Broad Medical Uncertainty and the ethical obligation for openness.

This paper argues that there exists a collective epistemic state of 'Broad Medical Uncertainty' (BMU) regarding the effectiveness of many medical interventions. We outline the features of BMU, and describe some of the main contributing factors. These include flaws in medical research methodologies, bias in publication practices, financial and other conflicts of interest, and features of how evidence is translated into practice. These result in a significant degree of uncertainty regarding the effectiveness of many medical treatments and unduly optimistic beliefs about the benefit/harm profiles of such treatments. We argue for an ethical presumption in favour of openness regarding BMU as part of a 'Corrective Response'. We then consider some objections to this position (the 'Anti-Corrective Response'), including concerns that public honesty about flaws in medical research could undermine trust in healthcare institutions. We suggest that, as it stands, the Anti-Corrective Response is unconvincing.

Birth attendants' hand hygiene compliance in healthcare facilities in low and middle-income countries: a systematic review.

BACKGROUND: With an increasing number of women delivering in healthcare facilities in Low and Middle Income Countries (LMICs), healthcare workers' hand hygiene compliance on labour wards is pivotal to preventing infections. Currently there are no estimates of how often birth attendants comply with hand hygiene, or of the factors influencing compliance in healthcare facilities in LMICs. METHODS: We conducted a systematic review to investigate the a) level of compliance, b) determinants of compliance and c) interventions to improve hand hygiene during labour and delivery among birth attendants in healthcare facilities of LMICs. We also aimed to assess the quality of the included studies and to report the intra-cluster correlation for studies conducted in multiple facilities. RESULTS: We obtained 797 results across four databases and reviewed 71 full texts. Of these, fifteen met our inclusion criteria. Overall, the quality of the included studies was particularly compromised by poorly described sampling methods and definitions. Hand hygiene compliance varied substantially across studies from 0 to 100%; however, the heterogeneity in definitions of hand hygiene did not allow us to combine or compare these meaningfully. The five studies with larger sample sizes and clearer definitions estimated compliance before aseptic procedures opportunities, to be low (range: 1-38%). Three studies described two multi-component interventions, both were shown to be feasible. CONCLUSIONS: Hand hygiene compliance was low for studies with larger sample sizes and clear definitions. This poses a substantial challenge to infection prevention during birth in LMICs facilities. We also found that the quality of many studies was suboptimal. Future studies of hand hygiene compliance on the labour ward should be designed with better sampling frames, assess inter-observer agreement, use measures to improve the quality of data collection, and report their hand hygiene definitions clearly.

Parasite stress and pathogen avoidance relate to distinct dimensions of political ideology across 30 nations.

People who are more avoidant of pathogens are more politically conservative, as are nations with greater parasite stress. In the current research, we test two prominent hypotheses that have been proposed as explanations for these relationships. The first, which is an intragroup account, holds that these relationships between pathogens and politics are based on motivations to adhere to local norms, which are sometimes shaped by cultural evolution to have pathogen-neutralizing properties. The second, which is an intergroup account, holds that these same relationships are based on motivations to avoid contact with outgroups, who might pose greater infectious disease threats than ingroup members. Results from a study surveying 11,501 participants across 30 nations are more consistent with the intragroup account than with the intergroup account. National parasite stress relates to traditionalism (an aspect of conservatism especially related to adherence to group norms) but not to social dominance orientation (SDO; an aspect of conservatism especially related to endorsements of intergroup barriers and negativity toward ethnic and racial outgroups). Further, individual differences in pathogen-avoidance motives (i.e., disgust sensitivity) relate more strongly to traditionalism than to SDO within the 30 nations.

Pharmacist services for non-hospitalised patients.

