Journal of Hospital Infection (2007) 65, 58e64

www.elsevierhealth.com/journals/jhin

Effective hand hygiene education with theuse of flipcharts in a hospital in El Salvador

M.A. Caniza a,*, G. Maron b, E.J. Moore c, Y. Quintana d, T. Liu e

a Department of Infectious Diseases and International Outreach Program, St Jude Children’s ResearchHospital, Memphis, TN, USb Department of Infectious Diseases, Hospital Nacional de Ninos Benjamin Bloom, San Salvador,El Salvadorc Office of Educational Assessment, University of Washington, Seattle, WA, USAd International Outreach Program, St Jude Children’s Research Hospital, Memphis, TN, USAe Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, TN, USA

Received 23 June 2006; accepted 29 August 2006Available online 4 December 2006

KEYWORDSHand hygiene;Infection control;Education; Developingcountries; El Salvador;Flipcharts

Summary In developing countries, continuing education for healthcarestaff may be limited by staff shortages and lack of sophisticated meansof delivery. These limitations have implications for compliance with an im-portant infection control practice, namely good hand hygiene. A compari-son was made between the efficacy of two educational tools commonlyused in healthcare and practical sanitation settings in developing coun-tries, i.e. videotapes and flipcharts, in delivering hand hygiene educationto 67 nurses in a paediatric hospital in El Salvador. Efficacy was measuredon the basis of scores obtained in pre- and post-training tests consisting of10 multiple-choice questions. Half of the nurses received video-basedinstruction and half received instruction via flipcharts. Both methods ofinstruction increased participants’ knowledge of good hand hygiene, andthe extent of knowledge acquisition by the two methods was similar. Feed-back obtained from flipchart users six months after training indicated thatmost of the respondents used the flipchart to teach hand hygiene to pa-tients’ families (62.5%), patients (50%) and healthcare workers (43.8%).Flipchart users ranked flipcharts as their favourite educational tool. Flip-charts offer an economical, easy-to-use, non-technological yet effectivealternative to videotapes for delivering education in developing countries.

* Corresponding author. Address: St Jude Children’s Research Hospital, 332 North Lauderdale St, MS 721, Memphis, TN 38105-2794,USA. Tel.: þ1 901 495 4194; fax: þ1 901 495 2099.

E-mail address: miguela.caniza@stjude.org

0195-6701/$ - see front matter ª 2006 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.jhin.2006.08.011

Effective hand hygiene education using flipcharts in El Salvador 59

Although the use of flipcharts requires a skilled and well-trained instructor,flipcharts could be used more widely to deliver education in resource-poorsettings.ª 2006 The Hospital Infection Society. Published by Elsevier Ltd. All rightsreserved.

Introduction

Careful hand hygiene is the single most importantfactor in preventing nosocomial infections.1 Theimportance of this practice is emphasized in thecurrent guidelines of the US Centers for DiseaseControl and Prevention2 and the World HealthOrganization (available at http://www.who.int/patientsafety/en/) All staff caring for patientsneed to comply with this practice and be providedwith education at periodic intervals.3

In developing countries, staff shortages limit thetime available for educational activities, andsophisticated means of delivery (e.g. onlinecourses, video presentations) are often lacking orprohibitively expensive and time-consuming toarrange (unpublished observations).4 Under suchconstraints, education may be facilitated by simple,non-technological, easy-to-use educational tools.

This study compared the efficacy of two educa-tional tools (videotapes and flipcharts) commonlyused in healthcare settings and in practicalsanitation programmes in developing countries (e.g.the solar water disinfection manuals publishedby the Swiss Federal Institute for EnvironmentalScience and Technology, available at http://www.sodis.ch/Text2002/T-EducationMaterials.htm).5 Thesetting was a paediatric hospital in El Salvador. Theefficacy of the tools for teaching nurses about handhygiene was measured by comparing pre- andpost-training knowledge. Usability of the flipchartswas assessed by a survey and a follow-up interviewof participants six months after the initial flipcharttraining. The participants were asked both open-ended and closed-ended questions about their ex-periences using the flipchart.

