Effectiveness of an Artificial Intelligence-Assisted App for Improving Eating Behaviors: Mixed Methods Evaluation.

BACKGROUND: A plethora of weight management apps are available, but many individuals, especially those living with overweight and obesity, still struggle to achieve adequate weight loss. An emerging area in weight management is the support for one's self-regulation over momentary eating impulses. OBJECTIVE: This study aims to examine the feasibility and effectiveness of a novel artificial intelligence-assisted weight management app in improving eating behaviors in a Southeast Asian cohort. METHODS: A single-group pretest-posttest study was conducted. Participants completed the 1-week run-in period of a 12-week app-based weight management program called the Eating Trigger-Response Inhibition Program (eTRIP). This self-monitoring system was built upon 3 main components, namely, (1) chatbot-based check-ins on eating lapse triggers, (2) food-based computer vision image recognition (system built based on local food items), and (3) automated time-based nudges and meal stopwatch. At every mealtime, participants were prompted to take a picture of their food items, which were identified by a computer vision image recognition technology, thereby triggering a set of chatbot-initiated questions on eating triggers such as who the users were eating with. Paired 2-sided t tests were used to compare the differences in the psychobehavioral constructs before and after the 7-day program, including overeating habits, snacking habits, consideration of future consequences, self-regulation of eating behaviors, anxiety, depression, and physical activity. Qualitative feedback were analyzed by content analysis according to 4 steps, namely, decontextualization, recontextualization, categorization, and compilation. RESULTS: The mean age, self-reported BMI, and waist circumference of the participants were 31.25 (SD 9.98) years, 28.86 (SD 7.02) kg/m2, and 92.60 (SD 18.24) cm, respectively. There were significant improvements in all the 7 psychobehavioral constructs, except for anxiety. After adjusting for multiple comparisons, statistically significant improvements were found for overeating habits (mean -0.32, SD 1.16; P<.001), snacking habits (mean -0.22, SD 1.12; P<.002), self-regulation of eating behavior (mean 0.08, SD 0.49; P=.007), depression (mean -0.12, SD 0.74; P=.007), and physical activity (mean 1288.60, SD 3055.20 metabolic equivalent task-min/day; P<.001). Forty-one participants reported skipping at least 1 meal (ie, breakfast, lunch, or dinner), summing to 578 (67.1%) of the 862 meals skipped. Of the 230 participants, 80 (34.8%) provided textual feedback that indicated satisfactory user experience with eTRIP. Four themes emerged, namely, (1) becoming more mindful of self-monitoring, (2) personalized reminders with prompts and chatbot, (3) food logging with image recognition, and (4) engaging with a simple, easy, and appealing user interface. The attrition rate was 8.4% (21/251). CONCLUSIONS: eTRIP is a feasible and effective weight management program to be tested in a larger population for its effectiveness and sustainability as a personalized weight management program for people with overweight and obesity. TRIAL REGISTRATION: ClinicalTrials.gov NCT04833803; https://classic.clinicaltrials.gov/ct2/show/NCT04833803.

Qualitative inquiry of a community dance program for older adults in Singapore.

Dance programs promote physical and psychosocial well-being. However, studies focusing on the experiences of older adults in dancing are limited. This study aims to develop a community dance program (CDP) for older adults at senior activity centers in Singapore, as well as to explore the older adults' and student instructors' experiences of the CDP. A qualitative inquiry of semi-structured and in-depth focus group discussions was conducted. In total, 20 older adults and 10 student dance instructors participated in the study. Student instructors who were undergraduate students from a dance society were trained in how to provide step-by-step instructions for the older adults. An inductive approach of thematic analysis was undertaken. Three main themes were identified: (i) promotion of physical, cognitive, and psychosocial health with dance; (ii) imagination is power-travel through dance; and (iii) further enhancement of the dance program. The themes highlighted the prominence of CDP in improving memory, physical health, mood, and social interactions-thus mitigating the risk of social isolation. The findings illustrated the benefits of CDP in cultivating intergenerational bonds amongst older adults and student instructors.

Socio-Demographic, Behavioral and Psychological Factors Associated with High BMI among Adults in a Southeast Asian Multi-Ethnic Society: A Structural Equation Model.

