|Year : 2021 | Volume
| Issue : 3 | Page : 158-164
Comparing the effects of face-to-face and video-based educations on hand hygiene knowledge and performance among mothers in neonatal intensive care unit: A randomized controlled trial
Zhilla Heydarpoor Damanabad1, Leila Valizadeh1, Mohammadbagher Hosseini2, Marzieh Abdolalipour3, Mohammad Asghari Jafarabadi4
1 Department of Pediatric Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
2 Pediatric Health Research Center, Tabriz University of Medical Sceinces, Tabriz, Iran
3 Nursing Scientific - Management Research Center, Department of Al- Zahra Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
4 Department of Epidemiology and Biostatistics, Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
|Date of Submission||30-Oct-2020|
|Date of Decision||25-Apr-2020|
|Date of Acceptance||30-Dec-2020|
|Date of Web Publication||23-Jul-2021|
Department of Pediatric Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz.
Source of Support: None, Conflict of Interest: None
Background: Hand hygiene is the first step in nosocomial infection control. However, most people have limited knowledge about proper hand hygiene. Objectives: This study aimed at comparing the effects of face-to-face education (FTFE) and video-based education (VBE) on hand hygiene knowledge and performance among mothers in neonatal intensive care unit (NICU). Methods: Using a three-group design, this randomized controlled trial was conducted in March–December 2019 in Al-Zahra University Hospital, Tabriz, Iran. In total, 132 mothers of neonates in NICU were recruited to the study through convenient sampling and were randomly allocated to either an FTFE group, a VBE group, or a control group. Data were collected before and 3 days after the intervention using a Maternal Hand Hygiene Knowledge Questionnaire and a Maternal Hand Hygiene Performance checklist. Data analysis was performed using the Chi-square test, paired-samples t-test, one-way analysis of variance, and analysis of covariance. Results: The mean scores of hand hygiene knowledge and performance significantly increased in both the intervention groups (P < 0.05) but did not significantly change in the control group (P > 0.05). There were no significant differences among the groups regarding the pretest mean scores of hand hygiene knowledge (P = 0.24) and performance (P = 0.26), while the posttest mean scores of hand hygiene knowledge and performance in both the intervention groups were significantly greater than the control group (P < 0.05). Conclusion: Both FTFE and VBE are effective in significantly improving hand hygiene knowledge and performance among the mothers of neonates in NICU.
Keywords: Education, Hand hygiene, Knowledge, Neonatal intensive care unit, Performance
|How to cite this article:|
Damanabad ZH, Valizadeh L, Hosseini M, Abdolalipour M, Jafarabadi MA. Comparing the effects of face-to-face and video-based educations on hand hygiene knowledge and performance among mothers in neonatal intensive care unit: A randomized controlled trial. Nurs Midwifery Stud 2021;10:158-64
|How to cite this URL:|
Damanabad ZH, Valizadeh L, Hosseini M, Abdolalipour M, Jafarabadi MA. Comparing the effects of face-to-face and video-based educations on hand hygiene knowledge and performance among mothers in neonatal intensive care unit: A randomized controlled trial. Nurs Midwifery Stud [serial online] 2021 [cited 2022 May 18];10:158-64. Available from: https://www.nmsjournal.com/text.asp?2021/10/3/158/322222
| Introduction|| |
Nosocomial infections are among of the major health challenges throughout the world. By definition, nosocomial infections are infections acquired due to stay in hospitals or other health-care settings. Estimates show that 7 out of every one hundred hospitalized patients in developed countries and 15 out of every one hundred hospitalized patients in low- and middle-income countries develop at least one nosocomial infection. The burden and the risk of nosocomial infections are significantly higher among high-risk patients such as those in intensive care unit (ICU), particularly neonates in neonatal intensive care unit (NICU). In NICU, neonates usually have prolonged hospital stay and immature immune system and hence are more prone to nosocomial infections.
One of the main routes of infection transmission in health-care settings is through hands., Therefore, the World Health Organization and the Centers for Disease Control and Prevention recommend hand hygiene as the first, simplest, and most cost-effective technique for infection control. Health-care providers, patients, and their family members in health-care settings need to closely adhere to hand hygiene guidelines in order to prevent and minimize nosocomial infections.