Methods

The study was conducted at the Hospital Nacionalde Ninos Benjamin Bloom (HNNBB) in San Salvador,El Salvador; a 300-bed, public, paediatric teachinghospital and major referral centre. The study wasapproved by the Research Ethics Committee ofHNNBB and by the St Jude Children’s ResearchHospital Institutional Review Board. Of the 383

nurses who work at the hospital, 167 were workingon the day of the study and 67 (40%) participatedin the study.

A videotape and a flipchart, comprising 13spiral-bound, laminated pages, 1000 wide and 1700

high (Figure 1), were created to convey the impor-tance of hand hygiene; when to practised handhygiene; how to practice hand hygiene effectively;the use of alternatives to traditional handwashing,such as waterless agents; the correct way to usewaterless agents; and how to protect the handsafter washing.2 The information was presented ina culturally appropriate context (i.e. in Spanishand using Latin American actors). A summary ofthe instructor’s narration and cues for interactionwith participants was printed on the back of eachpage of the flipchart. The flipchart presentationcould be delivered in approximately 10 min. Thevideotape, which included culturally appropriatebackground music and showed close-up scenesfor clarity, ran for 7 min. The video was repro-duced on VHS tape and DVD, and can be viewedat www.Cure4Kids.org, the educational websiteof the St Jude Children’s Research Hospital(SJCRH) International Outreach Program. Thiswebsite provides free education and communica-tion for healthcare professionals worldwide.

The instructors were nurses from 10 Latin Amer-ican countries who were trained at an intensiveinfection control course developed by the author(MC) and delivered in El Salvador during February

Figure 1 Demonstration of use of the hand hygieneflipchart during training.

60 M.A. Caniza et al.

2005. This four-week course, entitled ‘Intensivecourse in infection control for infection controlprofessionals of Latin America’, was planned andimplemented through the collaborative efforts ofSJCRH, the Centro de Investigacion y Desarrollo enSalud of the University of El Salvador, HNNBB, anda Salvadoran national nursing society. The 22 in-structors received classroom and practical trainingin hand hygiene. Before the study was conducted,the instructors also received detailed informationabout conducting an educational session and usingthe videotape or flipchart. The instructors prac-ticed the presentation under the guidance of theirinfection control course teachers.

Participants’ knowledge acquisition was mea-sured by applying an identical, 10-item multiplechoice test (see Appendix) before and after thepresentations. The test items, which related di-rectly to information provided in the presenta-tions, addressed the following points: how thetransmission of microbes is most easily prevented,which statement about hand hygiene (of severaloffered) is correct, how the use of lotions affectshygiene, hand hygiene techniques, how longappropriate handwashing takes, how to preventrecontamination of the hands after washing, howbest to dry the hands, use of waterless handhygiene products, when to wash the hands andhow to use waterless hand hygiene products appro-priately. Each correct response scored one point(maximum 10 points). The instrument was re-viewed by three nurse educators, and items wererevised as necessary before the test was adminis-tered. The internal consistency and reliability ofthe instrument was later evaluated on the basisof the combined post-training score. When thereliability coefficient was calculated using all 10items, Cronbach’s alpha was 0.40.

The design of the study was approved by theethics committee of HNNBB. Nurses completingtheir morning shift were invited to participate,and those who agreed were assigned at random toreceive instruction by either videotape or flipchart.Presentations were performed in a manner similarto the hospital’s usual method of presenting edu-cational seminars. The videotape was presented toa single group (N¼ 33) in a large conference room,and the flipchart presentation was given to sixgroups of four to 10 participants (N¼ 34) in smallerrooms. The measured outcome was the number ofcorrect answers obtained after instruction (post-training test result) relative to that obtained beforeinstruction (pre-training test result) for each teach-ing method. Instruction by both methods occurredsimultaneously, and the entire procedure was com-pleted within the allotted hour.

McNemar’s test was used to compare the pre-and post-training test scores. Logistic regressionwas applied to compare the effects of the twodifferent training methods for each question.Pooled data (scores from all questions) wereanalysed using generalized linear models; thegeneralized estimating equation method wasused to account for repeated measurements ofthe categorical response (i.e. multiple questionsfor each student).6 Odds ratios (OR) were esti-mated with 95% confidence intervals (CI). Statisti-cal analyses were conducted using SAS software(Version 9.1, SAS Institute, Cary, NC, USA).

