Correspondence (reply): In Reply

We thank Kramer and Kiesewetter for their comments on our original article on the compliance results of the PSYGIENE-study (1).

First, an apparent misconception by Kiesewetter must be clarified, namely the indication that hygienic hand disinfection compliance was assessed by questionnaire: in fact, it was operationalized via direct observation in line with the gold standard by the World Health Organization and Germany’s nationwide “Clean Hands Campaign” (Aktion Saubere Hände, ASH) (1). Thus, irrespective of their appraisal, the achieved increase rates are valid.

Also, it was with interest that we read his thoughts on video monitoring to promote compliance. The most recent systematic review article concluded that no sufficient evidence was available to recommend video monitoring systems (2), and whether more recent work such as the observational study on surgical hand washing in Pakistan (3), which Kiesewetter cites, is applicable to hygienic hand disinfection in German health care is questionable.

Yet, we agree with Kiesewetter when he at least indirectly poses the question of how compliance rates of = 80% can be sustainably achieved (which even the cluster-randomized controlled PSYGIENE-trial with its comparably long follow-up period did not accomplish). In this regard, it is in fact appropriate to evaluate technological, e.g. video-based, methods over and above interventions such as educational training sessions and feedback discussions.

However, in our view such methods will only be sustainable if they are not primarily used for repression, going as far as (as suggested by Kiesewetter) dismissal in case of repeated non-compliance, but only if they are integrated in evidence-based, multimodal strategies which allow for individual goal-setting, organizational incentives, and professional accountability (4).

Responding to the comment by Kramer, the fact that in the PSYGIENE-study, compliance initially increased in both study arms, despite participation rates in the educational training sessions of about 50% only, is probably explainable both by the intensified supervision of all wards (i. e. the „booster“-effect [1]) and the 100 percent participation rates in the feedback discussions.

Besides, we willingly clarify that the psychologically tailored interventions were compared to the local ASH at Hannover Medical School (MHH, Medizinische Hochschule Hannover). The narrative for this is the impression that while the Health Action Process Approach had been described as its compliance model by the national ASH on its homepage, and in this sense made available to the MHH as well, it had not been sufficiently recognized by MHH’s ASH-personnel. It is in this sense that the description of the PSYGIENE-control arm as a “one size fits all”-approach was implied.

However, we are convinced that campaigns, and thus the ASH as well, are in fact susceptible to this risk. Thus, hand hygiene interventions should proceed as theory-based as possible by consequent empirical assessment of relevant compliance determinants and matched selection of behavior change techniques (5). It is in this approach (and not so much in “new” methods) that the PSYGIENE-study’s innovation lies (1).

Finally, we agree with Kramer that hand hygiene promotion (like guideline implementation and quality management) is a continuous task.