Currently, NICU policies encourage parents’ active involvement in care delivery to their neonates in NICU. Thereby, they can play a critical role in nosocomial infection prevention through their close adherence to hand hygiene guidelines., However, evidence shows that health-care providers and patients’ family members in health-care settings have limited adherence to these guidelines,, and hence, poor hand hygiene is currently a major challenge in health-care settings.
A significant factor contributing to poor adherence to hand hygiene guidelines and nosocomial infection transmission through hands is lack of knowledge about hand hygiene techniques among patients’ family members. Therefore, providing them with education can improve their hand hygiene practice and reduce the risk of nosocomial infections., Active involvement of mothers in the process of care delivery to their neonates in NICU also highlights the importance of providing them with quality education about hand hygiene in order to minimize the risk of nosocomial infections.
There are various direct and indirect methods for providing patient and family education. The advantages of indirect methods such as video-based education (VBE) include the possibility of providing education with limited costs and limited number of staff and the possibility of sending quick educational messages to a large number of people. The use of VBE helps learners acquire better understanding about abstract and unfamiliar concepts. The most important direct method for patient and family education is face-to-face education (FTFE). In this method, instructors can provide learners with opportunities to actively engage in learning in real situations, ask their questions, discuss their concerns, independently manage their conditions, and correct their health-related misconceptions.
Previous studies into the effects of education on hand hygiene were mostly on health-care providers,, and there are little data about the effects of education on hand hygiene among family members. Therefore, this study was conducted to fill this gap.
The aim of this study was to compare the effects of FTFE and VBE on hand hygiene knowledge and performance among mothers in NICU.
| Methods|| |
Design and participants
This randomized controlled trial was conducted in March–December 2019 in Al-Zahra University Hospital, Tabriz, Iran, using a three-group design. Participants were 132 mothers of neonates in NICU who were recruited to the study through convenient sampling. Inclusion criteria were having a newly admitted neonate in NICU with an NICU stay of <1 day, active involvement in care delivery to the neonate, agreement for participation, no wounds or problems in hands, no sensory problem, no work experience as health-care provider, basic literacy skills, and no experience of hand hygiene education. Exclusion criteria were voluntary withdrawal from the study and neonatal death or discharge from NICU during the first 3 days of NICU stay.
Sample size was calculated using the formula for the comparison of two means and the results of a pilot study into the effects of FTFE on hand hygiene knowledge among 30 eligible mothers. With a confidence level of 0.95, a power of 0.90, a µ1 of 1.37, a µ2 of 0.77, an S1 of 0.89, and an S2 of 0.72, sample size was determined to be forty per group. Considering possible dropout rate, the sample size increased to 44 mothers per group (132 in total).
Eligible participants were randomly allocated to either an FTFE group, a VBE group, or a control group through the block randomization method with block size of three. The allocation sequence was generated by the statistical advisor of the study and using an online randomization service (www.randomizarion.com). The first author allocated participants to the groups using the generated allocation sequence. To conceal the allocation sequence, the numbers generated for random allocation were provided to the first author one by one.
Data collection instruments were a maternal and neonatal demographic characteristic questionnaire, a researcher-made Maternal Hand Hygiene Knowledge Questionnaire, and a researcher-made Maternal Hand Hygiene Performance checklist.
The demographic characteristic questionnaire included items on participants’ age, education level, employment status, number of deliveries, type of the last delivery, and number of daily involvements in neonatal care, as well as items on neonate’s gender, gestational age, and birth weight.
The researcher-made, ten-item Maternal Hand Hygiene Knowledge Questionnaire was developed through reviewing the existing hand hygiene guidelines and literature and seeking comments from several NICU nurses and a hospital infection control supervisor. It contained multiple-choice items on hand hygiene (five items) and nosocomial infections (five items). Wrong and right answers were, respectively, scored 0 and 1. The possible total score of this questionnaire was 0–10 with higher scores showing greater hand hygiene knowledge.