Results

Pre-training test results

The percentages of correct answers to all 10 ques-tions, according to presentation method and time oftesting (i.e. before or after the presentation), areshown in Table I. Overall, pre-training test resultswere statistically similar for the two training deliverymethods (P¼ 0.98).

Effects of training

McNemar’s test comparing the effects of the twomethods of delivery (Table II) found that the over-all training effect (results from both groups com-bined) was significant for most questions (2, 4, 5,7, 8, 9 and 10; P< 0.033). When the two methodswere compared with baseline, there was greaterimprovement over baseline in the responses toQuestions 2, 5, 7 and 8 after video-based training

Table I Percentage of correct answers by trainingmethod and testing time

Question Training

Video group Flipchart group

Beforetraining

(%)

Aftertraining

(%)

Beforetraining

(%)

Aftertraining

(%)

1 100 100 100 1002 9 85 24 413 33 45 29 414 85 97 76 885 12 82 21 916 76 88 74 797 18 39 24 388 36 85 41 829 58 79 47 5610 42 55 35 62

Effective hand hygiene education using flipcharts in El Salvador 61

Table II Comparison of training effects by McNemar’s test

Question Before training After training

Both groups Video group Flipchart group

Correct Incorrect P Correct Incorrect P Correct Incorrect P

1 Correct 67 0 e 33 0 e 34 0 eIncorrect 0 0 0 0 0 0

2 Correct 7 4 <0.001 3 0 <0.001 4 4 0.109Incorrect 35 21 25 5 10 16

3 Correct 15 6 0.074 9 2 0.290 6 4 0.250Incorrect 14 32 6 16 8 16

4 Correct 52 2 0.021 27 1 0.103 25 1 0.103Incorrect 10 3 5 0 5 3

5 Correct 11 0 <0.001 4 0 <0.001 7 0 <0.001Incorrect 47 9 23 6 24 3

6 Correct 46 4 0.109 24 1 0.103 22 3 0.480Incorrect 10 7 5 3 5 4

7 Correct 11 3 0.005 5 1 0.020 6 2 0.096Incorrect 15 38 8 19 7 19

8 Correct 25 1 <0.001 11 1 <0.001 14 0 <0.001Incorrect 31 10 17 4 14 6

9 Correct 29 6 0.033 16 3 0.052 13 3 0.320Incorrect 16 16 10 4 6 12

10 Correct 19 7 0.012 10 4 0.250 9 3 0.020Incorrect 20 21 8 11 12 10

(P� 0.020), and greater improvement over base-line in the responses to Questions 5, 8 and 10 afterthe flipchart presentation (P� 0.020).

Effects of the different training methods

This analysis estimated the OR for obtainingimproved performance (i.e. a greater increaseover baseline scores) on the post-training test,comparing the video and flipchart methods. Over-all, video-based training produced results similarto those of the flipchart method (estimated OR0.737; 95% CI 0.537e1.011; P¼ 0.059). Question-wise comparison showed that the two methodshad similar effects for all questions with the ex-ception of Question 2, for which video-based train-ing produced significantly more improvement thanthe flipchart method (estimated OR 8.032; 95% CI2.728e23.646; P< 0.001) (Question 2 asked whichof four statements about hand hygiene was true).

Feedback from users of the flipchart

User feedback was only sought for the flipchart.Hand hygiene flipcharts were given to all 22 partic-ipants on the infection control course in El Salvador.Six months after the course, feedback was obtainedusing a six-item questionnaire asking whether theyuse the flipchart (Question 1), the frequency of its

use and the type and number of people instructed ateach session (Question 2), their perception of thequality of the flipchart as an instructional tool(Question 3), the availability of other instructionaltools on hand hygiene at their institutions (Question4), how the flipchart, as an instructional tool,compared with other tools available for handhygiene education (Question 5) and the perceivedneed for developing flipcharts on other topics ininfection prevention and control (Question 6).

