ARTICLE IN PRESS

American Journal of Infection Control ■■ (2016) ■■-■■

Contents lists available at ScienceDirect

American Journal of Infection Control American Journal of

Infection Control

j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g

Major Article

Smartphone text message service to foster hand hygiene compliance

in health care workers
Jad Kerbaj MD a, Youssoupha Toure MS b, Alberto Soto Aladro MS b,c,
Sophia Boudjema MS a,b,c, Roch Giorgi MD, PhD b,d,e, Jean Charles Dufour MD, PhD b,d,e,
Philippe Brouqui MD, PhD a,b,c,*
a
CHU Nord, AP-HM, Pôle des Maladies Infectieuses et Tropicales, Maladies Infectieuses et Tropicales, France
b
Institut Hospitalo-Universitaire Méditerranée Infection, Marseille, France
c
URMITE, UM63, CNRS 7278, IRD 198, INSERM 1095, Aix Marseille Université, Marseille, France
d INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, Aix Marseille Univ, Marseille, France
e APHM, Hôpital de la Timone, Service Biostatistique et Technologies de l’Information et de la Communication, Marseille, France

Key Words: Background: Health care-associated infections are a major worldwide public health issue. Hand hygiene
SMS is a major component in the prevention of pathogen transmission in hospitals, and hand hygiene adher-
Feedback ence by health care workers is low in many studies. We report an intervention using text messages as
Reminders
reminders and feedback to improve hand hygiene adherence.
Intervention
Materials and methods: The study is a historical comparison proof-of-concept study. Eighteen health
Encouragement
care workers were monitored during 12 months by a radiofrequency identification system. Afterward we
sent 2 types of text messages, congratulation or encouragement, and we studied the evolution of hand
hygiene adherence.
Results: We recorded 15,723 hand hygiene opportunities, 8,973 before intervention and 6,750 during
and after the intervention. Using a multilevel logistic regression analysis, we found a significant in-
crease in hand hygiene adherence during the intervention (odds ratio, 1.68) compared with the historical
period.
Discussion: Despite limitations due to the type of study, a text message encouraging personnel to be more
vigilant is effective in increasing hand hygiene adherence in health care workers.
Conclusions: Text message feedback should be incorporated into multimodal approaches for improving
hand hygiene compliance.
© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier
Inc. All rights reserved.

Health care-associated infections (HCAI) affect 5%-15% of pa-
tients hospitalized in developed countries, causing an increased
duration of stay, mortality in Europe estimated to reach 50,000
deaths per year, mortality in the United States reaching 99,000 deaths
per year, and a financial burden of €13-24 billion in Europe.1 Up to
30% of patients admitted to intensive care units develop HCAI.2 The
most frequent types of infection are urinary tract infections, sur-
gical site infections, bloodstream infections, and pneumonia.3
* Address correspondence to Philippe Brouqui, MD, PhD, Service des Maladies
Infectieuses et Tropicales AP-HM Hopital Nord, Chemin des Bourrely, Marseille 13015,
France.
E-mail address: philippe.brouqui@univ-amu.fr (P. Brouqui).
Conflicts of interests: PB is a codiscoverer of MediHandTrace, part owner of the
patent, and is participating in a MediHandTrace start-up company.
JK and YT participated equally in the study.
Moreover, the use of broad spectrum antibiotics favors the devel-
opment of multidrug-resistant organisms, especially infections dues
to carbapenemase-resistant enterobacteriaceae, causing a world-
wide public health problem because they are associated with life-
threatening infections lacking significant therapeutic possibilities.4,5
Multidrug-resistant pathogens are usually contracted in hospital
environments.
Contaminated health care worker (HCW) hands play a very
important role in the transmission of health care-associated patho-
gens. Hand transmission of pathogens requires several conditions:
The presence of the organism on a patient’s skin, the transfer to a
HCW’s hand, the survival of the organism on the hands, the lack
of good hand hygiene, and finally the cross-transmission of the
organism.1
Many studies have evaluated the compliance of HCWs with
hand hygiene. A systematic review and meta-analysis performed