The researcher-made Maternal Hand Hygiene Performance checklist was developed based on the World Health Organization Guidelines on Hand Hygiene in Health Care. It contained 14 items on the steps of hand hygiene. Accurate performance of each step was scored 1 and its inaccurate performance was scored 0. The possible total score of the checklist was 0–14 with higher scores showing better hand hygiene performance. Participants’ hand hygiene performance was evaluated by a research assistant who was an NICU nurse from the study setting.
The face validity and the content validity of the study instruments were confirmed by ten instructors from the Schools of Nursing (n = 7) and Medicine (n = 3) of Tabriz University of Medical Sciences, Tabriz, Iran. The reliability of the knowledge and the performance questionnaires was assessed through internal consistency assessment, in which 45 mothers (in the pilot study) completed the instruments and the total Cronbach’s alpha of the instruments was calculated to be 0.85. Moreover, for inter-rater reliability assessment, two raters independently and simultaneously evaluated hand hygiene performance of 15 mothers and the Cohen’s kappa agreement coefficient was calculated to be 0.80.
Initially, participants were asked to complete the maternal demographic characteristic questionnaire and the knowledge questionnaire through the self-report method in the presence of the first author. Data on neonates’ demographic characteristics were collected through their medical records. Then, participants washed their hands before entering NICU while the research assistant evaluated their hand hygiene performance using the hand hygiene performance checklist. After that, participants in the FTFE group received 4-min education about hand hygiene from the first author, while their counterparts in the VBE group individually watched a 4-min video related to hand hygiene. The video had specifically been developed for the purpose of the present study and showed one of the authors of the study implementing and describing hand hygiene techniques. FTFE and VBE were almost the same in content and duration. Educational materials were developed based on the World Health Organization Guidelines on Hand Hygiene in Health Care and were approved by ten instructors from the Schools of Nursing (n = 7) and Medicine (n = 3) of Tabriz University of Medical Sciences, Tabriz, Iran. Participants in the control group did not receive any organized education about hand hygiene. Three days after the intervention, participants’ hand hygiene knowledge and performance were re-assessed in all the three groups. After the posttest, FTFE about hand hygiene was provided to participants in the control group and the hand hygiene video was presented to the authorities of the study setting.
The Ethics Committee of Tabriz University of Medical Sciences, Tabriz, Iran, approved this study (code: IR.TBZMED.REC.1397.276). Then, the study was registered in the Iranian Registry of Clinical Trials (code: IRCT20181207008315N29). Study aim was explained to participants and they were ensured of the confidentiality of the data, the voluntariness of participation in the study, and their freedom to withdraw from the study at will. Written informed consent was obtained from each participant.
The data were analyzed using the SPSS software v. 21.0 (SPSS Inc., Chicago, IL, USA). Categorical variables were described through absolute and relative frequencies, while numerical variables were described through mean and standard deviation. The Kolmogorov–Smirnov test was performed to test the normality of the variables which revealed that all data had normal distribution. Between-group comparisons regarding participants’ characteristics were made using the Chi-square test and the one-way analysis of variance. Within-group comparisons regarding the mean scores of hand hygiene knowledge and performance were also made through the paired-samples t-test. Moreover, the analysis of covariance with the Sidak post hoc method was used for between-group comparisons respecting the posttest mean scores of hand hygiene knowledge and performance. P < 0.05 was considered statistically significant.
| Results|| |
All 132 participating mothers completed the study [Figure 1]. Most participants had given birth through cesarean section (79.5%), were primiparous (56.8%), had high school diploma or below-diploma education (79.5), and were homemaker (76.5%). Around 41.7% of the participants involved in neonatal care 4–6 times a day. Groups did not significantly differ from each other regarding participants’ and their neonates’ characteristics [P > 0.05; [Table 1]].
|Table 1: Among-group comparisons regarding participants’ characteristics|
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There were no significant differences among the groups regarding the pretest mean scores of hand hygiene knowledge (P = 0.24) and performance (P = 0.26). The mean scores of hand hygiene knowledge and performance significantly increased in both the intervention groups (P < 0.05) but did not significantly change in the control group during the study [P > 0.05; [Table 2]].
