***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Although h and hygiene ( HH ) compliance has been an important issue for years , the compliance rate is still a problem in health care today . METHODS This was an observational , prospect i ve , before- and -after study . We measured HH knowledge and HH compliance  before ( baseline ) , directly after ( post strategy ) , and 6 months after the performance of HH team strategies ( follow-up ) . The study was composed of employed nurses and physicians working in the department of internal medicine of a university hospital . We performed a multifaceted improvement program including HH education , feedback , reminders , social influence activities including the use of role models , and improvement of HH facilities . RESULTS Ninety-two nurses and physicians were included . Compared with baseline , there was a significant improvement in the overall mean HH knowledge score at post strategy ( from 7.4 to 8.4 ) and follow-up ( from 7.4 to 8.3 ) . The overall HH compliance was 27 % at baseline , 83 % at post strategy , and 75 % at follow-up . At baseline , the compliance rate was 17 % in nurses and 43 % in physicians and significantly improved to 63 % in nurses and 91 % in physicians at follow-up . CONCLUSION Our multifaceted HH improvement program result ed in a sustained improvement of HH knowledge and compliance in nurses as well as physicians HighlightsAttitudes among nurses toward h and hygiene and h and rubbing with alcohol‐based h and rub are positive . Self‐reported alcohol‐based h and rub use is suboptimal . New graduate nurses report greater compliance with h and rubbing than more experienced nurses . Barriers to using alcohol‐based h and rub are improved in recent years . Existing barriers reported include skin sensitivity , skin damage , intolerance , and time . Background : H and hygiene reduces health care – associated infections significantly . However , international evidence suggests that practice s are suboptimal . The objective of this study was to compare and contrast h and hygiene attitudes and practice s and alcohol‐based h and rub ( ABHR ) use among nurses between 2007 and 2015 . Methods : In 2007 , a r and om sample of nurses in a large teaching hospital was invited to complete a postal survey using a vali date d question naire . In 2015 , the study was replicated among all nurses employed in a university hospital group , including the setting of the original study . Data were analyzed quantitatively and qualitatively using appropriate software . Results : Attitudes to h and hygiene were positive and > 90 % of respondents ' self‐reported compliance before and after patient contact . However , 13 % fewer in 2015 ( 42 % ) reported using ABHR  > 90 % of the time compared with in 2007 ( 55 % ) . Of nurses with < 2 years ' experience , 90 % reported using ABHR  > 50 % of the time compared with 73 % of nurses with 2‐5 years ' experience  . Barriers to ABHR  improved , but remained high ( skin sensitivity : 2007 : 23 % , 2015 : 17 % ; skin damage : 2007 : 18 % , 2015 : 13 % ; poor user acceptability and tolerance : 2007 and 2015 : 25 % ) . Conclusions : Use of positive role models , the adoption of a positive social and cultural norm within the organization , and the provision of continuing professional development opportunities may prove useful strategies in harnessing good practice among graduate nurses and in preventing negative socialization from occurring ISSUE H and hygiene is a cost-effective measure to reduce microbial transmission ( Teare EL , Cookson B , French GL , et al. UK h and washing initiative . J Hosp Infect . 1999;43:1 - 3 . ) and is considered to be the most important measure to prevent healthcare-associated infections ( Pittet D , Allegranzi B , Sax H , Evidence -based model for h and transmission during patient care and the role of improved practice s. Lancet Infect Dis 2006;6:641 - 52 ) . Unfortunately , the compliance rate of healthcare workers ( HCWs ) with recommended h and hygiene procedures is less than expected . INITIAL ASSESSMENT In order to estimate the effect of a multimodal intervention on improving  healthcare workers ' compliance with h and hygiene in eleven intensive care units ( ICUs ) from 11 hospitals of Buenos Aires , a r and omized cluster-stepped wedge trial was design ed . CHOICE OF SOLUTION AND IMPLEMENTATION A multimodal intervention was design ed based on practice s characterized by being evidence -based , low cost and suggested by qualitative research : ( i ) leadership commitment , ( ii ) surveillance of material s needed to comply with h and hygiene and alcohol consumption , ( iii ) utilization of reminders , ( iv ) a storyboard of the