BACKGROUND: This review focuses on non-dispensing services from pharmacists, i.e. pharmacists in community, primary or ambulatory-care settings, to non-hospitalised patients, and is an update of a previously-published Cochrane Review. OBJECTIVES: To examine the effect of pharmacists' non-dispensing services on non-hospitalised patient outcomes. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, two other databases and two trial registers in March 2015, together with reference checking and contact with study authors to identify additional studies. We included non-English language publications. We ran top-up searches in January 2018 and have added potentially eligible studies to 'Studies awaiting classification'. SELECTION CRITERIA: Randomised trials of pharmacist services compared with the delivery of usual care or equivalent/similar services with the same objective delivered by other health professionals. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures of Cochrane and the Effective Practice and Organisation of Care Group. Two review authors independently checked studies for inclusion, extracted data and assessed risks of bias. We evaluated the overall certainty of evidence using GRADE. MAIN RESULTS: We included 116 trials comprising 111 trials (39,729 participants) comparing pharmacist interventions with usual care and five trials (2122 participants) comparing pharmacist services with services from other healthcare professionals. Of the 116 trials, 76 were included in meta-analyses. The 40 remaining trials were not included in the meta-analyses because they each reported unique outcome measures which could not be combined. Most trials targeted chronic conditions and were conducted in a range of settings, mostly community pharmacies and hospital outpatient clinics, and were mainly but not exclusively conducted in high-income countries. Most trials had a low risk of reporting bias and about 25%-30% were at high risk of bias for performance, detection, and attrition. Selection bias was unclear for about half of the included studies.Compared with usual care, we are uncertain whether pharmacist services reduce the percentage of patients outside the glycated haemoglobin target range (5 trials, N = 558, odds ratio (OR) 0.29, 95% confidence interval (CI) 0.04 to 2.22; very low-certainty evidence). Pharmacist services may reduce the percentage of patients whose blood pressure is outside the target range (18 trials, N = 4107, OR 0.40, 95% CI 0.29 to 0.55; low-certainty evidence) and probably lead to little or no difference in hospital attendance or admissions (14 trials, N = 3631, OR 0.85, 95% CI 0.65 to 1.11; moderate-certainty evidence). Pharmacist services may make little or no difference to adverse drug effects (3 trials, N = 590, OR 1.65, 95% CI 0.84 to 3.24) and may slightly improve physical functioning (7 trials, N = 1329, mean difference (MD) 5.84, 95% CI 1.21 to 10.48; low-certainty evidence). Pharmacist services may make little or no difference to mortality (9 trials, N = 1980, OR 0.79, 95% CI 0.56 to 1.12, low-certaintly evidence).Of the five studies that compared services delivered by pharmacists with other health professionals, no studies evaluated the impact of the intervention on the percentage of patients outside blood pressure or glycated haemoglobin target range, hospital attendance and admission, adverse drug effects, or physical functioning. AUTHORS' CONCLUSIONS: The results demonstrate that pharmacist services have varying effects on patient outcomes compared with usual care. We found no studies comparing services delivered by pharmacists with other healthcare professionals that evaluated the impact of the intervention on the six main outcome measures. The results need to be interpreted cautiously because there was major heterogeneity in study populations, types of interventions delivered and reported outcomes.There was considerable heterogeneity within many of the meta-analyses, as well as considerable variation in the risks of bias.

Therapeutic encounters and the elicitation of community care.

Singh's analysis of shamanism is regarded as a contribution to the evolutionary study of healing encounters and evolutionary medicine. Shamans must create convincing healing spectacles, while sick individuals must convincingly express symptoms and suffering to motivate community care. Both have a shared interest in convincing onlookers. This is not restricted to shamanic treatment, but is still true in modern medical care.

How feedback biases give ineffective medical treatments a good reputation.

BACKGROUND: Medical treatments with no direct effect (like homeopathy) or that cause harm (like bloodletting) are common across cultures and throughout history. How do such treatments spread and persist? Most medical treatments result in a range of outcomes: some people improve while others deteriorate. If the people who improve are more inclined to tell others about their experiences than the people who deteriorate, ineffective or even harmful treatments can maintain a good reputation. OBJECTIVE: The intent of this study was to test the hypothesis that positive outcomes are overrepresented in online medical product reviews, to examine if this reputational distortion is large enough to bias people's decisions, and to explore the implications of this bias for the cultural evolution of medical treatments. METHODS: We compared outcomes of weight loss treatments and fertility treatments in clinical trials to outcomes reported in 1901 reviews on Amazon. Then, in a series of experiments, we evaluated people's choice of weight loss diet after reading different reviews. Finally, a mathematical model was used to examine if this bias could result in less effective treatments having a better reputation than more effective treatments. RESULTS: Data are consistent with the hypothesis that people with better outcomes are more inclined to write reviews. After 6 months on the diet, 93% (64/69) of online reviewers reported a weight loss of 10 kg or more while just 27% (19/71) of clinical trial participants experienced this level of weight change. A similar positive distortion was found in fertility treatment reviews. In a series of experiments, we show that people are more inclined to begin a diet with many positive reviews, than a diet with reviews that are representative of the diet's true effect. A mathematical model of medical cultural evolution shows that the size of the positive distortion critically depends on the shape of the outcome distribution. CONCLUSIONS: Online reviews overestimate the benefits of medical treatments, probably because people with negative outcomes are less inclined to tell others about their experiences. This bias can enable ineffective medical treatments to maintain a good reputation.

