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Journal of Community Health (2020) 45:1211–1219 https://doi.org/10.1007/s10900-020-00857-1

O R I G I N A L PA P E R

Fear of Hospital‑Acquired Infections: The Combined Impact of Patient’s Hygiene Sensitivity and Perceived Staff Preventive Behavior

Ben Bulmash1  · Ofir Ben‑Assuli2 · Moty Amar2

Published online: 12 June 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract Over the years, the public has paid growing attention to hospital-acquired infections (HAIs). Currently, infection prevention and control are considered a number one national priority in leading developed countries. However, while some hospital visitors are knowledgeable of the topic, others may be ignorant or careless as regards sterility and hygiene-related matters. This study, conducted in Israel, compared people cognizant of hygiene-related issues to those who are less so, in an attempt to account for differences in terms of attitudes and perceptions regarding the hospital environment. Based on Endsley’s (in: Proceedings of the IEEE 1988 national aerospace and electronics conference, IEEE, 1988, 1995) situation awareness concept, we hypothesized that people attending the hospital with different hygiene schema would react differently when faced with HAI-related triggers. Based on a survey of 208 respondents, the results support the hypotheses, and showed a significant moderating effect of hygiene-sensitivity on the relationship between the staffs’ hospital acquired infection-related proactive behavior and avoidance tendencies among hospital visitors. Theoretical as well as practical recommendations are discussed.

Keywords Hospital-acquired infections · Infection prevention · Hygiene sensitivity · Situation awareness · Hospital environment

Introduction

Hospital-acquired infections (HAIs), also known as noso- comial infections, are infections acquired in hospitals. HAIs are a serious safety concern for both health care providers and patients, with devastating outcomes particularly for immunocompromised persons who attend hospitals [1–3]. The media worldwide often report on the high prevalence of devastating outcomes among hospital visitors. For instance, recently the BBC reported that four babies and children had died from infections picked up during their stay at a Glas- gow hospital [4]. The financial impact of these infections

on healthcare organizations is huge in terms of morbidity, mortality, increased length of stay, tarnished hospital repu- tations, demands for reimbursement, etc. [5, 6]. In the UK, for instance, approximately 300,000 healthcare-associated infections occur annually and account for 5000 deaths [7]. These HAIs are thought to cost the National Health Ser- vice (NHS) in the region of £1 billion a year [8]. In the US, HAIs were estimated to cause or contribute to 99,000 deaths each year [9]. Not surprisingly, infection prevention and control are currently considered a number-one national priority and a serious concern in healthcare organizations in several leading developed countries [10]. In Israel, 100,000 hospital infections per year result in roughly 5000 deaths [11], although millions of dollars have been invested in fight- ing HAIs.

While considerable attention has been paid to financial and social aspects of HAIs, little is known about hospital visitors’ attitudes toward HAIs. In recent years, there has been increasing press coverage of outbreaks and infections in healthcare organizations [12–15]. This increased cover- age has resulted in making more people aware and knowl- edgeable of the dangers of HAIs. Research indicates that more highly educated people who are provided with prior

* Ben Bulmash [email protected]

Ofir Ben-Assuli [email protected]

Moty Amar [email protected]

1 Faculty of Technology Management, Holon Institute of Technology (HIT), 52 Golomb St., 58102 Holon, Israel

2 Faculty of Business Administration, Ono Academic College, 104 Zahal Street, 55000 Kiryat Ono, Israel

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information about HAIs show greater awareness [16]. Given this increased awareness, this study examined hospital visi- tors’ attitudes toward HAIs as well as their perceptions of the medical staff’s efforts to follow HAI-related protocols and recommended practices. This study is thus timely as well as important as it tests the impact of hospital visitors’ attitudes and perceptions on their behaviors. Specifically, we focus on behaviors related to avoidance, since such tenden- cies can negatively impact both patients’ as well as health maintenance organizations’ outcomes.

