Drawing a line from CO2 emissions to health-evaluation of medical students' knowledge and attitudes towards climate change and health following a novel serious game: a mixed-methods study.

BACKGROUND: Education is urgently needed to equip medical students with knowledge, values and skills to promote planetary health. However, the current literature offers little insight into evidence-based approaches and best practices. In response to this pressing need, a novel serious game was introduced into the medical curriculum at Erasmus Medical Center in 2023. The aim of this study was to evaluate the knowledge and attitudes of medical students after they had played a serious game that addresses climate change and health. METHODS: In accordance with a mixed-methods design, quantitative data were collected using pre- and post-intervention surveys. Differences were assessed using the Wilcoxon signed rank test. Focus group discussions were held after the game and thematically analysed. RESULTS: One hundred forty-five students (38.6% of the entire cohort) played the game, of which 59 students completed the pre- and post-intervention surveys. After the game, self-reported knowledge increased. Regarding objective knowledge, an increase in the proportion of students who answered one of the two questions correctly was observed, while the proportion of correct responses decreased for the other question. Student's responses to two out of five attitude questions were significantly more positive. The proportion of students who recognized the importance of climate change education, to inform patients and society about the health impacts of climate change, increased. Moreover, survey results indicated a significant increase in climate worry subsequent to the game. Eleven students participated in the focus group discussions. Thematic analysis highlighted participants' reflections on the roles and responsibilities in climate change and health, along with their realisation of the tools for action that climate and health co-benefits provide. Another significant aspect was the importance participants placed on learning alongside peers with diverse attitudes. Additionally, participants appreciated the tangible overview of climate change and health provided by the serious game. CONCLUSIONS: Our novel serious game addressed an important gap in the medical curriculum. The game can enable medical students to cultivate the necessary knowledge and attitudes to promote health in times of a climate crisis. The accompanying climate worry needs attention through the empowerment of students' agency to foster change.

Prerequisites, barriers and opportunities in care for Q-fever patients: a Delphi study among healthcare workers.

BACKGROUND: Q-fever is a zoonotic disease that can lead to illness, disability and death. This study aimed to provide insight into the perspectives of healthcare workers (HCWs) on prerequisites, barriers and opportunities in care for Q-fever patients. METHODS: A two-round online Delphi study was conducted among 94 Dutch HCWs involved in care for Q-fever patients. The questionnaires contained questions on prerequisites for high quality, barriers and facilitators in care, knowledge of Q-fever, and optimization of care. For multiple choice, ranking and Likert scale questions, frequencies were reported, while for rating and numerical questions, the median and interquartile range (IQR) were reported. RESULTS: The panel rated the care for Q-fever patients at a median score of 6/10 (IQR = 2). Sufficient knowledge of Q-fever among HCWs (36%), financial compensation of care (30%) and recognition of the disease by HCWs (26%) were considered the most important prerequisites for high quality care. A lack of knowledge was identified as the most important barrier (76%) and continuing medical education as the primary method for improving HCWs' knowledge (76%). HCWs rated their own knowledge at a median score of 8/10 (IQR = 1) and the general knowledge of other HCWs at a 5/10 (IQR = 2). According to HCWs, a median of eight healthcare providers (IQR = 4) should be involved in the care for Q-fever fatigue syndrome (QFS) and a median of seven (IQR = 5) in chronic Q-fever care. CONCLUSIONS: Ten years after the Dutch Q-fever epidemic, HCWs indicate that the long-term care for Q-fever patients leaves much room for improvement. Facilitation of reported prerequisites for high quality care, improved knowledge among HCWs, clearly defined roles and responsibilities, and guidance on how to support patients could possibly improve quality of care. These prerequisites may also improve care for patients with persisting symptoms due to other infectious diseases, such as COVID-19.

Personal preferences of participation in fall prevention programmes: a descriptive study.