Anger and disgust shape judgments of social sanctions across cultures, especially in high individual autonomy societies.

When someone violates a social norm, others may think that some sanction would be appropriate. We examine how the experience of emotions like anger and disgust relate to the judged appropriateness of sanctions, in a pre-registered analysis of data from a large-scale study in 56 societies. Across the world, we find that individuals who experience anger and disgust over a norm violation are more likely to endorse confrontation, ostracism and, to a smaller extent, gossip. Moreover, we find that the experience of anger is consistently the strongest predictor of judgments of confrontation, compared to other emotions. Although the link between state-based emotions and judgments may seem universal, its strength varies across countries. Aligned with theoretical predictions, this link is stronger in societies, and among individuals, that place higher value on individual autonomy. Thus, autonomy values may increase the role that emotions play in guiding judgments of social sanctions.

Changes in social norms during the early stages of the COVID-19 pandemic across 43 countries.

The emergence of COVID-19 dramatically changed social behavior across societies and contexts. Here we study whether social norms also changed. Specifically, we study this question for cultural tightness (the degree to which societies generally have strong norms), specific social norms (e.g. stealing, hand washing), and norms about enforcement, using survey data from 30,431 respondents in 43 countries recorded before and in the early stages following the emergence of COVID-19. Using variation in disease intensity, we shed light on the mechanisms predicting changes in social norm measures. We find evidence that, after the emergence of the COVID-19 pandemic, hand washing norms increased while tightness and punishing frequency slightly decreased but observe no evidence for a robust change in most other norms. Thus, at least in the short term, our findings suggest that cultures are largely stable to pandemic threats except in those norms, hand washing in this case, that are perceived to be directly relevant to dealing with the collective threat.

Signalling need for care: a neglected functional role of medical treatment.

Background and Objectives: While the primary goals of medical treatment are typically to shorten illness or relieve symptoms, we explore the idea that an important additional goal for some patients is to communicate their needs. Drawing on signalling theory, we argue that undergoing treatments can help patients legitimize their illness and thereby enable access to crucial support during convalescence. Methods and Results: Four pre-registered within-subjects experiments (n = 874) show that participants are more inclined to provide care to people who undergo treatment, especially when that treatment is painful. Results show this incentivizes the use of antibiotic treatments for viral infections as well as drug treatments for mental illness. A cross-sectional study of 194 chronic pain patients shows that those who experience stigma and doubt over the legitimacy of their illness are more likely to accept aversive treatments. Furthermore, two experiments (n = 653) indicate that subtle manipulations of one's sense of social support may increase willingness to accept treatment. Conclusions and Implications: These results indicate that people make decisions to provide care in part based on the presence or absence of treatment and furthermore that patients' treatment decision-making is informed by the social consequences of their choices. Signalling theory may help explain the surprising longevity of some ineffective and costly medical procedures.

A Taxonomy of Non-honesty in Public Health Communication.

This paper discusses the ethics of public health communication. We argue that a number of commonplace tools of public health communication risk qualifying as non-honest and question whether or not using such tools is ethically justified. First, we introduce the concept of honesty and suggest some reasons for thinking it is morally desirable. We then describe a number of common ways in which public health communication presents information about health-promoting interventions. These include the omission of information about the magnitude of benefits people can expect from health-promoting interventions, and failure to report uncertainty associated with the outcomes of interventions. Next we outline some forms of behaviour which are generally recognised by philosophers as being non-honest, including deception, manipulation, and so on. Finally, we suggest that many of the public health communicative practices identified earlier share features with the non-honest behaviours described and suggest this warrants reflection upon whether such non-honesty is justified by the goals of public health communication.

Are the pathogens of out-groups really more dangerous?