Theoretical Background

Although increasing numbers of hospital visitors are aware of HAIs and follow protocols, other may be ignorant or careless with respect to sterility and hygiene-related behav- iors and thus are more likely to get or transmit diseases. Kreps [17] argued that health literacy is a powerful driver that enables patients to make informed decisions about their hospital stay and medical care. Hygiene-sensitive patients are more likely to act proactively to avoid and prevent dis- ease transmission; for instance, by washing their hands as recommended, avoiding contact with surfaces and objects at the hospital, and keeping the length of their stay to the minimum. Patients with low hygiene awareness may not pay much attention to these protocols. As a result, health organi- zations attempt to educate hospital visitors about hygiene to empower them to be responsible for their own care and safety [18]. However, visitors’ safety derives from both their own behavior as well as that of the medical staff. In both cases, proactivity is likely to reduce the spread of disease. In Israel, for example, in recent years various private and public initiatives have been pilot-tested to increase staff and visitor proactivity. Stakeholders in general feel the need to change the norms with regard to HAI preventive behaviors [19].

Risk factors related to HAIs include visitors’ length of stay, the presence of invasive devices, high patient turnover, overcrowding [20], and a lack of adequate attention on the part of medical staff to protocol and recommended prac- tices [21–23]. Hand hygiene, for instance, is one of the most important measures to reduce transmission of nosocomial pathogens in healthcare settings [24] but compliance on the part of medical staff and patients varies considerably [25, 26]. It has been estimated that between 15 and 30% of HAIs could be prevented by compliance with infection control practices and appropriate hygiene measures [7]. Such pro- tocols may not be followed by medical staff for a number of reasons including lack of knowledge of guidelines [27], workload [23, 28], work setting and inaccessibility of hand hygiene supplies [29], low perceived risk of cross-transmis- sion, low perceived usefulness [30], and individual attitudes toward hand hygiene [31]. Hospitals often invest resources

to promote hygiene among staff members, in an effort to proactively combat HAIs [22].

However, despite concerted efforts on the part of hospi- tals to encourage staff members to fight HAIs proactively, one consideration that has received no attention to date is the impact of the medical staff’s proactive behaviors on visi- tors’ own attitudes and behaviors. Namely, medical staff’s proactivity (e.g. hand-hygiene including washing hands and wearing gloves, hazardous waste and correct handling and disposal of sharp objects, isolation precautions, communica- tion of HAI protocols to staff members as well as between medical staff and hospital visitors, etc.) may trigger differ- ent reactions among hospital’s visitors, and these reactions could vary across visitors. Visitors can take a number of steps including shortening the duration of their visits, avoid- ing contact with surfaces and objects, avoiding other people, communicating with staff on hygiene related matters, avoid- ing going to the hospital, and others.

People’s willingness to engage in an ‘appropriate act’ from a conflict-of-motivation perspective [32] can help clarify hospital hygiene-related behavior. People go to the hospital when they have a physical condition whose fear or suffering is associated with their ill-being. The greater the fear or suffering, the greater the likelihood that the person will want to go and remain in the hospital. On the other hand, risk factors associated with hospital stays may prompt people to avoid going to the hospital at all. As long as the motivation to visit the hospital, considering alternative options, is smaller than the motivation to avoid the visit, people are likely to choose not to go to the hospital, and if they do, they tend to stay for a short a time as possible and avoid contact with the hospital environment. Kumar et al. [33] refer to a “hesitancy continuum”, where similar moti- vational concerns apply to the acceptance or rejection of new vaccination programs.

Here we argue that physicians’ proactive behavior may have an impact on this conflict-of-motivation balance. If the medical staff’s proactive behavior decreases the stress and uncertainty associated with infection in the hospital environ- ment, people may experience lower levels of fear, and there- fore, may be more likely to go to the hospital. On the other hand, if the staff’s proactivity only triggers HAI-related thoughts and emotions, the result will be one of avoidance.