project and ( v ) feedback ( h and hygiene compliance rate ) . EVALUATION The study enrolled 705 participants , comprising nurses ( 66.4 % ) , physicians ( 25.8 % ) and other HCW ( 7.8 % ) along 9 months of observation . Compliance with h and hygiene in the control group was 66.0 % ( 2354/3565 ) vs. 75.6 % ( 5190/6864 ) in the intervention group . Univariate analysis showed an association between the intervention and h and hygiene compliance ( odds ratio , OR 1.17 ; 95 % confidence interval ( CI ) , 1.13 - 1.22 ) . The effect was still present after adjustment by calendar 's time and providers ' characteristics-age , gender and profession ( OR 1.08 ; 95 % CI , 1.03 - 1.14 ) . LESSONS LEARNED His study supports that a multimodal intervention was effective to improve compliance with h and hygiene in ICUs BACKGROUND Improving h and hygiene compliance is still a major challenge for most hospitals . Innovative approaches are needed . OBJECTIVE We tested whether an innovative , theory based , team and leaders-directed strategy would be more effective in increasing h and hygiene compliance rates in nurses than a literature based state-of-the-art strategy . DESIGN AND SETTING A cluster r and omised controlled trial called HELPING H AND S was conducted in 67 nursing wards of three hospitals in the Netherl and s. PARTICIPANTS All affiliated nurses of the nursing wards . Wards were r and omly assigned to either the team and leaders-directed strategy ( 30 wards ) or the state-of-the-art strategy ( 37 wards ) . METHODS The control arm received a state-of-the-art strategy including education , reminders , feedback and targeting adequate products and facilities . The experimental group received all elements of the state-of-the-art strategy supplemented with interventions based on social influence and leadership , comprising specific team and leaders-directed activities . Strategies were delivered during a period of six months . We monitored nurses ' HH compliance during routine patient care before and directly after strategy delivery , as well as six months later . Secondary outcomes were compliance with each type of h and hygiene opportunity , the presence of jewellery and whether the nurses wore long-sleeved clothes . The effects were evaluated on an intention-to-treat basis by comparing the post- strategy h and hygiene compliance rates with the baseline rates . Multilevel analysis was applied to compensate for the clustered nature of the data using mixed linear modelling techniques . RESULTS During the study , we observed 10,785 opportunities for appropriate h and hygiene in 2733 nurses . The compliance in the state-of-the-art group increased from 23 % to 42 % in the short term and to 46 % in the long run . The h and hygiene compliance in the team and leaders-directed group improved from 20 % to 53 % in the short term and remained 53 % in the long run . The difference between both strategies showed an Odds Ratio of 1.64 ( 95 % CI 1.33 - 2.02 ) in favour of the team and leaders-directed strategy . CONCLUSIONS Our results support the added value of social influence and enhanced leadership in h and hygiene improvement strategies . The methodology of the latter also seems promising for improving team performance with other patient safety issues . TRIAL REGISTRATION Clinical Trials.gov [ NCT00548015 ] Objective To improve h and hygiene in two outpatient health care clinics through the introduction of a gel sanitizer and an informational poster . Methods In this interventional study , health care workers at two outpatient clinics were observed for frequency of h and hygiene ( attempts versus opportunities ) . Gel sanitizer and informational posters were introduced together as an intervention . Direct observation of the frequency of h and hygiene was performed during baseline , intervention , and follow-up . A post study survey of health care workers was also distributed and collected . Results In both clinics , the frequency of h and hygiene was poor at baseline ( 11 % and 21 % ) but improved significantly after intervention ( 36 % and 54 % ) and was maintained through the follow-up period ( 32 % and 51 % ) . Throughout the study , postcontact h and hygiene was observed significantly more often than precontact h and hygiene . In both clinics , health care workers reported a preference for soap and water ; yet observations showed that when the intervention made gel sanitizer available , sanitizer use predominated . Fifty percent of the surveyed health care workers considered the introduction of gel sanitizer to be an effective motivating tool for improving h and hygiene . Conclusions H and hygiene performance by health care workers in outpatient clinics may be improved