The six-item questionnaire was e-mailed to the17 participants with Internet access and theiranswers were reviewed in a follow-up telephonecall. Responses were received from 16 of the 17participants. Fifteen of these used the flipchartsafter returning to their institutions, and 75% usedthe flipcharts once or twice per week. Of 13respondents, eight answered that each sessionwas attended by 11e20 people, four answeredthat each session was attended by one to 10 people,and one answered that each session was attendedby more than 20 people. Half of the participantsindicated that patients attended these sessions,62.5% indicated patients’ families as attendees,and 43.8% indicated that healthcare workersattended the sessions. The flipchart users com-mented that they were easy to use and durable,that the text was easily visible and readable by theaudience, that the content was clear, and that theprinciples were applicable to their practices and

62 M.A. Caniza et al.

activities. They found no obstacles to the use of theflipcharts at their institutions. The participantsranked flipcharts as their favourite educationaltool among a list that included oral presentations,group discussion without an audiovisual aid, prac-tical demonstrations of hand hygiene, and the useof pamphlets and video. The participants alsoranked topics in infection prevention by preferencefor development in a flipchart format. At the top oftheir lists was prevention of infection of vascularaccess devices, followed by prevention of urinarytract infections, surgical site infections, antibioticresistance and pneumonia associated with mechan-ical ventilation.

Discussion

This study showed that hand hygiene instructiondelivered by a flipchart or videotape presentationincreases participants’ knowledge of hand hy-giene, as measured by pre- and post-training tests.The amount of knowledge acquired and measuredby the test was similar regardless of the methodused to deliver the instruction. Given that video-tape-based instruction is technology dependent, itwas concluded that flipcharts, which require littletechnological support, can serve as a useful toolfor teaching hand hygiene in developing countries.

A previous study showed that healthcare workersare fully aware of the importance of hand hygiene inpreventing and controlling infection.7 This studyvalidated this finding, as all participants correctlyanswered the question asking about the easiestway to prevent infections. However, before train-ing, both groups were deficient in knowledge ofthe time required to wash their hands adequately;only four members (12%) of the videotape groupand seven members (21%) of the flipchart groupgave the correct response. Healthcare workers’perceptions of the duration of washing required toachieve adequate cleanliness is an important factorin their adherence to the practice. They may be dis-couraged not only by obstacles such as complexmethods and lack of access to sinks or water, butalso by lack of knowledge about the time it takesto achieve appropriate cleanliness, which may beshorter than they realize.8e10 Therefore, knowingthe minimum time required to wash their handsproperly is important. After training, 87% of all par-ticipants selected the correct acceptable minimumtime required to wash hands.

Comparison of the two methods of delivery re-vealed that the odds of improved test performancewere lower after flipchart-based training than aftervideo-based training, but this difference was only

marginally significant. It was concluded that eithereducational method can increase participants’knowledge about hand hygiene. The choice ofmethod will depend on the availability of theappropriate technology and infrastructure, and,perhaps, on the instructor’s experience. Althoughthe use of flipcharts requires more preparation timeby the instructor, who must be adequately trained intheir use and in hand hygiene, flipcharts can bedeveloped in their most basic form at low cost, aremore versatile, and have smaller infrastructural andtechnological requirements [a sample can be viewedat: http://www.soph.uab.edu/gorgas/Documents/AriasprisonposterParis03.pdf]. This method is alsoparticularly suitable for deliveringeducation to smallgroups of, say, 10 people.

One limitation of this study is that the testinginstrument had less than ideal reliability, witha Cronbach’s alpha of 0.40 for all 10 items and 0.59for the five ‘best’ items. A value of 0.70 or higher isconsidered to indicate good reliability.11 A low dis-crimination index is obtained when questions needfurther revision and modification, and the score canbe low when the test is short and when it measuresmany different content areas and cognitive skills.12