We question the plausibility of Fincher & Thornhill's (F&T's) argument that localised pathogen-host coevolution leads to out-groups having pathogens more damaging than those infecting one's own family or religious group.

Male commuters in north and south England: risk factors for the presence of faecal bacteria on hands.

BACKGROUND: A previous study found that the prevalence of contamination with bacteria of faecal-origin on the hands of men differed across UK cities, with a general trend of increased contamination in northern cities. The aim of this study was to (1) confirm the north-south trend (2) identify causes for the trend. METHODS: Hand swabs from commuters (n = 308) at train stations in 4 cities were tested for the presence of faecal bacteria. RESULTS: The prevalence of hand contamination with faecal bacteria was again higher in cities in the north compared to the south (5% in London, 4% in Birmingham, 10% in Liverpool and 19% in Newcastle). Contamination risk decreased with age and better personal hygiene (self-reported). Soil contact and shaking hands increased contamination with faecal bacteria. However, in multivariable analysis, none of these factors fully explained the variation in contamination across cities. CONCLUSION: The study confirmed the north-south differences in faecal contamination of hands without finding a clear cause for the trend. Faecal contamination of hands was associated with personal hygiene indicators suggesting that microbiological testing may contribute to evaluating hygiene promotion campaigns.

Understanding infection prevention behaviour in maternity wards: A mixed-methods analysis of hand hygiene in Zanzibar.

RATIONALE: Although women in low- and middle-income countries are increasingly encouraged to give birth at facilities, healthcare-associated infection of both the mother and newborn remain common. An important cause of infection is poor hand hygiene. There is a need to understand how environmental, behavioural, and organisational factors influence hygiene practice. OBJECTIVE: To understand variations between facilities and between people in hygiene behaviour and to explore potential intervention targets in four labour wards in Zanzibar. METHODS: Site visits including observation of deliveries and of day-to-day workings of the facilities. Thirty-three semi-structured interviews, totalling more than 46 hours, with birth attendants, orderlies, managerial staff and mothers. Transcribed interviews and observation notes were read and coded by two authors. Themes were developed and analysed in light of existing research. RESULTS: The physical preconditions for hand hygiene were met more regularly in the two highvolume facilities, where soap, water, gloves were almost always available. However, in all of the facilities, hand hygiene appeared impeded by poor ergonomics, like, for example, physical distance between water taps, gloves, or delivery beds. Recontamination of gloved hands following good hand hygiene was commonly observed, a pattern that the birth attendants attributed to high and unpredictable workload and equipment shortages. Interviews and focus groups suggested that birth attendants typically understood when and why hand hygiene should be implemented, and that they were aware of low handwashing rates among co-workers. In poorer performing facilities, managers were less inclined to visit wards and more likely to perceive hand hygiene as beyond their influence. CONCLUSIONS: Observations and interviews suggest improvements in the ergonomic design of delivery rooms, including convenient availability of sinks, soap, hand gel, hand towels and gloves, may be a low-cost way to reduce the infection burden from poor hand hygiene.

Perceptions of the appropriate response to norm violation in 57 societies.

Norm enforcement may be important for resolving conflicts and promoting cooperation. However, little is known about how preferred responses to norm violations vary across cultures and across domains. In a preregistered study of 57 countries (using convenience samples of 22,863 students and non-students), we measured perceptions of the appropriateness of various responses to a violation of a cooperative norm and to atypical social behaviors. Our findings highlight both cultural universals and cultural variation. We find a universal negative relation between appropriateness ratings of norm violations and appropriateness ratings of responses in the form of confrontation, social ostracism and gossip. Moreover, we find the country variation in the appropriateness of sanctions to be consistent across different norm violations but not across different sanctions. Specifically, in those countries where use of physical confrontation and social ostracism is rated as less appropriate, gossip is rated as more appropriate.

Using the behaviour change technique taxonomy v1 (BCTTv1) to identify the active ingredients of pharmacist interventions to improve non-hospitalised patient health outcomes.