|Table 2: Within-group comparisons regarding the mean scores of hand hygiene knowledge and performance|
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The results of the analysis of covariance showed that after adjusting the effects of education level, employment status, age, and pretest values of knowledge or performance, there were significant differences among the groups regarding the posttest mean scores of hand hygiene knowledge and performance (P < 0.05). Pairwise comparisons revealed that the posttest mean scores of hand hygiene knowledge and performance in both the intervention groups were significantly greater than the control group (P < 0.05). Moreover, the posttest mean score of hand hygiene performance in the FTFE group was significantly greater than the VBE group (P < 0.001), while there was no significant difference between the intervention groups regarding the posttest mean score of hand hygiene knowledge [P = 0.248; [Table 3]].
|Table 3: Among-group comparisons regarding the posttest mean scores of hand hygiene knowledge and performance|
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| Discussion|| |
This study showed that both FTFE and VBE significantly improved the mean scores of hand hygiene knowledge and performance among the mothers of neonates in NICU. In agreement with these findings, a previous study showed that education was effective in significantly improving hand hygiene knowledge among children and their visitors. A number of earlier studies also reported that both multimedia education and FTFE had positive effects on knowledge and performance among pregnant women and patients who used inhaler devices. These findings highlight the importance of education, through either FTFE or VBE, for improving hand hygiene knowledge and performance among mothers in hospital settings. As neither FTFE nor VBE is associated with serious adverse effects, they can safely be used for improving hand hygiene knowledge and performance in NICU and other health-care settings.
In the present study, FTFE significantly improved hand hygiene knowledge and performance. Moreover, findings showed that compared with VBE, FTFE was more effective in significantly improving hand hygiene performance. In line with these findings, a previous study found that FTFE significantly improved knowledge, attitude, and performance regarding the disinfection of surgical instruments among operating room staff. Two other studies also showed that FTFE was effective in significantly improving mothers’ knowledge and performance regarding breastfeeding., The significant effects of FTFE on hand hygiene knowledge and performance and its greater effects than VBE on hand hygiene performance are attributable to the closer relationships between instructors and learners in FTFE which result in learners’ greater attention to the provided education and the greater opportunity for learners to ask their questions, receive feedback, and clarify their ambiguities. However, FTFE is not always possible due to factors such as nurses’ heavy workload, their limited time for patient education, mothers’ limited physical and mental readiness for learning in hospital settings, NICU overcrowding, and lack of appropriate places for education in hospital settings.
Study findings also showed that VBE was effective in significantly improving hand hygiene knowledge and performance. In agreement with this finding, a study found that VBE improved adherence to hand hygiene guidelines among the family members of children in ICU. Another study reported the positive effects of VBE on knowledge and performance regarding behavioral problems among preschool children. Similarly, two studies showed that multimedia education improved parents’ knowledge about care delivery to children with asthma and children with colostomy.
Recent advances in multimedia technology have provided greater opportunities for the use of VBE in patient education. VBE has many advantages including simplicity of use, cost-effectiveness, the possibility of saving educational materials for multiple uses, and the possibility of maintaining the continuity of education. The lower effectiveness of VBE than FTFE in the present study may be due to the lack of face-to-face interaction between instructor and learners in VBE.
The main strength of this study was its randomized controlled design. Nevertheless, this study had some limitations. For example, its sample only consisted of mothers in NICU. Further studies are needed to evaluate and compare the effects of different patient education methods on hand hygiene knowledge and performance among patients and family members in health-care settings.
| Conclusion|| |
This study concludes that both FTFE and VBE have significant positive effects on hand hygiene knowledge and performance among the mothers of neonates in NICU. Moreover, FTFE is more effective than VBE in significantly improving hand hygiene performance. Therefore, nurses can use these interventions to improve hand hygiene knowledge and performance among the mothers of neonates in NICU and thereby reduce the risk of nosocomial infections in health-care settings. Education about hand hygiene should routinely be provided to all mothers in NICU. The selection of either of the FTFE or VBE method for patient education should be based on the immediate environmental conditions, learners’ characteristics, and available equipment.
