Overview
Background
Hand washing, or hand hygiene is one of the most essential, simple, inexpensive yet effective means to remove viruses, bacteria, micro organisms, dust, dust, or any other harmful substances. This in turn also ensures reduction in the transfer of said unwanted substances.
With the recent coronavirus disease (COVID-19), an infectious disease that attacks the respiratory system, it has become essential for all individuals to maintain proper hand hygiene. One of the most effective ways to protect oneself and others from this infection is to wash one’s hands with soap and water or an alcohol based rub frequently while not touching one’s face or other surfaces.
“On average healthcare providers clean their hands less than half of the time they should. On any given day about one in 31 hospital patients has at least one healthcare-associated infection.”
Taking into consideration COVID-19 and frontline healthcare workers, it is imperative to maintain rigorous infection control protocols beyond the optimal use of personal protective equipment. “Imaging is crucial for assessing the severity and progression of COVID-19. Radiographers are amongst the first-line health professionals that may be exposed to infected persons.”
It is this premise that led to selection of radiographers as the target audience. Since hand hygiene is one of the most cogent means of curbing the spread of the COVID-19 infection, it has been chosen as the targeted behaviour.
The illustration below shows the movement of 80+ imaging staff through The Royal London Hospital, on an average day. It further verifies the need to ensure optimal hand hygiene to limit the spread of infections through various sections of a hospital.
Movement of 80+ imaging staff at The Royal London Hospital
Evaluating hand hygiene around the world
The first step was to study and evaluate hand washing systems in hospitals in India and the UK. While the overall set-up in both the countries were similar, the UK had an extra set of posters alerting individuals about what zone they were entering and related protocol.
Posters at the entrance of different zones of The Royal London Hospital during COVID-19
The hand washing set-up at Christian Medical College Hospital in Vellore, India
The hand washing set-up at The Royal London Hospital
While the set-ups may have slight differences in the positioning of these hand hygiene stations within the hospitals and differences in the material to dry hands post-washing (paper towels vs. woven cloth towels), both the countries follow the same WHO protocols around the 5 moments of hand washing and the steps to wash hands, and have these protocols are pasted across both hospital walls to ensure recall.
The 5 moments of hand hygiene, followed by the method to wash hands and an example of its placement
The My 5 Moments for Hand Hygiene approach defines the key moments when health-care workers should perform hand hygiene. This evidence-based, field-tested, user-centred approach is designed to be easy to learn, logical and applicable in a wide range of settings. This approach recommends health-care workers to clean their hands: before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and, after touching patient surroundings.
Poster displaying the method to wash hands at Christian Medical College Hospital in Vellore, India
It was also interesting to look at how hand washing was taken to the world with the pandemic and a series of instances of such stations were captured and analysed. This helped understand attitudes, inspirations, motivations and behaviours of people across the globe indulging in hand hygiene.
Glossary of images of hand hygiene set-ups across the globe
It was then time to shift the focus back on the target audience: Radiographers. Interviews were carried out with radiographers in India (1 person) and in the UK (7 people). 5 out of 8 respondents mentioned how they were not fully aware of/adhering to the 5 moments of hand hygiene. When probed further, it was discovered that most individuals washed hands after interacting with patients or if their hands were soiled but seldom ensured to sanitise their hands when entering new departments or zones within a hospital.
Further analysis on the subject
The first step was to understand the scenario that was being specified. Who the actors were, what the action was, the context, the target and the time or situation where these actions were to take place. For this, an AACTT framework was filled out.
The AACTT framework for the given problem
The next step was to understand what kind of behaviours were displayed by these actors - what their automatic and reflective motivations were, what kind of psychological and physical capabilities were present in the system and the physical and social opportunities present.
The COM-B model illustrated above was formed through all the insights that were gained through primary research. It helped identify behavioural patterns that formed the basis of the solution proposed.
Building the Solution
An extensive analysis on the behaviours and motivations of radiographers was carried out to understand how to solve for the complex problem of ensuring hand hygiene while going through various departments/sections/wards of a hospital. The key barriers and facilitators were also analysed to feed what would become the final solution.
Behavioural drivers for radiographers from primary research
It was also essential to understand the culture followed by radiographers to be able to tap in to it and also ensure that the solution was built into their lives in a way that encouraged to be used rather than waited to be tricked/circumvented.
Culture of the backstage radiographer
A co-creation workshop was also conducted with a group of 7 radiographers, i.e., invested participants and end-users. The idea was to design build on inputs from end-users, playing a central role from beginning to end. It would ensure rapid ideation and collaborative conversations.
The ideas that came up during the co-creation workshop were documented and analysed. This helped understand expectations as well as behaviours.