BACKGROUND: Participation in fall prevention programmes is associated with lower risk of injurious falls among older adults. However participation rates in fall prevention interventions are low. The limited participation in fall prevention might increase with a preference based approach. Therefore, the aims of this study are to a) determine the personal preferences of older adults regarding fall prevention and b) explore the association between personal preferences and participation. METHODS: We assessed the personal preferences of older adults and the association between their preferences, chosen programme and participation level. Nine different programmes, with a focus on those best matching their personal preferences, were offered to participants. Twelve weeks after the start of the programme, participation was assessed by questionnaire. Logistic regression was performed to test the association between preferences and participation and an ANOVA was performed to assess differences between the number of preferences included in the chosen programme and participation level. RESULTS: Of the 134 participants, 49% preferred to exercise at home versus 43% elsewhere, 46% preferred to exercise alone versus 44% in a group and 41% indicated a programme must be free of charge while 51% were willing to pay. The combination of an external location, in a group and for a fee was preferred by 27%, whereas 26% preferred at home, alone and only for free. The presence of preferences or the extent to which the programme matched earlier preferences was not associated with participation. CONCLUSION: Despite the fact that preferences can vary greatly among older adults, local programmes should be available for at least the two largest subgroups. This includes a programme at home, offered individually and for free. In addition, local healthcare providers should cooperate to increase the accessibility of currently available group programmes.

Client perspectives on an outreach approach for HIV prevention targeting Indonesian MSM and transwomen.

This study explored clients' perspective on an outreach approach to promote HIV testing in Indonesia targeting men who have sex with men (MSM) and transgender women (transwomen or waria). Semi-structured qualitative interviews were conducted with 32 individuals (21 MSM and 11 waria) who had received services from outreach workers (OWs) in five cities in Indonesia. Participants in this study reported positive experiences with the outreach approach and perceived OWs as their motivators in accessing HIV testing as well as HIV care and treatment. OWs provided easy-to-understand HIV information. Clients expected OWs to be well-trained and more creative in performing outreach. They perceived that the Internet and social media have helped them considerably to stay in touch with OWs. Yet, they expressed that such virtual contacts could not simply replace the face-to-face contact, especially for waria. Furthermore, clients suggested outreach to be delivered in a more appealing manner, for example through activities that may facilitate clients learning professional or life skills. They also asserted that as an HIV prevention approach, outreach needs to use more positive framing and go beyond HIV and health contents, chiefly for the youth. Future outreach programmes should facilitate OWs in providing tailored services based on the level and type of support that the clients need, and in applying varied proportion and levels of sophistication in the use of online and virtual platforms for outreach.

Evaluation of a training aimed at building capacity for outreaching to men who have sex with men and transgender women in Indonesia.

Implementers of outreach program in Indonesia often provide formal training for their outreach workers (OWs) only at the startup. We believe continuous training can be provided by experienced OWs at any time if an appropriate training package is available. Using a one-group pre-test-post-test study design; we developed, implemented and evaluated an OW-informed training program aimed at increasing OWs' knowledge and skills for outreaching to men who have sex with men and transgender women. We analyzed longitudinal data from 75 OWs from 7 Indonesian cities using one-way within-subjects ANOVA to examine the effects of the training program on participants' knowledge and perceived skills over time Average overall knowledge among participants increased from pre-test to immediate post-test (P < 0.001) and from pre-test to 2-month post-test (P < 0.001), especially in basic human immunodeficiency virus and sexual transmitted infections; condoms and lubricants; sexual and reproductive health and rights; sexual orientation and gender identity and expression; and stages of behavior change. Average overall perceived skills increased significantly from pre-test to 2-month post-test (P = 0.018), especially in creating innovative outreach approaches; building effective teamwork; and coordinating with healthcare providers. This training package increased knowledge and perceived skills among OWs. Thus, if consistently applied, it could help maintaining quality of the outreach program.

Increased care demand and medical costs after falls in nursing homes: A Delphi study.

AIMS AND OBJECTIVE: To estimate the increased care demand and medical costs caused by falls in nursing homes. BACKGROUND: There is compelling evidence that falls in nursing homes are preventable. However, proper implementation of evidence-based guidelines to prevent falls is often hindered by insufficient management support, staff time and funding. DESIGN: A three-round Delphi study. METHODS: A panel of 41 experts, all working in nursing homes in the Netherlands, received three online questionnaires to estimate the extra hours of care needed during the first year after the fall. This was estimated for ten falls categories with different levels of injury severity, in three scenarios, that is a best-case, a typical-case and a worst-case scenario. We calculated the costs of falls by multiplying the mean amount of extra hours that the participants spent on the care for a resident after a fall with their hourly wages. RESULTS: In case of a noninjurious fall, the extra time spent on the faller is on average almost 5 hr, expressed in euros that add to € 193. The extra staff time and costs of falls increased with increasing severity of injury. In the case of a fracture of the lower limb, the extra staff time increased to 132 hr, expressed in euros that is € 4,604. In the worst-case scenario of a fracture of the lower limb, the extra staff time increased to 284 hr, expressed in euros that is € 10,170. CONCLUSIONS: Falls in nursing homes result in a great deal of extra staff time spent on care, with extra costs varying between € 193 for a noninjurious fall and € 10,170 for serious falls. RELEVANCE TO CLINICAL PRACTICE: This study could aid decision-making on investing in appropriate implementation of falls prevention interventions in nursing homes.