OBJECTIVES: The aim of this study was to identify which behaviour change techniques (BCTs) were present in intervention and control groups of randomised controlled trials (RCTs) included in a Cochrane systematic review. SETTING: The RCTs included were conducted in community, primary and/or ambulatory-care settings. PARTICIPANTS: The data set was derived from 86 RCTs from an interim update of the Cochrane review of the effectiveness of pharmacist services on non-hospitalised patient outcomes. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the identification of BCTs scheduled for delivery in intervention and control groups of the RCTs. The secondary outcome measure was to identify which BCTs are not being utilised in intervention and control groups of the RCTs. RESULTS: The intervention and control groups included 31 and 12 BCTs, respectively. The number of identifiable BCTs/study ranged from 0 to 12 in the intervention groups (mean 3.01 (SD 2.4)) and 0 to 6 in the control groups (mean 0.38 (SD 0.84)). The most commonly identified BCTs in the intervention groups were: instruction on how to perform the behaviour (55%, n=47) (also the most common BCT in control groups); problem solving (29%, n=25); information about health consequences (24%, n=21); social support (practical) (24%, n=21); and social support (unspecified) (23%, n=20) (the second most common BCT in control groups). Thirteen trials had no identifiable BCTs in either group. CONCLUSION: The pharmacist interventions presented in this study did not use the full range of available BCTs. Furthermore, the reporting of BCTs was incomplete for both intervention and control groups, thereby limiting the utility and reproducibility of the interventions. Future interventions should be designed and reported using relevant taxonomies and checklists for example, BCT taxonomy and TIDieR (the template for intervention description and replication).

A Practical Guide to Using Time-and-Motion Methods to Monitor Compliance With Hand Hygiene Guidelines: Experience From Tanzanian Labor Wards.

BACKGROUND: Good-quality evidence on hand hygiene compliance among birth attendants in low-resource labor wards is limited. The World Health Organization Hand Hygiene Observation Form is widely used for directly observing behaviors, but it does not support capturing complex patterns of behavior. We developed the HANDS at Birth tool for direct observational studies of complex patterns of hand rubbing/washing, glove use, recontamination, and their determinants among birth attendants. Understanding these behaviors is particularly critical in wards with variable patient volumes or unpredictable patient complications, such as emergency departments, operating wards, or triage and isolation wards during epidemics. Here we provide detailed information on the design and implementation of the HANDS at Birth tool, with a particular focus on low-resource settings. We developed the HANDS at Birth tool from available guidelines, unstructured observation, and iterative refinement based on consultation with collaborators and pilot results. We designed the tool with WOMBAT software, which supports collecting multidimensional time-and-motion data. Our analysis of the tool's performance centered on interobserver agreement and convergent validity and the implications of the data structure for data analysis. The HANDS at Birth tool encompasses various hand actions and context-relevant information. Hand actions include procedures relevant during labor and delivery; hand hygiene or glove actions; and other types of touch. During field implementation, we used the tool for continuous observation of the birth attendant. Interobserver agreement was good (kappa range: 0.7-0.9), and the tool showed convergent validity. Using the HANDS at Birth tool is a feasible way to obtain useful information about compliance with hand hygiene procedures. The tool could be used after simple training and allows for collection of reliable information about the complex pattern of hygiene behaviors. Future studies should explore using this tool to observe behavior in labor wards in other settings and in other types of wards.

Behavioural Determinants of Hand Washing and Glove Recontamination before Aseptic Procedures at Birth: A Time-and-Motion Study and Survey in Zanzibar Labour Wards.

Recent research calls for distinguishing whether the failure to comply with World Health Organisation hand hygiene guidelines is driven by omitting to rub/wash hands, or subsequently recontamination of clean hands or gloves prior to a procedure. This study examined the determinants of these two behaviours. Across the 10 highest-volume labour wards in Zanzibar, we observed 103 birth attendants across 779 hand hygiene opportunities before aseptic procedures (time-and-motion methods). They were then interviewed using a structured cross-sectional survey. We used mixed-effect multivariable logistic regressions to investigate the independent association of candidate determinants with hand rubbing/washing and avoiding glove recontamination. After controlling for confounders, we found that availability of single-use material to dry hands (OR:2.9; CI:1.58-5.14), a higher workload (OR:29.4; CI:12.9-67.0), more knowledge about hand hygiene (OR:1.89; CI:1.02-3.49), and an environment with more reminders from colleagues (OR:1.20; CI:0.98-1.46) were associated with more hand rubbing/washing. Only the length of time elapsed since donning gloves (OR:4.5; CI:2.5-8.0) was associated with avoiding glove recontamination. We identified multiple determinants of hand washing/rubbing. Only time elapsed since washing/rubbing was reliably associated with avoiding glove recontamination. In this setting, these two behaviours require different interventions. Future studies should measure them separately.

