiene courses with more than 800 trained IPC professionals nationwide.

The course methodology (i.e. simulation, scenario-based, bedside, hands-on training and individual experiences) showed improvement and the adaptability of the programme to the local context according to levels of progress, resources available and local culture. Simulation-based education has been proven to be an effective form of learning which leads to improved and lasting results [28‐30] and is associated with decreased HAI rates and increased hand hygiene compliance [13‐17]. The TTT promotes an interactive learning environment in small groups and encourages the application and synthesis of knowledge within a clinical context.

The benefit of the TTT programme was attested by improved in post-test scores. Our data show that overall the TTT course on hand hygiene best practices, WHO methodology for hand hygiene observations and clinical scenarios to assess My 5 Moments for Hand Hygiene was associated with significant improvement across all sites. The highest overall pre- and post-test scores were recorded in Spain and followed by Iran, while Thailand had the lowest scores. Spain is the only high-income country and this may possibly influence the high scores. We attributed the higher scores of IPC professionals in Spain and Iran to more appropriate IPC training and higher level of education before IPC specialisation [6, 7].

Hospital Infection Committees have been a legal obligation for all hospitals in Spain since 1987 [31] and a national hand hygiene programme has been promoted by the Ministry of Health Social Services and Equality since 2008 [32]. The Iranian Nosocomial Infection Surveillance System (INIS) was established in 2007 [33]. The findings of high scores from Iranian participants confirm the previously described acceptable knowledge and attitude scores of HCWs in Iran about hand hygiene [34]. On the other hand, in Thailand, the point prevalence of HAIs has been estimated at 6.5% with, on average, 250,000 patients affected each year [35]. In contrast, hand hygiene compliance rates of < 10% have been reported in the country [36, 37], clearly indicating that improvement of HCWs knowledge about HAIs and hand hygiene is needed. Our findings will stimulate the launch of coordinated educational activities that ultimately impact on improved hand hygiene compliance in countries worldwide.

Overall, the achievement of a greater improvement following the training programme was recorded in Mexico and Malaysia while greater knowledge improvement was achieved in Mexico and South Africa. Knowledge of course participants improved significantly after the TTT interventions across all sites, also it did not reach statistical significance between the pre- and post-test phases in Spain. Similarly, Allegranzi et al. [21] reported substantial progress and improvement with hand hygiene in low-and-middle-income countries (LMICs) than in high-income countries. In HCFs where basic IPC education and hand hygiene resources are scarce, the contribution of training could lead to immediate progress [21]. In addition, there is a need to increase training opportunities in IPC to expand the spread of educational training programmes to reach larger audiences including resource-limited settings. Training on hand hygiene is a priority across LMICs, where the educational needs of IPC professionals are not being met as they are assigned to the role with no previous training.

In Malaysia, the Ministry of Health (MoH), has set improved hand hygiene best practices as one of the priorities. Since 2013, the MoH has mandated all public HCFs to complete the WHO Hand Hygiene Self-Assessment Framework (HHSAF), a key tool aimed at tracking the level of progress of HCFs to improve best practices [38]. Following the TTT hand hygiene training in Malaysia, the IPC/WCC has been officially approved as a Continous Professional Development provider for all physicians in Malaysia to support with specialised education. Not all countries have the resources to organize local hand hygiene training modules: LMICs, in particular, tend to rely on international organizations to provide education and training. Training in hand hygiene multimodal improvement strategy should become part of IPC education and training certificates worldwide, as is the case already with the “European Certificate for Infection Control” established by the European Society for Clinical Microbiology and Infectious Diseases [5, 12, 13]. In addition, hand hygiene training should be part of the curricula of health sciences undergraduate courses.

Our data show that less than half of the participants across all countries, apart from Spain, were able to recognize correctly all My 5 Moments for Hand Hygiene in the practical scenario-based type of questions in the pre-test survey, regardless of the years of experience in IPC (see Additional file 4, figure on case scenario technical type questions to identify My 5 Moment for Hand Hygiene). Our findings confirm previous studies documenting low knowledge and adherence to the WHO 5 Moments for Hand Hygiene [21, 28]. The widespread nature of the challenges with hand hygiene direct monitoring and recognizing the correct 5 Moments highlights the need for standardized approaches to training IPC professionals. A recent multicenter study on hand hygiene improvement reported that Moment 2 before aseptic procedure and Moment 5 after touching patient’s surroundings were mentioned the least by study participants [29].

A structured and systematic approach to observation that entails auditor’s expertise and preparedness would be more rigorous at aiming to capture all Moments during an audit [9, 35, 36]. The hand hygiene programme in Geneva [39], an institution with a long history of hand hygiene promotion, [20, 32] uses experienced and validated hand hygiene observers to monitor compliance. Similarly, Hand Hygiene Australia requires hand hygiene auditors to attend auditor training, be validated and demonstrate related competencies to ensure standardization of auditors [40, 41].

Despite the proven success of the TTT programme, our study has limitations. First, the study had an observational design and course participants were selected from local organizers based on various reasons with no specific inclusion criteria. Therefore, selection bias may have reduced the generalizability of the results. Second, this was a quasi-experimental design; there was no control group and only pre- and post-measures were available. Furthermore, when assessing sustainability, other events in time may have confounded the results. However, the TTT serves as a guide for future interventions and as a starting point for other educational IPC interventions. Hand hygiene compliance before and after attending a TTT course was not monitored, and thus it remains unknown whether these events were associated with improved compliance. Subsequently, the association between improved knowledge scores after attending a TTT and HAI rates was out of the scope of the current study. Noteworthy, the pre-post and follow-up measures were based on a self-reported questionnaire tool. This limitation was minimised by ensuring that repeated measurements (follow-up phase) were carried out. Finally, the TTT requires professionals to take at least 3 days from work, and, in hospitals with limited human resources, attendance may be cumbersome and TTT requires some financial resources to be available.

Of future research interest is the evaluation of the impact of TTT training to improve hand hygiene compliance and best practices among HCWs and ultimately to reduce HAIs.

In conclusion, the Geneva TTT hand hygiene programme is a unique, comprehensive programme that can be used and adapted in an international scale for improvements in hand hygiene knowledge and best practices (the reader can access video reports from TTT courses, see [42]). Our findings suggest that the TTT is a successful method for expanding the reach of standardized hand hygiene training packages at local and national levels. This approach provides a blueprint in countries where hand hygiene training is still absent; it also allows to improve knowledge in countries were national promotion strategies are in place. Following the initial TTT courses in the aforementioned countries, a number of countries replicated TTT events with former course trainees acting as instructors for consecutive courses. To date, Brasil, Iran, Malaysia, South Africa, Mexico and Spain have replicated the TTT course in their countries. This demonstrates not only the capacity of the programme to reach large numbers, but also the sustainability of the programme to deliver future programmes by trained participants themselves in their own countries.