through promoting the use of gel sanitizer and using informational posters . Compared with surveys , direct observation by trained observers may provide more accurate information about worker preferences for h and hygiene tools BACKGROUND Although h and hygiene remains an essential aspect of quality care , adherence to best patient safety practice s continues to pose major challenges . OBJECTIVES The objectives of this study are to examine h and hygiene knowledge , beliefs , practice s , perceived importance and behaviors using Social Cognitive Theory and simulation-based intervention . DESIGN Participants were taken from a convenience sample of 131 undergraduate nursing students enrolled in a nursing fundamentals course at an urban university in the midwestern United States , and then r and omly assigned to their respective groups . Using an experimental pretest-posttest design , control and intervention groups received the same lecture pertaining to h and hygiene and 3 data collection points where van de Mortel 's H and Hygiene Question naire ( HHQ ) was administered . In addition , the intervention group viewed a 6.5min video related to healthcare acquired infection and participated in 4 simulated situations requiring h and hygiene , based on World Health Organization guidelines . For all students , the h and  hygiene technique was assessed through the use of Glo Germ , followed by h and washing and photography under ultraviolet light ( posttest only ) . Image illumination was analyzed using image processing software . Microbiological sampling plates ( pretest-posttest ) were assessed quantitatively by colony counting . RESULTS Study findings did not support differences in the intervention group for the 5 hypothesized relationships . Social desirability responding and negative item confusion were found to occur with the HHQ in the student population . There was a significant difference in the UV h and photographs , with students in the afternoon having lower values than students in the morning . CONCLUSIONS Given the study results , there were no definitive educational recommendations to teach h and hygiene to nursing students . Future research should continue to further examine multi-focal modalities to enhance adherence to h and hygiene practice s , as well as control for extraneous mediating or moderating variables found in educational setting OBJECTIVE To evaluate the effectiveness of a multimodal intervention in primary care health professionals for improved compliance with h and hygiene practice , based on the World Health Organization 's 5 Moments for Health Hygiene . DESIGN Cluster r and omized trial , parallel 2-group study ( intervention and control ) . SETTING Primary healthcare centers in Madrid , Spain . PARTICIPANTS Eleven healthcare centers with 198 healthcare workers ( general practitioners , nurses , pediatricians , auxiliary nurses , midwives , odontostomatologists , and dental hygienists ) . Methods . The multimodal h and hygiene improvement strategy consisted of training of healthcare workers by teaching sessions , implementation of hydroalcoholic solutions , and installation of reminder posters . The h and hygiene compliance level was evaluated by observation during regular care activities in the office visit setting , at the baseline moment , and 6 months after the intervention , all by a single external observer . RESULTS The overall baseline compliance level was 8.1 % ( 95 % confidence interval [ CI ] , 6.2 - 10.1 ) , and the healthcare workers of the intervention group increased their h and hygiene compliance level by 21.6 % ( 95 % CI , 13.83 - 28.48 ) compared with the control group . CONCLUSIONS This study has demonstrated that h and hygiene compliance in primary healthcare workers can be improved with a multimodal h and hygiene improvement strategy Objective To compare plain soap , alcohol h and rub and iodophors as h and hygiene measures in a neonatal intensive care unit ( NICU ) . Design R and omized , crossover , three-armed , controlled trial with blinded outcome measurementS ettingLevel III NICU Participants 35 NICU nursesIntervention Participants were assigned to plain soap h and washing , alcohol h and rub and povidone-iodine h and scrub by a r and om cross-over design . Interventions were preceded 
    Output:
    
Strategies such as reminder sounds , practical simulations , videos , and audiovisual media improved h and washing compliance .
Conclusions : The strategies that go beyond teaching techniques such as lectures may be more effective at increasing h and hygiene compliance .
Combined approaches to learning/instruction improve user satisfaction by enabling self-management , flexibility , and repetition