Behavioral interventions to reduce HIV risk behavior for MSM and transwomen in Southeast Asia: a systematic review.

This systematic review aims to gain insights from existing literature from Southeast Asian countries to improve future HIV prevention programs for men who have sex with men (MSM) and transgender women (transwomen). We conducted a systematic search in six international databases for literature published prior to 1 January 2015. We included studies describing behavioral interventions targeting MSM and/or transwomen, and conducted in at least one Southeast Asian country. Five out of 575 screened studies met the inclusion criteria and reported a significant intervention effect on at least one outcome measure, that is, condom use (with casual or commercial partner), water-based lubricant use, number of sex partners, HIV prevention knowledge, or willingness to use pre-exposure prophylaxis. Peer education/outreach was the most commonly employed type of intervention in the five included studies and was usually delivered as an element of a larger intervention package, together with condom distribution and the provision of drop-in centers. Motivational interviewing was effective, while internet-based interventions appeared to be a viable platform for intervention delivery. Nevertheless, research on behavioral interventions among MSM and transwomen in Southeast Asia is limited. Future interventions should be culturally appropriate, theoretically grounded, and rigorously evaluated. Only then can we best address the HIV epidemic among MSM and transwomen in this region.

Government supervision on quality of smoking-cessation counselling in midwifery practices: a qualitative exploration.

BACKGROUND: The Dutch Healthcare Inspectorate supervises care providers in order to improve quality of care. Recently the inspectorate assessed and promoted the use of a guideline on smoking-cessation counselling in midwifery practices. The supervision programme consisted of an announcement of the enforcement deadline for the guideline and site visits. The purpose of our qualitative study was to identify factors related to guideline adherence after the supervision programme, and investigate whether the programme had helped improve adherence. METHODS: We conducted semi-structured interviews with inspected and non-inspected midwives. Additionally, we studied documents and observed the inspection process. The sampled midwives all work in primary care midwifery practices providing care to pregnant smokers. The questions included the current provision of smoking-cessation counselling, support to the midwife in counselling, recent changes in provision of counselling, reasons for recent changes, knowledge about the supervision programme, and experiences with supervision by the inspectorate. RESULTS: Our results show that guideline adherence depends on several factors. Awareness and familiarity with the guideline are important, as is outcome expectancy. Additionally, motivation, guideline factors and environment factors were mentioned. Besides these previously documented factors, we found that professional collaboration also determined guideline adherence. Increased collaboration in counselling is associated with greater adherence to the guideline, such as provision of counselling and taking required training. The supervision programme helped improve stop-smoking counselling, by making midwives aware of the counselling and giving them an extrinsic motivation to provide counselling. CONCLUSION: Motivation and environmental aspects were the most important factors related to guideline adherence, and professional environment was added as significant factor. The improved guideline adherence is partly attributable to the supervision programme.

Are condom-promotion interventions reaching internal migrants in China? Integrated evidence from two cross-sectional surveys.

Behavioral interventions containing behavior change techniques (BCTs) that do not reach the target populations sufficiently will fail to accomplish their desired outcome. To guide sexually transmitted infection prevention policy for internal migrants in China, this study examines the extent to which BCTs aiming at increasing condom use reach the migrants and investigates the preference of the target population for these techniques among 364 migrants and 44 healthcare workers (HCWs) in Shenzhen, China. The results show that condom-promotion techniques that had been offered by HCWs to internal migrants reached a limited proportion of the population (range of reach ratio: 17.6-55.0%), although there appears to be a good match between what is offered and what is preferred by Chinese internal migrants regarding condom-promotion techniques (rank difference ≤ 1). Our findings highlight the need to increase the reach of condom-promotion techniques among Chinese internal migrants, and suggest techniques that are likely to reach the target population and match their preferred health education approaches.

Children's hand hygiene behaviour and available facilities: an observational study in Dutch day care centres.