Aversive medical treatments signal a need for support: a mathematical model.

Ineffective, aversive and harmful medical treatments are common cross-culturally, historically and today. Using evolutionary game theory, we develop the following model to explain their persistence. Humans are often incapacitated by illness and injury, and are unusually dependent on care from others during convalescence. However, such caregiving is vulnerable to exploitation via illness deception, whereby people feign or exaggerate illness in order to gain access to care. Our model demonstrates that aversive treatments can counter-intuitively increase the range of conditions where caregiving is evolutionarily viable, because only individuals who stand to gain substantially from care will accept the treatment. Thus, contemporary and historical "ineffective" treatments may be solutions to the problem of allocating care to people whose true need is difficult to discern.

Do pharmacy intervention reports adequately describe their interventions? A template for intervention description and replication analysis of reports included in a systematic review.

INTRODUCTION: Scientific progress and translation of evidence into practice is impeded by poorly described interventions. The Template for Intervention Description and Replication (TIDieR) was developed to specify the minimal intervention elements that should be reported. OBJECTIVES: (1) To assess the extent to which outpatient pharmacy interventions were adequately reported. (2) To examine the dimension(s) across which reporting quality varies. (3) To examine trial characteristics that predict better reporting. METHODS: The sample comprised 86 randomised controlled trials identified in a Cochrane review of the effectiveness of pharmacist interventions on patient health outcomes. Duplicate, independent application of a modified 15-item TIDieR checklist was undertaken to assess the intervention reporting. The reporting/non-reporting of TIDieR items was analysed with principal component analysis to evaluate the dimensionality of reporting quality and regression analyses to assess predictors of reporting quality RESULTS: In total, 422 (40%) TIDieR items were fully reported, 395 (38%) were partially reported and 231 (22%) were not reported. A further 242 items were deemed not applicable to the specific trials. Reporting quality loaded on one component which accounted for 26% of the variance in TIDieR scores. More recent trials reported a slightly greater number of TIDieR items (0.07 (95% CI 0.02 to 0.13) additional TIDieR items per year of publication). Trials reported an 0.09 (95% CI 0.04 to 0.14) additional TIDieR items per unit increase in impact factor (IF) of the journal in which the main report was published. CONCLUSIONS: Most trials lacked adequate intervention reporting. This diminished the applied and scientific value of their research. The standard of intervention reporting is, however, gradually increasing and appears somewhat better in journals with higher IFs. The use of the TIDieR checklist to improve reporting could enhance the utility and replicability of trials, and reduce research waste.

Hands washing, glove use, and avoiding recontamination before aseptic procedures at birth: A multicenter time-and-motion study conducted in Zanzibar.

BACKGROUND: Our primary objective was to assess hand hygiene (HH) compliance before aseptic procedures among birth attendants in the 10 highest-volume facilities in Zanzibar. We also examined the extent to which recontamination contributes to poor HH. Recording exact recontamination occurrences is not possible using the existing World Health Organization HH audit tool. METHODS: In this time-and-motion study, 3 trained coders used WOMBATv2 software to record the hand actions of all birth attendants present in the study sites. The percentage compliance and 95% confidence intervals (CIs) for individual behaviors (hand washing/rubbing, avoiding recontamination and glove use) and for behavioral sequences during labor and delivery were calculated. RESULTS: We observed 104 birth attendants and 781 HH opportunities before aseptic procedures. Compliance with hand rubbing/washing was 24.6% (95% CI, 21.6-27.8). Only 9.6% (95% CI, 7.6-11.9) of birth attendants also donned gloves and avoided recontamination. Half of the time when rubbing/washing or glove donning was performed, hands were recontaminated prior to the aseptic procedure. CONCLUSIONS: In this study, HH compliance by birth attendants before aseptic procedures was poor. To our knowledge, this is the first study in a low- to middle-income country to show the large contribution to poor HH compliance from hand and glove recontamination before the procedure. Recontamination is an important driver of infection risk from poor HH. It should be understood for the purposes of improvement and therefore included in HH monitoring and interventions.