While various influencing factors of overweight and obesity have been identified, the underlying mechanism remains unclear. We examined the relationships among sociodemographic, behavioral, and psychological factors on anthropometry in a multi-ethnic population with overweight and obesity. Participants (N = 251) were recruited from January to October 2022. Mean age and self-reported BMI were 31.7 ± 10.1 years and 29.2 ± 7.2 kg/m2. Participants were mostly female (52.4%) and overweight (58.2%). Multivariate multiple regression was performed using maximum likelihood estimation. Body mass index was associated with waist circumference, age, sex, race, marital status, education level, residential region, overeating habit, immediate thinking, self-regulation, and physical activity, but not anxiety, depression, or the intention to change eating habits. Final model indicated good fit: χ2 (30, N = 250) = 33.5, p = 0.32, CFI = 0.993, TLI = 0.988, RMSEA = 0.022, and SRMR = 0.041. Direct effects were found between BMI and overeating (ß = 0.10, p = 0.004), race (ß = -0.82, p < 0.001), marital status (ß = -0.42, p = 0.001), and education level (ß = -0.28, p = 0.019). Crisps (68.8%), cake (66.8%) and chocolate (65.6%) were identified as the most tempting foods. Immediate thinking indirectly increased overeating habits through poor self-regulation, although sociodemographic characteristics better predicted anthropometry than psycho-behavioral constructs.

The effects of forest bathing on psychological well-being: A systematic review and meta-analysis.

Globally, around half (55%) of the population live in fast-paced urban settings where many people find it challenging to manage their stress and respond to crises with a positive mindset. This resulted in prolonged distress where anxiety and fatigue caused physical and mental health concerns. Nature walks involving immersive exposure in the forest, and green spaces have been posited to offer physiological and psychological benefits. Therefore, in this systematic review, we evaluated the effects of forest bathing on psychological and physiological outcomes. We searched four English and five non-English databases (Chinese and Korean) for peer-reviewed studies published between January 2000 and March 2021. This review adhered to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analysis Statement 2020. The primary outcomes explored in this review were mainly psychological, including anxiety, depression, mood and quality of life. The secondary outcomes were physiological outcomes such as blood pressure and heart rate. We conducted a meta-analysis on each outcome using the random-effects model. Heterogeneity was assessed by the I2 statistic. Thirty-six articles (21 in English, 3 in Chinese and 12 in Korean) with 3554 participants were included in this review. Our meta-analysis suggested that forest bathing can significantly reduce symptoms of depression and anxiety. However, we did not observe as many benefits in physiological outcomes. Against the background of the negative effects of urbanization on mental well-being, this review highlighted the potential therapeutic role of forests in the contemporary world, lending further evidence-based support for forest conservation.

Barriers to healthy eating among nurses working in hospitals: A meta-synthesis.

AIM: To explore the barriers to healthy eating among nurses working in hospitals. DESIGN: Meta-synthesis. DATA SOURCES: Published and unpublished papers were identified through electronic searches on PubMed, CINAHL, PsycINFO, Embase, Scopus, COCHRANE Library, Food Science and Technology Abstract, ProQuest Dissertations and Theses and OpenGrey from inception until 6 September 2020. English-language primary qualitative or mixed-method studies on barriers to healthy eating among hospital nurses were included. Mixed-method studies were eligible if their qualitative data were distinguishable. Studies on nursing assistants, enrolled nurses, nursing students, and patient-care assistants were excluded, as well as studies without full-texts, correlational studies, quantitative surveys, exploratory studies, conference abstracts and reviews. METHODS: The studies were appraised using Critical Appraisal Skills Programme checklist. Qualitative data were extracted using Joanna Briggs Institute Qualitative Data Extraction Tool. Data synthesis followed two stages, meta-summary and meta-synthesis, proposed by Sandelowski & Barroso. RESULTS: Twelve studies published from 2008 to 2020 involving 618 hospital nurses were included. The meta-summary generated 10 themes, which were meta-synthesized into three interrelated themes: personal barriers (e.g. nonchalance towards unhealthy eating), interprofessional and patient-related barriers (e.g. sharing unhealthy food), and organizational barriers (e.g. overwhelming work demands). CONCLUSION: Insufficient self-control and self-confidence, nonchalance and negligence towards healthy eating and cultural beliefs that oppose the practice of healthy eating (personal barriers), exposure of unhealthy food practices in wards (interprofessional and patient-related barriers) and hospital cafeterias, overwhelming work exigencies and institutional constraints (organizational barriers) hindered nurses to achieve wholesome healthy eating. IMPACT: Many hospital nurses' encountered challenges in healthy eating, thereby potentially jeopardizing their health and work performance. The findings emphasized the need of a joint effort by hospital nurses, families and colleagues, and hospital institutions to overcome the barriers to healthy eating faced by the hospital nurses.