0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2016.10.018
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2 J. Kerbaj et al. / American Journal of Infection Control ■■ (2016) ■■-■■

by Ofek Shlomai et al6 concerning interventions improving hand

hygiene compliance in neonatal units indicates that educational
campaigns, reminders, easy access to hand hygiene sanitizers and
UV sensors improve hand hygiene, and that performance feed-
back can greatly improve compliance with hand hygiene. Another
systematic review by Erasmus et al7 found an overall compliance
rate of 40% for hand hygiene, with compliance of only 21% before
contact with patients. The overall compliance with hand hygiene
remains low in many studies, and is probably lower than what is
already known, because the gold standard for monitoring hand
hygiene is the direct observational survey, which is prone to the
Hawthorne effect.8,9
A multimodal intervention, including feedback and reminders
seems to play a very important role in the success of hand hygiene
campaigns. To improve compliance with hand hygiene in our ward,10
we aimed to evaluate the influence of text message feedback on hand
hygiene compliance of our HCWs. To do so, after a 12-month period
spent monitoring the personnel with our automatized continuous
monitoring system11 without any outside intervention, we sent a
weekly text message to HCWs, encouraging them in better com-
pliance with hand hygiene or congratulating them for their good
compliance. We report here the behavioral changes of HCWs toward
hand hygiene consequent to this smartphone feedback.
Fig 1. Schematics of a room equipped with an MediHandTrace system
(MediHandTrace SAS, La Garde, France). 1 = Outdoor hand disinfection. 2 = En-
trance. 3 = Indoor hand disinfection before contact. 4 = Contact with patient. 5 =
MATERIALS AND METHODS Indoor hand disinfection after contact.

The study took place in the Infectious Diseases Department of

the North Hospital in Marseille, France, between October 2014 and
August 2015. The ward is composed of 15 rooms and divided into
2 sectors, among which 7 single patient rooms have been equipped
with MediHandTrace (MHT; MediHandTrace SAS, La Garde, France),
a radiofrequency identification-based (RFID) real-time automated
continuous recording system.11
The MHT monitoring system
Hand hygiene alcoholic dispensers were installed outside and
inside each room. The MHT system is an automated RFID micro-
chip traceability system identifying in real time a HCW’s entrance
and exit, and recording the use of a hydroalcoholic solution inside
and outside the room in each of the 7 rooms where it is imple-
mented (Fig 1). It has been evaluated against video recording with
an accuracy of 99.2%, sensitivity of 95.65%, and specificity of 100%.11
Personal electronic microchip-tagged shoes were given to all the
participants in this study. A short demo video is available at
https://www.youtube.com/watch?v=d1Oa7vNT_iQ.
The population
The study design
This study was a nonrandomized before–after comparison study
with alternate periods of intervention during which we moni-
tored the participants’ compliance with hand hygiene for 360 days
before starting to send text message feedback to define a baseline.
For organizational purposes, we established alternate interven-
tion periods following this pattern: Half of HCW participants in the
study received a text message every Monday for 4 weeks. After 4
weeks, we stopped sending messages for 48 days, and we started
sending text messages to the other half of the participants every
Monday for 4 weeks. We performed this entire procedure 3 times
in succession. We then regrouped the 2 groups and studied them
simultaneously. We divided the study into 4 periods, the first being
the 360 days before receiving the messages; the second period con-
sisted of 28 days during which we sent a text message once a week
to the participants (phase 1), and 48 days following during which
we did not send any text message (phase 2); then a third and fourth
period identical to the second period. The duration of the fourth
period was a little shorter because we sent messages for only 21
days (Fig 2).