BACKGROUND: Children attending day care centres are at increased risk of infectious diseases, in particular gastrointestinal and respiratory infections. Hand hygiene of both caregivers and children is an effective prevention measure. This study examined hand hygiene behaviour of children attending day care centres, and describes hygiene facilities at day care centres. METHODS: Data were collected at 115 Dutch day care centres, among 2318 children cared for by 231 caregivers (August to October 2010). Children's hand hygiene behaviour was observed and data on hand hygiene facilities of the day care centres collected by direct unobtrusive observation. National guidelines indicate hand hygiene is required before eating, after toilet use and after playing outside. RESULTS: Among 1930 observed hand hygiene opportunities for children, overall adherence to hand hygiene guidelines was 31% (95% CI: 29-33%). Adherence after both toilet use and playing outside was 48%. Hands were less frequently washed before eating, where guideline adherence was 15%. In 38% of the playrooms there was no soap within reach of children and 17% had no towel facilities. In over 40% of the playrooms, appropriate hand hygiene facilities for children were lacking. CONCLUSION: Adequate hand washing facilities were available for children in only half of the participating day care centres in our study and children washed their hands in only 15-48% of the occasions defined by official guidelines. More attention is needed to hand hygiene of children attending day care centres in the prevention of infectious diseases.

Does government supervision improve stop-smoking counseling in midwifery practices?

INTRODUCTION: Smoking-cessation counseling during pregnancy is important to prevent smoking-related harm in pregnant smokers and their children. Therefore we evaluated the effects of an Inspectorate's supervision programme on the provision of smoking-cessation counseling by midwifery practices in the Netherlands. The supervision programme consisted of 3 elements: A) A deadline was announced by which all practices should comply with professional norms on such counseling (2011); B) A set of randomly selected practices were assessed using a questionnaire and a personal feedback report (2010); C) Another set of randomly selected practices were assessed through a site visit and a personal feedback report (2012). METHODS: Programme A was evaluated in a before-after study, Programmes B and C were evaluated in a randomized controlled trial (RCT) with only a post-intervention measurement. Primary outcome was provision of smoking-cessation counseling through a minimal-intervention strategy (V-MIS). Linear and logistic regression models were used to analyze data from 233 primary-care midwifery practices. RESULTS: A) After announcement of the deadline, Dutch midwifery practices reported significantly more provision of smoking-cessation counseling. For example, the use of V-MIS increased substantially from 28% to 80%; B) In practices that were assessed with a questionnaire, the provision of counseling improved partially compared to controls; C) The provision of counseling did not differ between practices that were visited and their controls. While the training participation rate in counseling by midwifery practices did not differ between the intervention and control groups, the rate increased significantly in all practices after the start of the supervision programme. CONCLUSIONS: The provision of smoking-cessation counseling improved spectacularly in Dutch midwifery practices. Despite some limitations of our study, the Inspectorate's supervision programme is likely to have contributed to the improvements in provision of counseling.

Preventing HIV transmission in Chinese internal migrants: a behavioral approach.

This study is a step towards a behavioral intervention to prevent HIV transmission among Chinese internal migrants. To explore important and changeable determinants of condom use and inspect effective and feasible methods to increase condom use for the target population, we conducted a three-round web-based Delphi study among a panel of 62 experts between October 2012 and March 2013. The panelists were purposely selected using a stepwise procedure to represent topic-related areas of expertise. The response rate per round ranges from 21% to 81%. The panelists identified 19 possible determinants of condom use and reported 16 intervention methods they considered successful. They agreed that attitude towards condom use was the most important and changeable determinant, while applying behavioral theory, increasing sexual education and condom access, performing worksite health promotion, detecting risk factors, and working closely with relevant organizations and the government were effective and feasible methods to increase condom use among internal migrants in China. In conclusion, results of this study highlight the importance of attitude in changing condom use and underscore the need to apply behavior theory and integrate multiple educational approaches for developing behavioral HIV prevention interventions targeting internal migrants in China.

A hand hygiene intervention to decrease infections among children attending day care centers: design of a cluster randomized controlled trial.