Endsley’s situation awareness concept [34] may shed light on how people make this choice. Situation awareness is defined as the “perception of the elements in the environ- ment within a volume of time and space, the comprehen- sion of their meaning, and the projection of their status in the near future” (pp. 32–64). Situation awareness has been discussed in terms of potentially preventable morbidity and mortality due to ineffective clinical monitoring of patients in hospitals [35]. Sarter and Woods [36] refer to the enhanced complexity of “data-rich environments”. Complex data

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streams pose a uniquely difficult problem for medical staff, since lack of detection (or untimely detection) or incorrect interpretation of important medical cues in real-time may result in serious medical errors [37, 38].

By extension, ‘hazard awareness’ has to do with visitors’ sense-making with regard to their environment in terms of perceived risk. For pilots, for instance, hazard awareness includes awareness of the weather, terrain, and other aircraft in the surrounding space, which enables pilots to safely per- form their assigned tasks [39]. Hence, to better understand visitors’ reactions to physicians’ proactive behavior, the per- ception of elements in the environment and the interpreta- tion of those elements need to be taken into account.

Endsley suggested that the perception and interpreta- tion of a situation are subject to each person’s schema [40] (1995). Namely, in order to understand people’s awareness of and reaction to a situation, we need to account not only for information in the environment, but also for pre-existing knowledge and previous experience [41]. Thus, visitors’ reactions to medical staff’s proactive behavior may vary, and this variation may be attributed to people’s prior knowledge of hospitals and HAIs. In other words, the same element in the hospital environment (i.e. staff proactivity) may be trans- lated in different ways by different people. Specifically in the context of HAIs, we suggest that high hygiene-sensitive peo- ple will react differently than low hygiene-sensitive people, due to a different embedded schema with regard to hospitals and HAIs. In the case of HAIs, people’s schema are much more significant since most disease-causing pathogens are not visible to the human eye. Hence, information from the environmental or cues per se are not readily evident, mak- ing the human disease avoidance system heavily reliant on beliefs, mental images, emotions, and various assumptions regarding the hospital environment [42].

Hypotheses

According to Endsley’s situation awareness framework, people interpret environmental cues as a function of their pre-existing knowledge or experience with regard to the situ- ation. We hypothesized that high hygiene-sensitive visitors would “read” the staff’s proactive behavior differently than low hygiene-sensitive visitors. Specifically, we posited that high hygiene-sensitive visitors acknowledge the HAI risk to a greater extent than low hygiene-sensitive visitors. As a result, when this hygiene-sensitive group witnesses staff pro- active hygiene behavior, they will feel safer and more moti- vated to engage with the medical environment. Proactive behavior assures them that the medical staff is also aware of the risks in the environment and takes precautions to lessen these risks. By contrast, low hygiene-sensitive visitors are likely to be less aware of HAIs and diseases in general. In

this case, staff proactivity may direct their attention to the notion of HAIs. The staff’s proactive behavior may actu- ally make the low hygiene-sensitive group consciously or subconsciously more attuned to HAIs. Preventive behavior on the part of the medical staff may also sharpen visitors’ sense of risk from an abstract idea to a real possibility (i.e. hazard proximity) which could lead to increased preventive measures [43].

Hence, the medical staff, as part of the societal context may alter the focus and scope of risk assessment by hospi- tal visitors [44]. Here, we hypothesized that low hygiene- sensitive visitors and high hygiene-sensitive visitors would react in opposite ways to the same proactive behavior by medical staff.

Hypothesis 1 High-hygiene sensitive hospital visitors’ perceived proactivity of medical staff with respect to HAIs will result in increased engagement with the healthcare environment.

Hypothesis 2 Low hygiene sensitive hospital visitors’ perceived proactivity of medical staff with respect to HAIs will result in decreased engagement with the healthcare environment.

Methods

Sample

Two hundred and eight respondents were interviewed and surveyed. Except for two instances, the interviews were all conducted face to face. About half of the sample was surveyed in a hospital emergency department (ED), and the remainder were interviewed at work or at home. Peo- ple with a professional medical background were excluded from the sample, and in the few cases where profession was not indicated, the person was included in the analysis and the missing information was controlled for in the analyses. The average age of the participants was 40.11 (ranging from 18 to 72) and about 70% of the participants were females. The research is IRB approved (202014ono) and follows the required procedures such as debriefing of the study and its purpose to participants, anonymity and confidentiality of the participants’ personal information, as well as informed consent of all the study participants.