Eighty-eight HCWs had tagged shoes and were monitored, in-
cluding doctors, residents, medical students, nurses, nursing
assistants, and housekeeping personnel aged between 21 and 56
years. We excluded participants who refused to participate in the
study, participants who did not work for the entire period of the
study, participants who did not have at least 50 recordings before
the feedback period, and participants who did not receive any text
messages. Finally, 18 staff members working full time in the de-
partment were included to participate in this study, among them
2 doctors (11.11%), 8 nurses (44.44%), 5 nursing assistants (27.78%),
and 3 housekeeping personnel (16.67%). These staff members gave
their consent to be included in the study, and were present for the
entire duration of the study.
Studied variables
Compliance with hand hygiene was defined as rubbing hands
together with a hydroalcoholic solution inside a patient’s room im-
mediately before patient contact.
In our system, this was recorded as a “3-4. . ..” sequence, reflect-
ing taking the hydroalcoholic solution from the distributor inside
the room while at the same time being in contact with antenna No.
3 (sequence 3) and before contact with antenna No. 4 (sequence
4). No hand hygiene before patient contact was recorded by all se-
quences as “no 3 before 4” (Fig 1).
The period of intervention was the period during which we sent
text messages every Monday of every week.
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J. Kerbaj et al. / American Journal of Infection Control ■■ (2016) ■■-■■
Fig 2. The 4 study periods. Period 1 was the preintervention period. Periods 2, 3, and 4 were composed of 2 phases each: phase 1 was the period during which health care
workers received text message feedback every Monday (28 days in periods 2 and 3, and 21 days in period 4), and phase 2 was the period during which health care workers
did not receive feedback (48 days).
Short message service text messages
The participants in our study received 1 of 2 types of text mes-
sages every Monday morning. The first type was a congratulatory
message: “From date X to date Y, you have improved your hand
hygiene. Congratulations, keep it going, good work.”
The second type was an encouragement message: “From date
X to date Y, your hand hygiene did not improve, and we encour-
age you to be more vigilant.”
The participants received the congratulatory message when
they had improved hand hygiene in comparison with the previous
week (higher hand hygiene adherence rate registered versus the
previous week), and they received the encouragement message
when they had not improved their compliance in comparison with
the previous week (lower or unchanged hand hygiene adherence
rate registered versus previous week). The first week of the study
was compared with the 360 monitored days before sending text
messages.
Statistical analysis
The statistical analysis was performed using SPSS software
package version 20.0 (IBM-SPSS Inc, Armonk, NY). We first global-
ly compared the hand hygiene adherence rate before and during
the period of intervention, using the χ2 test. The null hypothesis was
that there were no differences in the compliance level with hand
hygiene before and during the period of intervention; the alterna-
tive hypothesis was that there was a progression in the level of
compliance with hand hygiene during the intervention. Differ-
ences were considered statistically significant at P < .05.
In a previous study not yet published, we showed that the in-
dividual behavior toward hand hygiene combined with the number
of hand hygiene opportunities (activity) of a specific HCW may
bias the data, because this HCW may over- or underestimate the
other participants’ data. (Dufour JC, unpublished data). To check
this hypothesis, we proceeded to an empty multilevel logistic re-
