To date, this is the first study evaluating the association between knowledge of AMR epidemiology, the associated control measures, and the individual cognitive factors, including both MWs and NMWs from a national representative population of HCFs. The 74% participation rate was unexpectedly high and may be ascribable to the active participation of IPC teams and the direct physical contact of investigators with ward staff. This large panel therefore accurately reflects the situation in France and enabled comparison of the KS in different categories of HCFs and types of healthcare units.
We found poor knowledge of current AMR epidemiology and modest knowledge of best practices in prevention of cross-transmission. Variations were observed across professional categories, highlighting two profiles. Professionals with the highest knowledge profile were young medical doctors, working in an ICU, recently trained and with awareness of and readiness to act against AMR. This profile perceived poor compliance with hand hygiene as a breach in patient safety, with a willingness to comply with hand hygiene recommendations. The 26–35-year age class working in UHs was associated with greater knowledge, possibly reflecting improved and fresh education on the topic during medical or nursing studies. On the other hand, low knowledge was found among nurse aides from small LTCFs. Nurse aides are key people for infection control. They routinely contribute to patient care and diaper changes, with a high risk of hand contamination and subsequent transmission [18]. This strongly suggests that knowledge should primarily be improved in that population. Small HCFs should also be a target for education as they may suffer of a lack of IPC human resources.
Fifteen years after the introduction of AHR in French healthcare settings [17, 19], knowledge of hand hygiene best practices still appeared poor. AHR was considered less effective than antiseptic or plain soap in a significant proportion of respondents, as high as 50% of NMWs, which was very disappointing given the multiple national campaigns promoting AHR and the use of AHR consumption as a national quality indicator. Two previous studies reported that medical students considered poor hand hygiene compliance as one of the least important contributors to AMR [11, 20]. In consequence, educational messages provided by IPC teams should be simplified, focused on the reasons for and consequences of poor hand hygiene practices and be tailored to the healthcare professionals involved.
Furthermore, less than 50% of HCWs thought that hand hygiene was more important after than before a contact with patients. These results illustrate a general misconception of hand hygiene best practices, even though reported consumption of AHR in France is fairly high compared to other European countries [21]. Healthcare-associated infections are the result of a complex chain, including the many individuals involved in patient care. The consequences of poor hand hygiene compliance are intangible for front-line staff, not considering the actual burden of AMR for patients as a consequence of their individual practices. The perception of AMR as a national problem but not a local or individual one supports this hypothesis. Accurate feedback of local data may improve awareness of HCWs [22].
.HCWs still believe they need to wear gloves for contact precautions despite its withdrawal from French recommendations in 2010. Several guidelines have recently been issued for the control of MDRO transmission, with evolving recommendations (e.g. the debated need for contact precaution for ESBLP-E. coli) [1, 23]. These recurrent changes in recommendations may be confusing for HCWs, complicating the implementation of good practices. Sixty-eight percent of HCWs reported having received training on hand hygiene during the last 3 years. This proportion, albeit high, may be considered insufficient. Education and training of HCWs are one pillar of infection control programmes and efforts must be made to implement regular courses and target all HCW categories [24]. However, formal training should be included in a larger programme including combined measures, according to the rules of bundling and multifaceted interventions: reminders at the workplace, audit and feedback, use of AHR consumption as a performance indicator, leadership, incentive and rewards … [25]. For example, AHR consumption is a publicly released quality indicator for all healthcare facilities in France, and facilities are urged to use AHR consumption as an internal quality indicator; most healthcare facilities are registered to take part in national hand hygiene day, on the 5th of May, as well as in the national yearly week of patient safety. Until now, educational programmes have usually been based on classic presentations with lectures given to a passive audience. New technologies such as simulation, virtual reality, serious games and e-learning applications, playing with the trainee’s emotions, bring new possibilities to the field of medical training and could lead to valuable improvement in learning outcomes [26]. After adjustment for confounding variables, a higher KS was significantly associated with four cognitive factors: perceived susceptibility, attitude toward hand hygiene, self-efficacy, and motivation. Our survey, as previously described [27], suggests a perceived lack in patient safety by HCWs when hand hygiene in inadequately performed. One may consider that the perceived susceptibility, i.e. the perceived risk to patient, which was the strongest factor linked to higher knowledge, derived from the higher knowledge by itself. Nevertheless, it is unknown whether the other cognitive factors impact higher knowledge, or whether higher knowledge obtained from other sources, such as training sessions or medical education, translates into more belief in and perception of the importance of hand hygiene. The interactions probably are intricate, suggesting that training on hand hygiene and AMR is critical in shaping beliefs in and perceptions of the control of AMR. A new approach based on psychologically tailored hand hygiene interventions regarding MDRO has recently been described [28]. Tailored intervention based on the Health Action Process Approach (HAPA) led to better compliance with hand hygiene, with in turn a decrease in the MDRO infection rate.
Understanding the impact of individual infection control behaviours on AMR spread may increase the likelihood of compliance. An adapted approach is needed to heighten an individual’s understanding. A unique strategy is not sufficient in a such context and efforts should be made to implement personalised and multiple tools. One approach could be supported by evidence-based medicine. A recent study stated that recommendations appear to be imposed on medical students and junior physicians without reference to the scientific evidence, which therefore does not encourage high compliance with hand hygiene [22]. Feedback of local data could increase awareness among HCWs, while demonstrating threats in their own setting and the consequences of their own practices. On the other hand, social norms (perceived behavioural and subjective norms) are independent of awareness, but surveys have demonstrated that they shape hygiene behaviours [17, 29]. For instance, perceived peer handwashing frequency significantly impacted the behaviour of professionals. Intervention regarding social norms could be a complementary approach.
Our survey had some limitations. Firstly, the study was performed in France and was probably not representative of the healthcare systems of other countries. Indeed, to our knowledge, only one study has been conducted in several European countries, but focused on antibiotic prescribing and AMR among medical students [11]. Secondly, the questionnaire was unique and questions could have been understood differently by individuals according to their professional status. Hence, use of a 7-point scale permitted a large range of responses and more precision [30]. Thirdly, it is likely that the respondents were more motivated and better informed than non-respondents, thus increasing the rate of positive responses. However, the high participation rate could offset this bias. Finally, some answers may have been collective rather than individual, thereby falsely increasing KS.