For a response quality check, two opposite questions were used to determine whether participants had paid attention to the survey questions. For instance, if a participant simul- taneously indicated “feeling safe from infectious diseases in the hospital” and “worried about getting infected in the hospital” as highly true or highly false, these participants

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were excluded from the analysis. In total 16 subjects (about 7.7%) were excluded.

The resulting sample thus consisted of 192 participants.

Measures

Independent Variables

Perceived Staff Hygiene Proactivity This variable encom- passes the participants’ perception of the medical staff’s proactivity with respect to fighting infections in the hospi- tal. This scale was comprised of six items that pertained to staff awareness of disease transfer, staff motivation to fight diseases, staff attempts to fight diseases, the importance of hospital hygiene to the staff, as well as the frequency at which medical staff used an antiseptic disinfecting soap. All responses were made on a 7-point Likert scale. The Cron- bach’s Alpha for this scale was 0.73.

Hygiene Sensitivity The participants were asked to indicate the importance of the hospital’s level of hygiene to them, on a 7 point Likert scale where 7 indicated very high impor- tance and one indicated not important at all. This variable thus assessed the participants’ degree of hygiene sensitivity.

Covariates were included in all the analyses; namely, age, gender, level of education, the survey location (in the hospi- tal or not), and whether the person had ever received guid- ance on the prevention of infectious diseases. About 35% of the sample had never received any such guidance.

Dependent Variables

We used a number of indicators that reflect avoidance ten- dencies in relation to the hospital environment. These indi- cators referred to both general attitudes as well as behavior: (1) A behavioral measure indicating the frequency at which the participant went to the ED but left without receiving a diagnosis from the medical staff. Normally, people wait in the ED until they receive a diagnosis. Hygiene-related avoid- ance could prompt someone to leave earlier, (2) a behavioral

indicator pertaining to the participants’ tendency to avoid contact with objects and surfaces in the hospital, (3) an indicator reflecting their fear of washing their hands in the hospital, (4) the extent to which the participants were con- cerned about getting infected while at the hospital, and (5) the extent to which the participants were afraid to accom- pany a relative to the hospital. All responses to these vari- ants on hygiene related avoidance were rated on a 7-point Likert scale.

Results

Descriptive

Table 1 shows that respondents reported a high degree of hygiene sensitivity (a mean of 6.53 out of 7). Participants tended to perceive the staff as overall proactive in fighting infections (a mean 5.22 out of 7). In terms of the correla- tions, hygiene sensitive participants reported higher staff proactivity than individuals with lower hygiene sensitivity. The five avoidance indicators were significantly associated with values ranging from 0.20 (p < .01) to 0.73 (p < .001), supporting the supposition that they mutually relate to hygiene related avoidance.

Regression Analyses

Table 2 presents the multiple regression analyses for the five dependent variables. Since the covariates overall dem- onstrated no significant effect, they were omitted from the table, although they were included in the analyses. The single consistent effect among the covariates pertained to whether the participants completed the questionnaires in the hospital or not. Participants who filled in the questionnaires in the hospital reported increased avoidance tendencies. This finding is consistent with our theorizing that people become more avoidant when the environment prompts them to think about possible risks and diseases.