In this case, the elimination or modification of prob-lem questions was difficult because all questionswere needed to cover the course’s content and ob-jectives adequately. In addition, the setting and cir-cumstances of the study’s design and conduct did notallow the authors the time or resources needed toperfect the instrument. The problem items will beimproved for future use. A second possible limitationof this study is thatvideo-based instructionwasdeliv-ered to a single large group, whereas the flipchartswere used in six small groups. The smaller group set-ting may have enhanced the learning experience ofthe participants, and biased the results in favour ofthe flipchart method. Conversely, variable presenta-tion skills among the instructors delivering the flip-chart presentations may have biased the findings inthe opposite direction. However, the sizes of thetest audiences were similar to those that might beexpected in a real-life setting. Furthermore, it isacknowledged that improved adherence to handhygiene among healthcare personnel depends notonly on technical knowledge and awareness of its im-portance, but also on the availability of necessarysupplies, accessible sinks, appropriate staffing,periodic performance feedback, and institutionalsupport.13e16

The users’ positive feedback was encouraging. Atrue measure of the efficacy of these educationalinterventions will require an evaluation of theattendees’ compliance with hand hygiene practiceat a later date. Additionally, evaluation of the

Effective hand hygiene education using flipcharts in El Salvador 63

durability of the knowledge acquired will informeducators about the necessary frequency of theseeducational interventions.

In conclusion, flipcharts provide an inexpensive,easy-to-use, educational tool for hand hygiene in-struction. They require minimal infrastructure andtechnology, and work well when the instructor istrained in their use. The flipchart training methodprovides a good alternative to the use of videotape,particularly in low-resource settings. Importantly,flipcharts can be used not only to educate healthcareprofessionals but also patients and their familiesabout the benefits of hand hygiene.

Acknowledgements

The authors wish to thank the HNNBB infectioncontrol doctors and nurses, and the students of theinfection control course for Latin American health-care workers held in San Salvador in 2005. Theauthors also thank Marcela Hill, the Cure4Kids staff,SJCRH Biomedical Communications, and actors whoparticipated in production of the flipchart and video.Janet R. Davies, PhD, provided excellent editorialadvice. Item analysis of the test instrument wasundertaken using ScorePak testing software at theUniversity of Washington Office of Educational As-sessment. This study was supported by the AmericanLebanese Syrian Associated Charities.

Appendix

Pre- and post-training test*

1. Which is one of the easiest ways to prevent thetransmission of microbes?a. Administration of antibiotics.b. Vaccination.c. Practising hand hygiene.d. Use of gloves.

2. Indicate which of the following statementsabout hand hygiene is correct.a. Hands must be washed for at least 2 min.b. If the skin is damaged, the number ofmicrobes

increases and hand hygiene becomesinefficient.

* This is an approximate translation of the original Spanish textused in the study. Correct answers are 1c, 2b, 3d, 4b, 5b, 6a,7b, 8d, 9b and 10c.

c. Hand hygiene agents never damage thehands.

d. The efficacy of hand hygiene is not affectedby damage to the skin.

3. Why should hand lotions not be used whenworking with patients?a. They produce ideal conditions for the rapid

growth of bacteria on the hands.b. They make the hands very greasy.c. They decrease the efficacy of latex gloves.d. a and c.

4. The most important issue in handwashing is:a. the type of soap used.b. the time for which friction is applied.c. the water temperature.d. none of the above.

5. The length of time required to wash the handseffectively is:a. at least 5 s.b. at least 10 s.c. at least 30 s.d. at least 60 s.

6. The best way to prevent recontamination ofthe hands after washing is by:a. using the same towel to dry the hands and

close the tap.b. using soap at least twice during

handwashing.c. using more than one towel to dry the

hands.d. applying lotion to the hands after washing.

7. When drying the hands, it is important to:a. use a multi-use towel.b. use a single-use towel.c. use a paper towel.d. use hot air.

8. To be effective, waterless hand hygiene agentsshould contain an alcohol concentration of:a. 10%.b. 40%.c. 50%.d. 60%.

9. Hand hygiene is not necessary:a. at the beginning and end of the hospital

working day.b. before getting information from a patient.c. when the hands are not visibly dirty.d. after removing gloves.

64 M.A. Caniza et al.

10. Indicate which of the following statementsabout using waterless alcohol gel productsis NOT correct.

a. The gel must be allowed to air dry.b. When your hands are visibly dirty, do not use

alcohol gel; soap and water must be used.c. Use a single-use towel to dry your hands

after applying the alcohol gel.d. Alcohol gel may dry out your skin.

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