BACKGROUND: Day care center attendance has been recognized as a risk factor for acquiring gastrointestinal and respiratory infections, which can be prevented with adequate hand hygiene (HH). Based on previous studies on environmental and sociocognitive determinants of caregivers' compliance with HH guidelines in day care centers (DCCs), an intervention has been developed aiming to improve caregivers' and children's HH compliance and decrease infections among children attending DCCs. The aim of this paper is to describe the design of a cluster randomized controlled trial to evaluate the effectiveness of this intervention. METHODS/DESIGN: The intervention will be evaluated in a two-arm cluster randomized controlled trial among 71 DCCs in the Netherlands. In total, 36 DCCs will receive the intervention consisting of four components: 1) HH products (dispensers and refills for paper towels, soap, alcohol-based hand sanitizer, and hand cream); 2) training to educate about the Dutch national HH guidelines; 3) two team training sessions aimed at goal setting and formulating specific HH improvement activities; and 4) reminders and cues to action (posters/stickers). Intervention DCCs will be compared to 35 control DCCs continuing usual practice. The primary outcome measure will be observed HH compliance of caregivers and children, measured at baseline and one, three, and six months after start of the intervention. The secondary outcome measure will be the incidence of gastrointestinal and respiratory infections in 600 children attending DCCs, monitored over six months by parents using a calendar to mark the days their child has diarrhea and/or a cold. Multilevel logistic regression will be performed to assess the effect of the intervention on HH compliance. Multilevel poisson regression will be performed to assess the incidence of gastrointestinal and respiratory infections in children attending DCCs. DISCUSSION: This is one of the first DCC intervention studies to assess HH compliance of both caregivers and children, as well as the incidence of gastrointestinal and respiratory infections in children, as outcome measures. When an effect of the intervention on improving HH compliance and/or reducing incidence of infections is shown, (inter)national dissemination of the intervention in other DCCs may be considered. TRIAL REGISTRATION: Netherlands trial registry: NTR3000.

Assessing the optimal location for alcohol-based hand rub dispensers in a patient room in an intensive care unit.

BACKGROUND: The introduction of alcohol-based hand rub dispensers has had a positive influence on compliance of healthcare workers with the recommended guidelines for hand hygiene. However, establishing the best location for alcohol-based hand rub dispensers remains a problem, and no method is currently available to optimize the location of these devices. In this paper we describe a method to determine the optimal location for alcohol-based hand rub dispensers in patient rooms. METHODS: We composed a method that consists of a combination of qualitative and quantitative research methods. Firstly, different arrangements of dispensers were determined based on the results of two types of assessment: workflow observations and interviews with nurses and physicians. Each arrangement was then evaluated using two types of assessment: interviews with nurses and physicians and electronic measurements of the user frequency of the dispensers. This procedure was applied in a single-bed patient room on a thoracic surgery intensive care unit. RESULTS: The workflow observations revealed that the activities of patient care were most often at the entrance and near the computer at the right side of the test room. Healthcare workers stated that the location of the dispenser should meet several requirements. Measurements of the frequency of use showed that the dispenser located near the computer, at the back of the room, was used less frequently than the dispenser located near the sink and the dispenser located at the entrance to the room. CONCLUSION: The applied method has potential for determining the optimal location for alcohol-based hand rub dispensers in a patient room. Workflow observations and the expressed preferences of healthcare workers guide the choice for the location of alcohol-based hand rub dispensers. These choices may be optimized based on measurement of the frequency of use of the dispensers.

Effects of a management team training intervention on the compliance with a surgical site infection bundle: a before-after study in operating theatres in the Netherlands.

OBJECTIVES: To assess the effects of a quality improvement (QI) team training intervention, by measuring the intervention fidelity and the compliance with a surgical site infection (SSI) bundle in the operating theatre (OT). DESIGN: Multicentre before-after study. SETTING: This study was performed in four Dutch hospitals. INTERVENTION: The QI team training intervention consisted of four sessions per hospital and stimulated participants to set culture norms and targets, identify barriers, and formulate management activities to improve compliance with four standard operating procedures (SOPs) of a SSI bundle in the OT. Participants were executive board members, top-level managers, leading clinicians and support staff. The four SOPs were: (1) reducing door movements; (2) preoperative antibiotic prophylaxis prescribing; (3) preoperative shaving; and (4) postoperative normothermia. Poisson and logistic regression analyses were performed to analyse the effect of the intervention on compliance with the individual SOPs (primary outcome measure) and on the influence of medical specialty, time of day the procedure took place and time in the OT (secondary outcome measures). RESULTS: Not all management layers were successfully involved during all sessions in the hospitals. Top-level managers were best represented in all hospitals, leading clinicians the least. The number of implemented improvement activities was low, ranging between 2 and 14. The team training intervention we developed was not associated with improvements in the compliance with the four SOP of the SSI bundle. Medical specialty, time of day, and time in OT were associated with median number of door movements, and preoperative antibiotic prophylaxis administration. CONCLUSION: This study showed that after the QI team training intervention the overall compliance with the four SOPs did not improve. Minimal involvement of leading clinicians and a low number of self-initiated activities after the team training were important barriers for compliance.

