key: cord-325612-a24qbiyd
authors: Bae, Suyeon
title: The ways in which healthcare interior environments are associated with perception of safety from infectious diseases and coping behaviours
date: 2020-06-23
journal: J Hosp Infect
DOI: 10.1016/j.jhin.2020.06.022
sha: 
doc_id: 325612
cord_uid: a24qbiyd

BACKGROUND: Global pandemic outbreaks often have people fear. Healthcare personnel (HCP), especially those fighting the pathogens at the front lines, encounter a higher risk of being infected, while they treat patients. In addition, a variety of environmental fomites in hospitals, which may contain infectious agents, can post a high risk of getting infectious diseases. AIM: Making HCP feel safe from infectious diseases is critical to delivering the best healthcare practice. Therefore, this study aims provide a better understanding of HCP’s HH behaviours and perceptions of infectious diseases from psychological perspectives. METHOD: Observations measured different environmental features at three different departments and questionnaires asked HCP’s perception of safety from infectious diseases and coping behaviors (e.g., avoidance and disinfection). FINDINGS: This study has implications for potential interventions that enough HH stations at convenient locations would increase HH compliance rate from psychological perspectives, perception of safety from infectious diseases. In response to the current research gap in psychological aspects associated with HH, this study also presents HCP’s coping behaviours (e.g., avoidance and disinfection) would be predicted by their perceived contamination likelihoods and their perceived vulnerability enhanced the associations. CONCLUSIONS: Nonetheless, due to several limitations, those findings should be carefully interpreted and further studies must be conducted with more solid academic rigor.

Continuous outbreaks of infectious diseases, from Severe Acute Respiratory Syndrome To explore how interior environments are associated with HCP's perception of safety 7 from infectious diseases and coping behaviours, a mixed-method design consisting of 8 observations and questionnaires was applied. In the observations, data were collected regarding 9 environmental features, such as HH stations, sharing medical equipment (SME), and traffic 10 volume. The questionnaires were conducted to measure participants' perception of safety from 11 infectious diseases and their behaviours. The observations were conducted to examine the interior environmental features (i.e., the 14 number of HH stations, the number of SME, and traffic volume) in the three departments. Each 15 department was observed for one and a half hours at five randomly selected days and times. 16 Before the initial observation, the numbers of HH stations and SME were counted. The HH 17 stations included form/gel-type sanitizers and sinks with a hand-soap. The examples counted for 18 the SME are a computer, mouse, keyboard, phone, thermometer, blood pressure equipment, etc. 19 Therefore, a HH ratio for each department was calculated by dividing the total number of HH 20 stations by the average number of HCP at each department, and an SME ratio for each 21 department was calculated by dividing the total number of SMEs by the average number of HCP. 22 Additionally, the numbers of people who occupied the space were counted at the beginning and Table 1 summarizes the environmental features for each department. ICU had a relatively 5 medium HH ratio and a low SME ratio, but it had a high traffic volume. ER had high HH and 6 SME ratios but a low traffic volume, while OP had a low HH ratio but a high SME ratio and 7 traffic volume. 

Paper questionnaires were distributed and a total of 104 HCP completed the 10 questionnaires throughout the three departments (ICU = 26, ER = 24, and OP = 54). Table 1 11 summarizes the participants' demographic information. The participants were asked to report the 12 degree of their perceptions of safety from infectious diseases at work (α = 0.92) and perceived 13 vulnerability on the 7-Likert scale (strongly disagree to strongly agree), the likelihoods of a 14 physical object being contaminated and causing infection (α = 0.94) on the 0-100 scale (not at all 15 to extremely likely), their behaviours (α = 0.94) on the 5-Likerts scale (never to always), and HH 16 compliance rates among the HCPs themselves. For the HH compliance rates, all three 17 departments reported higher compliance rates for their own rates compared to their colleagues' 18 rates.

Insert Table 1 20

To explore how the participants at the three different departments differently reported 22 their perception and behaviours, ANOVA analyses were conducted. Subsequently, Mann-Whitney U tests were used to examine the statistical differences in the self-reported HH 1 compliance rates between two groups (i.e., the participants who perceived the hindrance of HH 2 stations' quantity and location and the participants who did not perceive the hindrance). Finally, 3 regression analyses were conducted to find any associations between perceived contamination 4 likelihoods and coping behaviours and the role of perceived vulnerability on the associations. To 5 analyse data, IBM SPSS version 24 (Armonk, New York) was used. This study was approved by the institutional review board of [a university to be named].

All participants were included in the study after provided written informed consent. All data 9 were analysed and presented anonymously. 

The participants across the three departments felt safe from infectious diseases at their 13 workplace (see Table 2 ). To be specific, they perceived safety from infectious diseases because 14 of the supportive conditions of physical environments (e.g., easily cleanable furniture materials 15 and fomites), sufficient and accessible HH stations, and their HH protocol compliance. The participants reported high HH compliance rates for themselves and their colleagues 3 (see Table 1 ). When they were asked about the reasons for poor HH adherence or any barriers 4 against appropriate HH compliance, the most frequent reason was "not thinking about 5 it/forgetfulness" (65%) followed by "skin irritation and dryness" (59%), "too busy/insufficient 6 time" (47%), and "inconvenient location/shortage of HH stations" (42%) (see Figure 1 ).