The authors would like to acknowledge the research deputy at Tabriz University of Medical Sciences for their support. The authors would like to thank all the mothers who participated in this research. Furthermore, they would like to thank all staffs and authorities of the Al-Zahra Teaching Hospital affiliated to Tabriz University of Medical Sciences.
Financial support and sponsorship
This study was financially supported by Tabriz University of Medical Sciences (Ethics code: IR.TBZMED.REC.1397.276). This article was derived from a thesis research project.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Presterl E, Diab-El Schahawi M, Lusignani LS, Paula H, Reilly JS. Hospital Infections. Basic microbiology and infection control for midwives. Heidelberg, Germany: Springer;2019. p. 85-91.
Rosenthal VD, Bat-Erdene I, Gupta D, Belkebir S, Rajhans P, Zand F, et al
International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module. Am J Infect Control 2020;48:423-32.
Cantey JB. Healthcare-Associated Infections in the NICU: A Brief Review. Healthcare-associated infections in children. Cham, Switzerland: Springer;2019. p. 261-79.
Alijani Ranani H, Tour M, Nikfar R, Latifi SM, Zadeh FM. The effect of controlled contact on nosocomial infection in children intensive wards. J Nurs Educ 2019;7:41-50.
Demmler-Harrison GJ. Healthcare-associated viral infections: Considerations for nosocomial transmission and infection control. Healthcare-Associated Infections in Children . Cham, Switzerland: Springer;2019. p. 229-57.
Saito H, Timurkaynak F, Borzykowski T, Kilpatrick C, Pires D, Allegranzi B, et al
“It’s in your hands–prevent sepsis in health care”; 5th May 2018 World Health Organization (WHO) SAVE LIVES: Clean Your Hands Campaign. Klimik Dergisi 2018;31:2-3.
Kilpatrick C, Tartari E, Gayet-Ageron A, Storr J, Tomczyk S, Allegranzi B, et al
Global hand hygiene improvement progress: Two surveys using the WHO hand hygiene self-assessment framework. J Hosp Infect 2018;100:202-6.
Pineda R, Bender J, Hall B, Shabosky L, Annecca A, Smith J. Parent participation in the neonatal intensive care unit: Predictors and relationships to neurobehavior and developmental outcomes. Early Hum Dev 2018;117:32-8.
Pong S, Holliday P, Fernie G. Secondary measures of hand hygiene performance in health care available with continuous electronic monitoring of individuals. Am J Infect Control 2019;47:38-44.
Alshehari AA, Park S, Rashid H. Strategies to improve hand hygiene compliance among healthcare workers in adult intensive care units: A mini systematic review. J Hosp Infect 2018;100:152-8.
Sande-Meijide M, Lorenzo-González M, Mori-Gamarra F, Cortés-Gago I, González-Vázquez A, Moure-Rodríguez L, et al
Perceptions and attitudes of patients and health care workers toward patient empowerment in promoting hand hygiene. Am J Infect Control 2019;47:45-50.
Chandonnet CJ, Boutwell KM, Spigel N, Carter J, DeGrazia M, Ozonoff A, et al
It’s in your hands: An educational initiative to improve parent/family hand hygiene compliance. Dimens Crit Care Nurs 2017;36:327-33.
McFubara KG, Ogbe DK, Mbooh RT, Nwizia BP, Nasamu UP, Ogori DS. Hand washing among health workers in tertiary health facilities in Bayelsa State, Nigeria. Int J Community Med Public Health 2017;4:1459-65.
Zhang S, Kong X, Lamb KV, Wu Y. High nursing workload is a main associated factor of poor hand hygiene adherence in Beijing, China: An observational study. Int J Nurs Pract 2019;25:e12720.
Staines A, Vanderavero P, Duvillard B, Deriaz P, Erard P, Kundig F, et al
Sustained improvement in hand hygiene compliance using a multi-modal improvement programme at a Swiss multi-site regional hospital. J Hosp Infect 2018;100:176-82.
van der Kooi T, Sax H, Pittet D, van Dissel J, van Benthem B, Walder B, et al
Prevention of hospital infections by intervention and training (PROHIBIT): Results of a pan-European cluster-randomized multicentre study to reduce central venous catheter-related bloodstream infections. Intensive Care Med 2018;44:48-60.