Contact investigations for antibiotic-resistant bacteria: a mixed-methods study of patients' comprehension of and compliance with self-sampling requests post-discharge.

BACKGROUND: Contact investigation is an important tool to identify unrecognized patients who are colonized with antibiotic-resistant bacteria. Many Dutch hospitals include already discharged contact patients by sending them a self-sampling request at home, incl. an information letter and sampling materials. Each hospital composes these information letters on their own initiative, however, whether discharged patients comprehend and comply with these requests remains unclear. Therefore, the aim was to provide insight into patients' comprehension of and self-reported compliance with self-sampling requests post-discharge. METHODS: This mixed-methods study was performed in eight Dutch hospitals. First, the Common European Framework of Reference (CEFR) language level of self-sampling request letters was established. Second, a questionnaire about patients' comprehension of the letter, self-reported compliance, and reasons for compliance or non-compliance were sent to patients that received such a request in 2018/2019. Finally, a random selection of questionnaire respondents was interviewed between January and March 2020 to gain additional insights. RESULTS: CEFR levels of 15 letters were established. Four letters were assigned level B1, four letters B1-B2, and seven letters B2. The majority of patients reported good comprehension of the letter they had received. Conversely, some respondents indicated that information about the bacterium (18.4%), the way in which results would be communicated (18.1%), and the self-sampling instructions (9.7%) were (partially) unclear. Furthermore, self-reported compliance was high (88.8%). Reasons to comply were personal health (84.3%), the health of others (71.9%), and general patient safety (96.1%). Compliant patients appeared to have a need for confirmation, wanted to protect family and/or friends, and felt they were providing the hospital the ability to control the transmission of antibiotic-resistant bacteria. Although a limited number of non-compliant patients responded to the questionnaire, it seemed that more patients did not comply with self-sampling requests when they received a letter in a higher CEFR-level (B2) compared to a lower CEFR-level (< B2) (9.8% vs. 2.5%, P = 0.049). CONCLUSIONS: This study showed an overall good comprehension of and high self-reported compliance with self-sampling requests post-discharge. Providing balanced information in self-sampling request letters has the potential to reduce patient's ambiguity and concerns, and can cause increased compliance with self-sampling requests.

Teamwork Training With a Multiplayer Game in Health Care: Content Analysis of the Teamwork Principles Applied.

BACKGROUND: In health care, teamwork skills are critical for patient safety; therefore, great emphasis is placed on training these skills. Given that training is increasingly designed in a blended way, serious games may offer an efficient method of preparing face-to-face simulation training of these procedural skills. OBJECTIVE: This study aimed to investigate the teamwork principles that were used during gameplay by medical students and teamwork experts. Findings can improve our understanding of the potential of serious games for training these complex skills. METHODS: We investigated a web-based multiplayer game designed for training students' interprofessional teamwork skills. During gameplay, 4 players in different roles (physician, nurse, medical student, and student nurse) had to share information, prioritize tasks, and decide on next steps to take in web-based patient scenarios, using one-to-one and team chats. We performed a qualitative study (content analysis) on these chats with 144 fifth-year medical students and 24 health care teamwork experts (as a benchmark study) playing the game in groups of 4. Game chat data from 2 scenarios were analyzed. For the analysis, a deductive approach was used, starting with a conceptual framework based on Crew Resource Management principles, including shared situational awareness, decision-making, communication, team management, and debriefing. RESULTS: Results showed that most teamwork principles were used during gameplay: shared situational awareness, decision-making (eg, re-evaluation), communication (eg, closed loop), and team management (eg, distributing the workload). Among students, these principles were often used on a basic level. Among experts, teamwork principles were used with more open forms of speak up and more justification of decisions. Some specific Crew Resource Management principles were less observed among both groups, for example, prevention of fixation errors and use of cognitive aids. Both groups showed relatively superficial debriefing reflections. CONCLUSIONS: Playing a multiplayer game for interprofessional teamwork appears to facilitate the application of teamwork principles by students in all important teamwork domains on a basic level. Expert players applied similar teamwork principles on a moderately high complexity level. Some teamwork principles were less observed among both students and expert groups, probably owing to the artifacts of the game environment (eg, chatting instead of talking). A multiplayer game for teamwork training can elicit the application of important, basic teamwork principles, both among novices and experts, and provides them with a flexible, accessible, and engaging learning environment. This may create time for exercising more complex skills during face-to-face training.