Simultaneously, analogous studies were carried out to understand instances of successful behaviour change. There were lots of areas of inspiration that looked at people behave in a specific suggested manner by incorporating various aspects of behaviour change.
Based on the workshop responses, the interviews part of primary research and understanding of behaviours, ideation towards the final solution was started. A white- boarding session followed, where a myriad of ideas were generated which were then dot voted upon, to shortlist concepts that could be taken forward.
While ideating, the most important factors that were being considered beyond the original scope were how to reduce cognitive load, make use of familiarity, reward people for behaving in a certain manner, and to reduce obstacles (what are we asking people to give up?). Apart from this, a framework to design along was also built.
Having delved into and gone through the entire process above and analysed the research, certain behavioural strategies were shortlisted.
It was after this, that the final solution started being built.
The Solution
The solution was a combination of visual stimuli, audio cues, salience and competitive scoring.
How it works
Radiographers currently have to swipe their access cards on doors to enter wards. Keeping a sanitisation station post entry to a ward would require the radiographer to leave the X-ray cart, sanitise their hands, and then get back to the cart. This break in the flow immediately resulted in the chances of low adherence. Also, audio and visual cues would have to be built at every ward entrance and would entail higher cost of equipment, infrastructure updates and would require time.
A small update to the X-Ray carts, instead, could tackle the aforementioned issues and be in close proximity to the user, ensuring ease of access.
Adherence would be taken care of by adding an element of competitive gamification, persuading the user to sanitise their hands, leading them to a reward. The audio and visual cues work towards building a recognition pattern, upon entry to each ward, and go on for 20 seconds, before the radiographer approaches any patients. Having said this, it was imperative to ensure that the cues are prominent enough for radiographers to notice, but subtle enough to ensure it is acceptable within a hospital.
The reward system built is a small yet effective one. Just a cup of coffee, or a coupon for a cup of coffee at the end of the week, for a person who’s sanitised their hands the most, reduces the risk for people trying to ‘trick’ the system. Also, the entire process of giving the cues, using the sanitiser and adding a point on the score board only happens when a radiographer crosses different wards. There is no addition of points if the cart is stationary, or has not entered any new wards.
The following storyboard illustrates the entire solution.
A proximity sensor was made use of at this moment to automatically open the doors to a ward, to ensure lesser surfaces are touched while entering and exiting these wards.
The audio and visual cues start after the user enters the ward. There is a sanitiser holder on the cart that has a subtle light-show to bring the sanitiser to the user’s attention. The idea is to keep switching these light patterns from time to time to ensure it doesn’t lead to too much familiarity followed by dis-engagement.
A quick audio cue to recall the positive feedback loop
The final reward
System Flowchart
Building the Prototype
An Arduino prototype along with a clay model play were created to showcase the entire concept.
A clear understanding of how the entire back-end system would work need to be established. The first step was to create a step-by-step breakdown of this entire process.
This was then further refined to understand the specifics of the backend interactions to be built that would complete the overall infrastructure.
Arduino Sketches
Conclusion
The overall aim was to ensure radiographers sanitise their hands more often, specially while entering new wards and departments in a hospital, reducing the risk of cross-contamination. The entire process of understanding user behaviour towards building for behaviour change had to be thorough to ensure it would have a definitive and positive impact. While it is easy to make suggestions to an outside system, it was essential to involve the end users to make sure that the solution proposed would take into consideration all the granular aspects of these users’ behaviours, their psychology, their cultures and the hospitals in general. It was also built to ensure scalability to different parts of the world where all these aspects would have a great deal of dissimilarity and variance.
One of the major things to take into account were the strengths and weaknesses of the system proposed. For this, a SWOT analysis was conducted.
There was also feedback taken from radiographers and doctors in India and the UK. It was extremely reassuring to receive positive feedback towards the outlined behaviour change solution.
Future Scope
While the solution takes into consideration behaviour change and rewards users based on it, a budgetary evaluation would need to be carried out to ensure all carts could be equipped with the proposed solution, along with a budget for the rewards.
A clear vision for the revisions in processes and daily activities within the hospital premises would also be required. The solution can later be extended to other hospital personnel based on their behaviour patterns and associated equipment.
However, a clear understanding of the entire hospital network and its nuances will be required.
It will also be essential to build further on the strengths that were identified and also reduce the weaknesses and threats that are posed to/with the proposed solution.
While the feedback was positive, it needs to be brought to light that the feedback taken was remotely, without the presence of the actual setup, but simply by sharing the concept and associated videos. A thorough usability testing would need to be carried out to scale this solution and take it to real hospitals with actual users.