Impact of sense of coherence, resilience and loneliness on quality of life amongst older adults in long-term care: A correlational study using the salutogenic model.

AIMS: This study aimed to identify the predicting factors of quality of life (QoL) from a set of psychosocial, sociodemographic and clinical variables amongst older adults in a long-term care setting. DESIGN: A cross-sectional, descriptive correlational study. METHOD: The study was conducted in a nursing home and a day care centre from July to December 2019. Two hundred older adults were recruited. Guided by the salutogenic model, the sense of coherence (SOC) scale, Connor-Davidson resilience scale, de Jong Gierveld loneliness scale and World Health Organization quality of life instrument-older adults (WHOQOL-OLD) were used. The sociodemographic and clinical profiles of participants were collected. Descriptive statistics, Pearson product-moment correlation coefficient, independent-samples t test, one-way analysis of variance and stepwise regression were utilised in the analysis. RESULTS: The mean score for WHOQOL-OLD was 94.42 ± 19.55. The highest mean score was observed in the "Death and Dying" facet, while the lowest mean scores were reflected in the "Autonomy" and "Intimacy" facets of QoL. Regardless of resident type, most QoL scores were similar across different variables. Based on the stepwise regression, higher manageability and meaningfulness in SOC, higher resilience, lower social loneliness, lower emotional loneliness and hearing impairments are significantly associated with higher QoL. CONCLUSION: Manageability, meaningfulness and resilience should be enhanced while ameliorating feelings of loneliness to improve the QoL amongst older adults receiving long-term care. Age, marital status, educational level, care arrangement, body mass index, performance in activities of daily living, comorbidities and hearing and mobility impairments could influence QoL and thus warrant more attention. IMPACT: Future interventions can be conducted in group sessions to facilitate social interaction and alleviate loneliness. More resources should be allocated to enhance older adults' care arrangements and coping mechanisms to provide them with the support, as they face challenges in daily life due to mobility impairment and other restrictions.

Effects of online stigma-reduction programme for people experiencing mental health conditions: A systematic review and meta-analysis.

Despite the increased awareness of mental health-related issues, people experiencing mental health conditions have continued to face stigmatization worldwide. The literature on help-seeking behaviours has frequently highlighted the development of self-stigma because of public stigma and emphasized the need to address public stigmatization faced by them. Given the increasing acceptance of digital services in recent years, this systematic review aimed to examine the effects of online and face-to-face anti-stigma interventions in reducing public stigma towards people experiencing mental health conditions. A search was conducted on the Cochrane Library, CINAHL, PubMed, Embase, PsycInfo, and ProQuest from inception of the databases to October 2020. Studies were included in this review if they have explored: (i) public stigmatization towards people of all ages with different types of mental health conditions; (ii) online interventions; and (iii) face-to-face interventions. Nine studies were included in this review, of which only five were included in the meta-analysis as the remaining four had incomplete data. The meta-analysis included an aggregate of 1203 participants while the four excluded studies included 713 participants. Results revealed that online interventions performed favourably with small effect sizes in comparison to face-to-face, wait-list control, and no-intervention groups. Results from the studies excluded from the meta-analysis also found a significant reduction of public stigmatization with online interventions. Such findings provide insightful evidence for the effectiveness of online interventions in reducing public stigmatization. Hence, mental health organizations and groups can consider adopting online interventions suitable for their target audience and type of mental health conditions.

Exploring long-term volunteerism in a community family service centre in Singapore: A Focused Ethnographic Study.