The ACCOMPLISH study. A cluster randomised trial on the cost-effectiveness of a multicomponent intervention to improve hand hygiene compliance and reduce healthcare associated infections.

BACKGROUND: Public health authorities have recognized lack of hand hygiene in hospitals as one of the important causes of preventable mortality and morbidity at population level. The implementation strategy ACCOMPLISH (Actively Creating COMPLIance Saving Health) targets both individual and environmental determinants of hand hygiene. This study aims to evaluate the cost-effectiveness of a multicomponent implementation strategy aimed at the reduction of healthcare associated infections in Dutch hospital care, by promotion of hand hygiene. METHODS/DESIGN: The ACCOMPLISH package will be evaluated in a two-arm cluster randomised trial in 16 hospitals in the Netherlands, in one intensive care unit and one surgical ward per hospital. INTERVENTION: A multicomponent package, including e-learning, team training, introduction of electronic alcohol based hand rub dispensers and performance feedback. VARIABLES: The primary outcome measure will be the observed hand hygiene compliance rate, measured at baseline and after 6, 12 and 18 months; as a secondary outcome measure the prevalence of healthcare associated infections will be measured at the same time points. Process indicators of the intervention will be collected pre and post intervention. An ex-post economic evaluation of the ACCOMPLISH package from a healthcare perspective will be performed. STATISTICAL ANALYSIS: Multilevel analysis, using mixed linear modelling techniques will be conducted to assess the effect of the intervention strategy on the overall compliance rate among healthcare workers and on prevalence of healthcare associated infections. Questionnaires on process indicators will be analysed with multivariable linear regression, and will include both behavioural determinants and determinants of innovation. Cost-effectiveness will be assessed by calculating the incremental cost-effectiveness ratio, defined here as the costs for the intervention divided by the difference in prevalence of healthcare associated infections between the intervention and control group. DISCUSSION: This study is the first RCT to investigate the effects of a hand hygiene intervention programme on the number of healthcare associated infections, and the first to investigate the cost-effectiveness of such an intervention. In addition, if the ACCOMPLISH package proves successful in improving hand hygiene compliance and lowering the prevalence of healthcare associated infections, the package could be disseminated at (inter)national level. TRIAL REGISTRATION: NTR2448.

Voices of Those Who Bear the Brunt - Experiences of Programme Personnel Concerning Private Sector Tuberculosis Notifications in Bengaluru City, India.

This study aims to assess private and public sector contributions to Tuberculosis (TB) notification in Bengaluru city (2011 to 2016) and identify challenges of program personnel in their interaction with private practitioners and procedural barriers for TB notification from the private sector as perceived by them. A mixed methods study was carried out in Bengaluru city, India with TB notification data obtained from TB Units in addition to in-depth interviews with key program implementers. Results showed the contribution of private practitioners to TB notification to be about 20%. Barriers and challenges were: the private practitioners' hesitancy to refer the patients to public sector due to their fear of losing patients and dishonoring of diagnosis from private practitioners, lack of awareness about TB notification, lack of legal punitive measures and constant glitches on the notification website. These need to be resolved on priority to achieve the national target of TB elimination by 2025.

Can Fall Risk Screening and Fall Prevention Advice in Hospital Settings Motivate Older Adult Patients to Take Action to Reduce Fall Risk?

OBJECTIVE: We investigated whether an in-hospital intervention consisting of fall risk screening and tailored advice could prompt patients to take preventive action. METHOD: Patients (≥70) attending the emergency department and nephrology outpatient clinic in a Dutch hospital were screened. Patients at high risk received tailored advice based on their individual risk factors. Three months after screening, preventive steps taken by patients were surveyed. RESULTS: Two hundred sixteen patients were screened. Of the 83 patients completing a 3-month follow-up, 51.8% took action; among patients who received tailored advice (n = 20), 70% took action. Patients most often adhered to advice on improving muscle strength and undergoing vision checkups (20%). Tailored advice and a reported low quality of life were associated with consulting a health care provider. DISCUSSION: Patients at risk in these settings are inclined to take action after screening. However, they do not always adhere to the tailored prevention advice.