ANOVA analyses showed that the participants at three departments differently selected the 8 reasons for poor HH adherence. Specifically, more than 50% of the participants at OP reported 9 that inconvenient locations and shortage of HH stations can hinder their HH compliance, while 10 approximately 26% of the participants at ICU and ER reported it as the reason for poor HH 11 adherence. In contrast, roughly 50% of the participants at ICU and ER identified that priority of 12 patient care would hinder the HH compliance, whereas the significantly fewer participants at OP 13 selected it as a barrier against good HH adherence. To understand the association between the HH compliance rate and HH stations, Mann-16 Whitney U tests were conducted because the Shapiro-Wilk test indicated the non-normality of 17 the data distribution (see Table 3 ). The results implied that the participants, who perceived the 18 inconveniently located and insufficient HH stations as the barrier against good compliance, 19 reported statistically significant lower HH compliance rate (M = 83.65) than the HH compliance 20 rate among the participants, who did not perceive the HH stations' locations and quantity as the 21 barrier (M = 90.05). 1 The participants were asked to indicate a likelihood that eight objects would be 2 contaminated and that touching the objects would cause infection (see Table 4 ). The participants 3 perceived that all of the objects had higher likelihoods being contaminated than causing infection. Table 4 8 When the participants were asked about their responding behaviours to the eight objects 9 which might be contaminated and cause infection, their coping behaviours (e.g., disinfecting 10 hands and avoiding touching the objects) were different depending on the objects (see Table 5 ).

To be specific, the participants at all three departments more frequently washed/disinfected their 12 hands after using the toilet, touching medical equipment and the objects in restrooms (e.g., Insert Table 6 10 Additional regression analyses (Models 2, 4, and 6) included the perceived vulnerability 11 of the participants to infectious diseases to examine its moderating effects on the associations in 12 Models 1, 3, and 5. The results demonstrated the perceived vulnerability to infectious diseases, 13 as a moderator, strengthened the associations between three objects' contamination likelihoods 14 and coping behaviours by explaining more variance through the increased values of adjusted R 2 . 15 because of a sufficient number and accessible HH stations (see Table 2 ). This result might be 1 because the ER had a higher HH ratio but a lower traffic volume than the ICU and OP (see Table   2 1).

Previous literature has also investigated the perception of safety from infectious diseases 4 and HH compliance. Pediatric residents indicated their concern about getting infectious 5 themselves as well as infecting their loved ones could motivate them to adhere to a proper HH 6

[29]. One qualitative research also found that nurses believed that HH protected them from 7 infectious diseases as a protective behaviour [25] . Another study showed that beliefs about 8 consequence were the most compelling facilitator of HH among HCP [8] . Even more, a control 9 belief, where nurses believed they possessed or had access to HH resources to adhere to the HH 10 recommendation, had a strong association with their adherence intentions, which also led to a 11 higher HH compliance rate [24] . In addition, a previous study explored HCP's perception of 12 design factors in hospitals and found the participants ranked the factors associated with safety 13 higher than aesthetics [30] . The study also showed that they perceived provision for HH as an In conclusion, HCP's concern, salient beliefs about HH outcomes, and 16 preference on safety features including provision for HH can explain that HCP might perceive a 17 higher degree of safety from infectious diseases if ample HH stations are located appropriately.

In light of our findings, this paper further explored the association between interior 19 environments and HH compliance. More than 40% of the participants thought not enough and 20 inconveniently located HH stations would hinder appropriate HH compliance (see Figure 1 ).

Furthermore, more participants working at the OP (above 50%), where the HH ratio was the 22 lowest, perceived the inconveniently located and insufficient HH stations as the barrier than the participants working at the ICU and ER, where the HH ratios are higher. In addition, the 1 participants, who thought inconvenient locations of and not enough number of HH stations, 2 reported a statistically lower HH compliance rate, compared to the participants who did not 3 perceive the spatial barrier (see Table 3 ).

What is highlighting from this study is that the perception of barriers affects a self- Third, HH compliance and the coping behaviours are self-reported values. Whether or not 20 the actual HH compliance rates were increased with convenient locations and sufficient numbers 21 of HH stations is still questionable. Also, the participants could report a higher HH compliance ratios and their coping behaviours reflect the reality is unproven. Hence, future studies should 1 enhance the reliabilities of the HH compliance and coping behaviours. 8.32 ** 6.14 ** Adjusted R 2 0.07 ** 0.11 ** Note. *** p < 0.001, ** p < 0.01, * p < 0.05. M: Mean, SD: Standard deviation. 

9241501502, Report on the burden of endemic health care-associated

Note. *** p < 0.001, ** p < 0.01, * p < 0.05. M: Mean, SD: Standard deviation.