Volunteerism contributes significantly to the social development of a country. Although the rate of volunteerism has steadily increased over the years, the numbers of regular volunteers remains small. While the existing literature has elucidated individuals' motivations for volunteerism, research is lacking on their motivations and challenges in sustaining long-term volunteerism. A focused ethnographic approach was adopted in this study to explore 20 participants' motivations and challenges towards long-term volunteerism. Purposive sampling was used to recruit participants in one single-family service centre in Singapore from October to December 2018. Data were collected through covert observations and semi-structured interviews. Field notes, observational data and findings from the interviews were triangulated and analysed through thematic analysis. In this study, a central exhaustive description of the volunteers 'providing help while receiving good deeds' is established. This was supported with three main themes revolving around the volunteers: fulfilling life goals, deriving meaning from experiences and striking a balance in the life. These themes characterised the motivations and challenges faced by them amidst their voluntary works. They reported that the satisfaction and fulfilment through volunteering had brought personal growth, well-being and happiness to them. The sense of purpose through volunteering further enhanced their experiences. Finally, some volunteers reported that volunteering enabled them to strike a balance in their own life by engaging it as a form of solace. The findings suggest that sustained volunteerism is a multidimensional construct involving the interplay of different factors in the individual's life. By understanding motivations underlying long-term volunteerism, voluntary organisations can create volunteering opportunities that dovetail with volunteers' personal goals, thus boosting their satisfaction and incentivising their sustained engagement. Additionally, the organisations can hold regular bonding activities to promote rapport among their volunteers, beneficiaries and staff, thus encouraging the volunteers to persevere on their volunteering journey.

Registered nurses' perceptions towards advanced practice nursing: A nationwide cross-sectional study.

AIMS: To explore registered nurses' perceptions towards the role of advanced practice nurses and to examine registered nurses' interests in becoming advanced practice nurses. BACKGROUND: Globally, the development and implementation of advanced practice nurses have been deemed propitious. Advanced practice nurses are recruited and developed from the current pool of registered nurses. Empirical research is needed to inform practice on ensuring the sustainability of the advanced practice nurse workforce through the recruitment and development of the current population of registered nurses. METHODS: A nationwide cross-sectional online survey was conducted in Singapore. Registered nurses from all public health care institutions were surveyed. RESULTS: Respondents (n = 1,025) displayed optimism and acceptance towards advanced practice nurses. However, only 30.7% hoped to become advanced practice nurses. Nursing leaders were reported to have a low success rate in identifying registered nurses who were both suitable and interested in the advanced practice nurse role. CONCLUSIONS: Registered nurses' positive perspectives towards the role of advanced practice nurses do not translate into interests in the role. The study offers pragmatic applicability in ensuring the sustainability of the advanced practice nurse workforce. IMPLICATIONS FOR NURSING MANAGEMENT: Advanced practice nurse-specific residency programmes for pre-master registered nurses may be facilitative to retaining and recruiting registered nurses for the advanced practice nurse workforce.

An exploration of factors influencing inpatient nurses' care behaviour in an acute hospital setting.

OBJECTIVE: To examine factors influencing caring behaviour of nurses in Singapore. DESIGN: Descriptive correlational study using Care Behaviour Inventory (CBI-24) questionnaire to assess nurses' perceptions of their caring behaviours. SETTING: Acute tertiary hospital in Singapore. PARTICIPANTS: A convenience sample of 167 full time registered nurses working in subsidized wards, with more than 1 year of experience in current practising ward were recruited. MAIN OUTCOME MEASURE(S): Nurses' perception of their caring behaviours. RESULTS: Data analysis yielded a mean CBI score of 123.11 out of 144, indicating that nurses had a positive perception of their caring behaviours. Among the 4 CBI subscales, Respectfulness and Connectedness components of CBI were ranked the lowest with a mean score of 4.2 and 4.9, respectively. This indicated that although nurses generally performed adequate caring during patient care, they appeared to be lacking in the expressive aspect of caring. Significant differences (P < 0.05) were found among subgroups of nationality, ethnicity, religion and education level. Nurses' perception of their caring behaviours was positively correlated to their age and total working experience. Linear regression showed that age, religion, education level positively influenced nurses' perception of their caring behaviours. CONCLUSION: Findings from this study raise awareness to the caring behaviours that nurses were lacking in and also offer valuable insights to the potential factors influencing nurses' caring behaviours. This information serves as a foundational knowledge to guide the development of interventions aimed to promote patient-centred care and improve quality of future nursing care.

Prevalence of depression among nursing students: A systematic review and meta-analysis.