Hill C, Knafl KA, Santacroce SJ. Family-centered care from the perspective of parents of children cared for in a pediatric intensive care unit: An integrative review. J Pediatr Nurs 2018;41:22-33.
Ridwan Hasyim MA, Junadi P. Analyzing patient education methods to improve patient care in hospital: A systematic review. In the 2nd international conference on hospital administration. KnE Life Sciences 2018;4:244-64.
Adam M, McMahon SA, Prober C, Bärnighausen T. Human-centered design of video-based health education: An iterative, collaborative, community-based approach. J Med Internet Res 2019;21:e12128.
Bastable SB. Nurse as Educator: Principles of Teaching and Learning for Nursing Practice. Burlington, MA: Jones & Bartlett Learning;2017.
Alrumi N, Aghaalkurdi M, Habib H, Abed S, Böttcher B. Infection control measures in neonatal units: Implementation of change in the Gaza-Strip. J Matern Fetal Neonatal Med 2020;33:3490-6.
Munir M, Maqbool M, Bilal S, Hussain M, Ghani Z, Yaqub A. Handwashing practices in health care professionals of allied hospitals of Rawalpindi Medical University. Ann PIMS 2018;14:269-73.
Barkin JL, Stausmire JM, Te MN, Pazik-Huckaby A, Serati M, Buoli M, et al
Evaluation of maternal functioning in mothers of infants admitted to the neonatal intensive care unit. J Womens Health (Larchmt) 2019;28:941-50.
World Health Organization. World Health Organization Guidelines on Hand Hygiene in Health Care. Geneva: World Health Organization;2009.
Lary D, Hardie K, Randle J. Improving children’s and their visitors’ hand hygiene compliance. Antimicrob Resist Infect Control 2013;2:166.
Rajabi Naeeni M, Farid M, Tizvir A. A comparative study of the effectiveness of multimedia software and FTFE methods on pregnant women’s knowledge about danger signs in pregnancy and postpartum. J Educ Community Health 2015;2:50-7.
Adib-Hajbaghery M, Karimi Z. Comparing the effects of face-to-face and video-based education on inhaler use: A randomized, two-group pretest/posttest study. Iran J Nurs Midwifery Res 2018;23:352-7.
Shabani Hamedan M, Habibi R, Soltani Z, Shafikhani M, Hashemi Hefzabad F. Comparison of face-to-face and distance learning on KAP of washing and disinfection of surgical instruments among operating room staff of the teaching hospitals in Qazvin. J Qazvin Univ Med Sci 2013;17:47-53.
Mokhtari L, Habibpor Z, Khorami Markani A. The effect of face to face education and pamphlet giving on knowledge of mothers about breast feeding. J Urmia Nurs Midwifery 2014;12:825-32.
Khorshidifard M, Amini M, Dehghani MR, Zaree N, Pishva N, Zarifsanaiey N. Assessment of breastfeeding education by face to face and small-group education methods in mothers’ self-efficacy in Kazeroun Health Centers in 2015. Women Health Bull 2017;4:e41919.
Chen YC, Chiang LC. Effectiveness of hand-washing teaching programs for families of children in paediatric intensive care units. J Clin Nurs 2007;16:1173-9.
Romantika IW, Lusmilasari L, Prabandari YS, Syahrul S. Application of video-based health education in improving mother’s knowledge and attitudes about behavioral problems among preschool children. Enferm Clin 2020;30 Suppl 2:172-6.
Zarei AR, Jahanpour F, Alhani F, Razazan N, Ostovar A. The impact of multimedia education on knowledge and self-efficacy among parents of children with asthma: A randomized clinical trial. J Caring Sci 2014;3:185-92.
Merhi A, Abdi SA, Valizadeh S, Ghojazadeh M, Tabari AK. Randomized controlled trial to determine the effectiveness of a mutimedia teacthing program on management of infants colostomy: Evaluation of its impact on caregivers. J Pharmacopher 2017;8:1-8.
[Table 1], [Table 2], [Table 3]