gression model that confirmed the necessity of using a unilateral
multilevel regression model, to take the individual effect, and the
number of hand hygiene opportunities by each HCW into
consideration.
We used the interclass correlation coefficient that was esti-
mated based on assumptions for a binary variable, with the variable
attributable to an individual variable effect as numerator and the
total variance as denominator. All statistical analyses were consid-
ered statistically significant with P values < .05 with a 2-sided test.
Finally, we tested changes in hand hygiene behavior depend-
ing on the type of message sent during each period of our study.
We compared the evolution of the hand hygiene adherence rate in
HCWs receiving 3 or more congratulatory messages versus HCWs
receiving 3 or more encouragement messages during each period.
For statistical analysis we used a multilevel regression model. The
3
comparison was done between the 28 days during which the par-
ticipants received the messages and the 48 days following, during
which they received no feedback (phase 1 vs phase 2 of periods 2,
3, and 4).
Ethics
An oral and written consent to participate in the study was
obtained from the HCWs. To ensure anonymity of data, a random
number was attributed to each participant when entered in the
database. This study was declared to the French Commission on
Individual Data Protection and Public Liberties. This study was ap-
proved by the ethics committee of our foundation (No. 2016-018).
RESULTS
We recorded 15,723 hand hygiene opportunities during our study
done by 18 HCWs, including 8,973 (57.1%) hand hygiene opportu-
nities before the intervention (period 1) and 6,750 (42.9%) during
the intervention (periods 2, 3, and 4) (Table 1). During the first period,
the hand hygiene adherence rate was 1,336 out of 15,723 (14.89%).
During the intervention period, hand hygiene adherence rate in-
creased significantly to 1,559 out of 6,750 (23.09%) (Pearson χ2,
41.038; P < .001).
When we used an empty multilevel logistic regression model to
integrate the individual effect on the hand hygiene adherence rate,
we found that 26% of the total variation of hand hygiene adher-
ence was due to the sole difference in hand hygiene behavior
between the individuals themselves (intraclass correlation coeffi-
cient, 0.26; AIC [Alkaide Information Criterion], 9193.94). We
integrated those data and then used a univariate multilevel regres-
sion model, allowing us to consider the individual effect that we
tested previously with the empty multilevel regression model. Once
adjusted, the value of the odds ratio was 1.68 (95% confidence in-
terval, 1.45-1.79] (P = .001). The HCWs had an increase of 1.68 times
in their hand hygiene adherence rate during the intervention period
compared with before the intervention.
HCWs responded differently to text messages stimulation. Fifteen
of 18 (83.33%) HCWs improved their hand hygiene during the text
messages feedback period. Of those who decreased their hand
hygiene adherence rate, there was a nurse with an initial 47% ad-
herence rate and 2 housekeeping personnel (Fig 3). The rate of
improvement after the intervention varied between 2.10% and 32.10%,
depending on the subject.
We were interested in the type of text message sent and its in-
fluence on compliance with hand hygiene. During all 3 periods of
the study (4 weeks of feedback, followed by 48 days without feed-
back), the congratulatory messages led to nonsignificant changes
in the hand hygiene adherence rate, whereas encouragement mes-
sages led to a significant increase in the hand hygiene adherence
rate; the results were identical during periods 2, 3, and 4 (Table 2).
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Table 1
Number of hand hygiene opportunities (HHOs) per participant