OBJECTIVES: To examine the global prevalence of depression among nursing students and the variation in depression rates influenced by demographic and educational factors. BACKGROUND: Depression affects approximately 350 million people worldwide and is the world's leading cause of disability. Nursing students struggle to cope with not only stressors common in higher education institutions but also anxiety towards clinical placements. Evidence has suggested high prevalence of depression among them, but no reviews have been conducted to report a consolidated prevalence. DESIGN: Systematic review and meta-analysis. REVIEW METHODS AND DATA SOURCES: A search was conducted from November 2015 to January 2016 on CINAHL, EMBASE, Medline OVID, Medline ProQuest, PsycINFO, PubMed, ScienceDirect, and SCOPUS, using a combination of keywords "depression", "nursing students", "mood disorder", "affective disorder", 'undergraduate nursing', "nursing education", "nursing undergraduate", and "nursing diploma". RESULTS: A total of 27 cross-sectional studies were included. The sample comprised 8918 nursing students and the mean age ranged from 17.4 to 28.4 years. Among these studies, the proportion of female students ranged from 79.0% to 100.0%. A high pooled prevalence of depression of 34.0% was reported among nursing students. Significant differences in depression prevalence were noted for different subgroups of age, with a higher prevalence noted in younger students (41.0%), and for different geographical regions, with Asian nursing students experiencing a higher prevalence of depression (43.0%). No significant difference was noted between nursing and non-nursing students. CONCLUSION: The findings suggest a high prevalence of depression among nursing students. This serves as an impetus for educational reforms in nursing schools and proposes for further research to aid prospective nurses in safeguarding their psychological wellbeing. In the long run, it is imperative that competent nurses be nurtured to improve the standards of healthcare and patients' quality of life.

Spiritual perspectives of emergency medicine doctors and nurses in caring for end-of-life patients: A mixed-method study.

BACKGROUND: End-of-life care is becoming more prevalent in the Emergency Department. Quality end-of-life care includes spiritual support. As spirituality is a relatively vague concept, understanding healthcare professionals' spiritual perspectives is important. AIMS: To explore the perspectives of Emergency Department doctors and nurses in (i) spirituality, (ii) spiritual care domain in end-of-life care and (iii) factors influencing spiritual care provision in the Emergency Department. DESIGN: A sequential explanatory mixed-method design was used. SETTING: An Emergency Department of a tertiary teaching hospital in Singapore, which treats more than 120,000 patients annually. PARTICIPANTS: This study involved Emergency Department doctors and nurses who meet the eligibility criteria. In phase one, 64 doctors and 112 nurses were recruited. In phase two, 14 doctors and 15 nurses participated. METHODS: The quantitative phase was conducted first using a socio-demographic form and validated Spiritual Care-Giving Scale on all potential participants. The Spiritual Care-Giving Scale explores one's perspectives of spirituality and spiritual care. Using a six-point Likert scale, participants would indicate their degree of agreement towards the statements. The qualitative phase was then conducted using focus group discussions on a convenience sample of 14 doctors and 15 nurses. RESULTS: Overall, participants had positive attitudes and understanding of spirituality and spiritual care, as the mean total Spiritual Care-Giving Scale score was 167.87 (SD=24.35) out of 210. Some knowledge deficits were observed in the focus group discussions as several participants equated spirituality to religion and had limited understanding about spiritual care. Significant differences between the spiritual perspectives of doctors and nurses were reported in Spiritual Perspectives (p-value=0.018) and Spiritual Care Values (p-value=0.004) of the Spiritual Care-Giving Scale. Scores by nurses were higher than those of doctors. CONCLUSION: The study findings emphasized the need for education regarding spirituality and spiritual care across different cultures. This may help healthcare professionals feel more competent to broach such issues and cope with the emotional burden when providing spiritual care.

Therapist-Supported Internet-Based Cognitive Behavior Therapy for Stress, Anxiety, and Depressive Symptoms Among Postpartum Women: A Systematic Review and Meta-Analysis.

BACKGROUND: A growing number of meta-analyses have supported the application of therapist-supported Internet-based cognitive behavior therapy (iCBT) for psychological disorders across different populations, but relatively few meta-analyses have concentrated on postpartum women. OBJECTIVE: This meta-analysis evaluated the efficacy of therapist-supported iCBT in improving stress, anxiety, and depressive symptoms among postpartum women. METHODS: A total of 10 electronic databases were used to search for published and unpublished trials. Cochrane Collaboration tool for assessing risk of bias was utilized to measure methodological quality. Meta-analysis was performed using the RevMan software (Review Manager version 5.3 for Windows from the Nordic Cochrane Centre, the Cochrane Collaboration, 2014). Among the 789 studies identified, 8 randomized controlled trials were selected, involving 1523 participants across 6 countries. RESULTS: More than half (65%) of the eligible studies had a low risk of bias with no heterogeneity. Results revealed that therapist-supported iCBT significantly improved stress (d=0.84, n=5), anxiety (d=0.36, n=6), and depressive symptoms (d=0.63, n=8) of the intervention group compared with those of the control group at post-intervention. CONCLUSIONS: This review revealed that therapist-supported iCBT significantly improves stress, anxiety, and depressive symptoms among postpartum women with small to large effects. Future effectiveness studies should establish the essential components, format, and approach of iCBT with optimal levels of human support to maximize a long-term effect.