Table 1 Means, standard deviations, and Pearson correlations for the main study variables

N ranges 178–190 *p < .05; **p < .01; ***p < .001

Variables Means SD 1 2 3 4 5 6

Hygiene sensitivity 6.53 1.13 – Perceived staff proactivity 5.22 1.00 .20** – Left ER with no answer 2.20 1.80 − .12+ − .11 – Avoided contact with objects 4.61 2.02 − .01 .02 .20** – Afraid to wash hands 3.09 2.25 − .18* − .03 .35*** .40*** – Afraid of getting infected in the hospital 4.12 2.07 − .02 − .08 .27*** .55*** .42*** – Afraid to accompany a relative 3.41 2.12 − .00 − .09 .31*** .42*** .39*** .73***

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There was no significant main effects for the two inde- pendent variables (hygiene sensitivity and perceived staff proactivity) on hygiene related avoidance attitudes, imply- ing that on average, participants who were hygiene sensi- tive were not more avoidant than participants who were less aware of hospital hygiene. Nonetheless, the participants who reported higher hygiene sensitivity were more willing to wash their hands (B = − 0.451, p < 0.05) and less will- ing to leave the ED before getting a diagnosis (B = − 0.381, p < 0.05). There was no significant effect for perceived staff proactivity.

In Step 2 of the regression analyses, four out of the five interaction effects were significant, with the exception of one that was marginally significant (avoiding contact with objects and surfaces). All the interaction terms were negative, ranging from B = −  0.312 (p < 0.1) to −  0.617 (p < 0.001). Thus, the interaction results suggest consistency across the dependent variables.

Figure 1 presents all five interactions. In terms of pres- entation, ‘high’ and ‘low’ were calculated as + 1 SD and − 1 SD for the hygiene sensitivity level and for perceived staff proactivity. The figures indicate a general trend. When the medical staff was perceived as passive with regard to fighting infectious diseases, there were no substantial differ- ences between participants who reported high hygiene sensi- tivity or low hygiene sensitivity in terms of their avoidance tendencies. However, when the medical staff’s proactivity in fighting infectious diseases was perceived as high, differ- ences emerged in the responses between the two hygiene- sensitivity groups. As expected, participants who reported

a high level of hygiene sensitivity became less avoidant as medical staff was perceived as more proactive in prevent- ing infectious diseases (Hypothesis 1, fully supported). By contrast, participants who reported a low level of hygiene sensitivity became more avoidant when perceiving the medical staff as proactive (Hypothesis 2, fully supported). Hence, the results suggest, quite firmly, that the medical staff’s proactive behavior can either increase avoidance or decrease avoidance depending on people’s personal hygiene sensitivity.

Discussion and Conclusion

The findings suggest that the degree of hygiene sensitiv- ity may prompt hospital visitors to respond differently as a function of their perception of the medical staff as proactive in fighting infectious diseases. Specifically, visitors who are hygiene-sensitive and who perceive the medical staff as pro- active and motivated to fight diseases emerged as less afraid of getting an infectious disease at the hospital in comparison to others visiting the hospital. Likewise, this group was also more willing to go with a relative to the hospital, less afraid to wash their hands in the hospital, less likely to leave the ED before getting a diagnosis, and also more willing to be in contact with objects and surfaces in the hospital. Thus, the combination of high hygiene-sensitivity along with the percep- tion of medical staff attentiveness and awareness of hospital contaminations leads to a greater sense of safety, which may increase engagement (rather than avoidance) with the hospital

Table 2 Predicting avoidance behavior and attitudes via personal hygiene level, perception of medical staff proactivity, and covariates

N = 130–131 due to missing cases. Covariates are not presented for simplicity. ΔR2 pertains to the difference in models with and without the interaction term + p < .10; *p < .05; **p < .01; ***p < .001 Bold values are significant for b = −0.617*** (p < 0.001), b = −0.312+ (p = 0.099), b = −0.486* (p = 0.019), b = −0.448* (p = 0.016), b = −0.386* (p = 0.038)

Variables Leaving ED without an answer

Avoiding contact with objects and surfaces

Afraid to wash hands

Afraid of getting infected while in the hospital

Afraid to accom- pany a relative

b SE B SE b SE b SE b SE

Step 1  Personal hygiene sensitivity − 0.381* 0.161 0.125 0.193 − 0.451* 0.213 − 0.042 0.191 0.055 0.191  Perceived medical staff proactivity − 0.012 0.183 − 0.112 0.221 0.073 0.243 − 0.148 0.218 − 0.018 0.22  R2 0.133 0.031 0.084 0.037 0.046