Study period
Subject identification No. Work category 1 2 3 4 Total
18 Nursing assistant 1,357 251 198 301 2,107
22 Doctor 122 31 30 26 209
25 Doctor 69 19 19 5 112
29 Nurse 75 13 17 10 115
34 Nurse 682 82 99 54 917
52 Housekeeping personnel 310 36 64 5 415
56 Nurse 172 78 156 97 503
61 Nurse 495 51 87 31 664
70 Nursing assistant 1,222 333 254 119 1,928
76 Nurse 667 210 129 74 1,080
79 Housekeeping personnel 318 233 200 96 847
88 Nurse 365 195 136 49 745
102 Nurse 645 147 114 47 953
104 Nursing assistant 263 181 114 129 687
105 Nursing assistant 407 147 89 96 739
108 Nursing assistant 1198 161 132 150 1,641
129 Housekeeping personnel 308 300 340 215 1,163
135 Nurse 298 226 200 174 898
Total 8,973 2,694 2,378 1,678 15,723

Fig 3. The evolution of good compliance per participant during intervention. Fifteen of 18 health care workers improved their hand hygiene adherence during the inter-
vention. Two of the 3 others were housekeeping (HK) personnel and the third was a nurse with an initial 47% adherence with hand hygiene protocols.

DISCUSSION Individual hand hygiene behavior coupled with personal activ-

To our knowledge, this is the first study reporting the evalua-
tion of text messages feedback on hand hygiene adherence rate.
Some mobile applications have emerged over the past few years.
A review of existing mobile telephone applications for preventing
HCAIs by Schnall et al12 found 17 relevant primary applications
with very narrow functionalities, mostly limited to providing
information, with no application providing reminders or alerts to
the HCW. Moreover, very few downloads are reported for these
applications, limiting their use.
Many studies have showed improvement of hand hygiene after
an intervention, from 7.5% to 30.6%, depending on the study, but
the duration of most of the studies was not known or very short
(3 months), and most of these studies were based on a multimodal
approach to improving hand hygiene.13-15
ity (which depends on the workflow and the number of shifts per
month) was shown to bias the data, as demonstrated by the empty
multilevel model. A multilevel analytic strategy thus appeared to
us to be the most accurate methodology.16 Case–control or ran-
domized studies are usually preferred to historical comparison proof-
of-concept studies. However, in our case, neither case–control nor
randomization was possible. Our monitoring system is not yet avail-
able in the entire hospital, because it would not allow multisite
studies, and randomization of HCWs is debatable due to the small
number of persons, occupational responsibilities, and the influence
of professional categories, as well as the overestimate of individ-
ual behavior and workflow, as discussed above.
Many reminders and feedback techniques have been created and
studied during the past few years, beginning with new optimized
evidence-based signs in a case–control study by Birnbach et al17 that
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Table 2
Health care workers having received at least 3 congratulatory messages or encouragement mes-
sages during phase 1 of every period
NOTE. Increase in hand hygiene adherence after sending 3 encouragement messages. No change in
hand hygiene adherence after sending 3 congratulatory messages.
found low hand hygiene compliance (16%) with no statistically sig-
nificant difference using normal, nonspecific signs, suggesting that
the content and design of signs do not increase hand hygiene com-
pliance. Another case–control study using chimes and continuous
real-time display of compliance in the form of hand hygiene re-
minder systems for HCWs showed an increase in hand hygiene
activity without decay in activity during a 5-week period when the
2 systems were in place together, whereas when using only chimes
or only the display there was an initial increase, with an apparent
decay of the effectiveness over 5 weeks.18 Another study using flash-
ing lights fixed to hand hygiene sanitizers and including signs as
reminders for a period of 6 weeks found that flashing lights in-
creased adherence with hand hygiene by 8.9%, with an association
between the level of brightness of the light and compliance. The
preemptive signs did not have any significant effect on hand hygiene
rates.19 Many studies have tried applying psychological frame-
works to improve hand hygiene compliance, showing that increased
emotional empathy improves hand hygiene adherence in HCWs, and
psychological frameworks seem to be interesting tools in enhanc-
ing hand hygiene adherence.20,21 We decided to observe whether
there was any difference in the reaction of HCWs to 1 of the 2 types
of text messages sent during each period. Our results showed that
encouraging the personnel to be more vigilant makes them improve
their compliance with hand hygiene after the end of the interven-
tion, whereas congratulating them for their good work was not
associated with an increase in compliance after the end of the in-
tervention. The results were identical in each of the 3 periods of
the study.
The main strength of our study is its long duration (10 months),
whereas most of the studies using reminders or feedback have du-
rations of a few weeks to a few months, and the large number of
hand hygiene opportunities (n = 15,723). Sending text messages once
a week was very well accepted by the HCWs; they are inexpen-
sive, time-sparing, and may be less annoying than continuous chimes,
5
and they are more effective than signs. No decay effect was de-
tected over the duration of our study, and the effectiveness of this
method was maintained during the 48 days following the last text
message when sending an encouragement message.
A study aiming to identify key beliefs of hospital nurses toward
hand hygiene showed that lack of time and forgetfulness are seen
as the main barriers to good adherence with hand hygiene. Thus,
regular, effective reminders in the workplace are necessary to combat
forgetfulness.22 In our study, we showed that encouragement
feedback is more effective in the middle term than congratulatory
feedback.
CONCLUSIONS
Text message feedback should be incorporated into a multimodal
approach (including education and behavior approaches) for
improving hand hygiene compliance and reducing the risk of
HCAIs. Decay of efficacy seems to be very common after interven-
tions to improve hand hygiene adherence, and sustaining good hand
hygiene compliance in the long term is very important; thus, a short
intervention might not be very effective in the long term. For this
reason, we encourage long-term, regular, random text messages
to HCWs encouraging them to be in in good adherence with hand
hygiene. This method would contribute greatly to decreasing for-
getfulness and encouraging good compliance in HCWs, thus limiting
HCAIs.
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