Efficacy of Internet-Based Self-Monitoring Interventions on Maternal and Neonatal Outcomes in Perinatal Diabetic Women: A Systematic Review and Meta-Analysis.

BACKGROUND: Self-monitoring using the Internet offers new opportunities to engage perinatal diabetic women in self-management to reduce maternal and neonatal complications. OBJECTIVE: This review aims to synthesize the best available evidence to evaluate the efficacy of Internet-based self-monitoring interventions in improving maternal and neonatal outcomes among perinatal diabetic women. METHODS: The review was conducted using Cochrane Central Register of Controlled Trials, PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsyINFO, Scopus, and ProQuest Dissertations and Theses to search for English-language research studies without any year limitation. A risk of bias table was used to assess methodological quality. Meta-analysis was performed with RevMan software. Cochran Q and I(2) tests were used to assess heterogeneity. The overall effect was assessed using z tests at P<.05. Of the 438 studies identified through electronic searches and reference lists, nine experimental studies from 10 publications were selected. RESULTS: Half of the selected studies showed low risk of bias and comprised 852 perinatal diabetic women in six countries. The meta-analysis revealed that Internet-based self-monitoring interventions significantly decreased the level of maternal glycated hemoglobin A1c (z=2.23, P=.03) compared to usual care among perinatal diabetic women at postintervention. Moreover, Internet-based self-monitoring interventions significantly decreased the cesarean delivery rate (z=2.23, P=.03) compared to usual care among the mixed group at postintervention. CONCLUSIONS: This review shows neonatal or other maternal outcomes are similar between Internet-based self-monitoring interventions and usual diabetes care among perinatal diabetic women. The long-term effects of the intervention must be confirmed in future studies using randomized controlled trials and follow-up data.

Clustered randomized controlled trial of a hand hygiene intervention involving pocket-sized containers of alcohol-based hand rub for the control of infections in long-term care facilities.

OBJECTIVE: To investigate the effectiveness of a multifaceted hand hygiene program involving the use of pocket-sized containers of antiseptic gel in long-term care facilities (LTCFs) with elderly residents. METHODS: In this clustered randomized controlled trial, Hong Kong LTCFs for elderly persons were recruited via snowball sampling. Staff hand hygiene adherence was directly observed, and residents' infections necessitating hospitalization were recorded. After a 3-month preintervention period, LTCFs were randomized to receive pocket-sized containers of alcohol-based gel, reminder materials, and education for all HCWs (treatment group) or to receive basic life support education and workshops for all healthcare workers (HCWs) (control group). A 2-week intervention period (April 1-15, 2007) was followed by 7 months of postintervention observations. RESULTS: In the 3 treatment LTCFs, adherence to hand rubbing increased from 5 (1.5%) of 333 to 233 (15.9%) of 1,465 hand hygiene opportunities (P = .001)and total hand hygiene adherence increased from 86 (25.8%) of 333 to 488 (33.3%) of 1,465 opportunities (P = .01)after intervention; the 3 control LTCFs showed no significant change. In the treatment group, the incidence of serious infections decreased from 31 cases in 21,862 resident-days (1.42 cases per 1,000 resident-days) to 33 cases in 50,441 resident-days (0.65 cases per 1,000 resident-days) (P = .002), whereas in the control group, it increased from 16 cases in 32,726 resident-days (0.49 cases per 1,000 resident-days) to 85 cases in 81,177 resident-days (1.05 cases per 1,000 resident-days) (P = .004]). In the treatment group, the incidence of pneumonia decreased from 0.91 to 0.28 cases per 1,000 resident-days (P = .001) and the death rate due to infection decreased from 0.37 to 0.10 deaths per 1,000 resident-days (P = .01); the control group revealed no significant change. CONCLUSIONS: A hand hygiene program involving the use of pocket-sized containers of antiseptic gel and education could effectively increase adherence to hand rubbing and reduce the incidence of serious infections in LTCFs with elderly residents.