Step 2  Personal hygiene sensitivity − 0.878*** 0.192 − 0.126 0.244 − 0.842 0.265 − 0.507* 0.238 − 0.255 0.24  Perceived medical staff proactivity 0.035 0.172 − 0.088 0.219 0.109 0.239 0.008 0.214 0.009 0.217  Hygiene sensitivity × perceived

staff proactivity − 0.617*** 0.147 − 0.312+ 0.188 − 0.486* 0.204 − 0.448* 0.183 − 0.386* 0.185

 R2 0.244 0.052 0.125 0.082 0.079  ΔR2 0.110*** 0.022+ 0.041* 0.045* 0.034*

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Fig. 1 Interaction effects for hygiene sensitivity level and perceived medical staff proactivity in predicting avoidance tendencies

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environment. This result also suggests although indirectly, that people may believe that HAIs are preventable [45]. This belief likely accounts for the behaviors found in our analyses. By contrast, visitors who are less sensitive to hygiene and who perceive physicians as proactive in fighting infectious diseases felt less safe consulting or remaining at the hospital, and were more likely to avoid objects as well as wash their hands in the hospital.

This result is well within the scope of our schema-trigger- awareness theorizing, based on Endsley’s situation awareness framework [40] (1995). Theoretically, whereas physicians’ proactive behavior promotes confidence and sense of safety for those who are already aware of HAIs, the same behavior triggers the risks involved in going to the hospital for those who are less aware of HAIs and hygiene-related issues in the first place. This trigger-awareness result was also supported by the fact that participants who were interviewed in the hospital reported a higher level of avoidance tendencies than the partic- ipants surveyed at home or at work. Just as the medical staff’s proactivity triggers and brings to mind the idea of infections and diseases, being at the hospital produces a similar mental state, promoting avoidance rather than engagement with the hospital environment.

Practical Implications

These findings highlight two distinct factors, which together can possibly be linked to people’s hospital avoidance. The first factor is people’s hygiene schema. This consists of an a priori mindset and knowledge base with regard to HAIs and hospital- related risks in general. This factor is the basis for people’s reactions to the second factor; i.e., the medical staff’s proactiv- ity (the trigger). Hence, in addition to investing resources in training staff and in programs directed at fighting HAIs, addi- tional resources are needed to educate people about HAIs and the steps taken by staff members to secure people’s wellness during their time in the hospital. Only when the right schema is constructed and medical staff proactively engages with HAIs, will visitors’ engagement with the hospital environment be maximized and avoidance be minimized. Avoiding the hospital altogether or leaving early may reflect an attractive alterna- tive for some people; however, this may result in undesirable medical consequences. This study may thus enables medical decision makers to better understand people’s attitudes and behaviors, and thus promote more effective behavior on the part of the medical staff and hospital visitors.

Limitations and Future Research

This study also has a number of limitations. First, the study relied solely questionnaires. It remains unclear whether these subjective responses constitute an accurate representation

of real-life intentions and attitudes, and should be explored in future research. This could include real-life observations in the hospital environment as well as experiments that manipulate the main variables (for instance, medical staff proactivity) in a controlled or semi-controlled setting.

Second, this study focused on HAI-related triggers that stem from staff proactivity. However, such triggers may also result from others’ behavior in the hospital environment. We reasoned that people react to what they see or experience around them as a function of their hospital hygiene and HAI schema. Clearly people who go to the hospital are not only exposed to staff members, but to other people as well; hence the perceived behavior of the latter should also be consid- ered in future research.

Third, this study examined people’s avoidance attitudes. It would also be important to consider clinical outcomes related to staff proactivity, combined with people’s attitudes and behaviors. Specifically it would be useful to probe peo- ple’s engagement or avoidance with the hospital environ- ment to determine the medical consequences of these atti- tudes [46].

Finally, this study dealt with people visiting the hospital and their perceptions of the medical staff. Future research could also examine the medical staff’s actual adherence to protocols and recommended practices, thus supplementing the subjective perceptions analyzed in this study.

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