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Do Peer Effects Improve Hand Hygiene Adherence among Healthcare Workers?

Published online by Cambridge University Press:  10 May 2016

Mauricio N. Monsalve
Department of Computer Science, University of Iowa, Iowa City, Iowa
Sriram V. Pemmaraju
Department of Computer Science, University of Iowa, Iowa City, Iowa
Geb W. Thomas
Department of Mechanical and Industrial Engineering, University of Iowa, Iowa City, Iowa
Ted Herman
Department of Computer Science, University of Iowa, Iowa City, Iowa
Alberto M. Segre
Department of Computer Science, University of Iowa, Iowa City, Iowa
Philip M. Polgreen*
Department of Internal Medicine and Department of Epidemiology, University of Iowa, Iowa City, Iowa
MPH, Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City, IA 52242 (



To determine whether hand hygiene adherence is influenced by peer effects and, specifically, whether the presence and proximity of other healthcare workers has a positive effect on hand hygiene adherence


An observational study using a sensor network.


A 20-bed medical intensive care unit at a large university hospital.


Hospital staff assigned to the medical intensive care unit.


We deployed a custom-built, automated, hand hygiene monitoring system that can (1) detect whether a healthcare worker has practiced hand hygiene on entering and exiting a patient’s room and (2) estimate the location of other healthcare workers with respect to each healthcare worker exiting or entering a room.


We identified a total of 47,694 in-room and out-of-room hand hygiene opportunities during the 10-day study period. When a worker was alone (no recent healthcare worker contacts), the observed adherence rate was 20.85% (95% confidence interval [CI], 19.78%–21.92%). In contrast, when other healthcare workers were present, observed adherence was 27.90% (95% CI, 27.48%–28.33%). This absolute increase was statistically significant (P < .01). We also found that adherence increased with the number of nearby healthcare workers but at a decreasing rate. These results were consistent at different times of day, for different measures of social context, and after controlling for possible confounding factors.


The presence and proximity of other healthcare workers is associated with higher hand hygiene rates. Furthermore, our results also indicate that rates increase as the social environment becomes more crowded, but with diminishing marginal returns.

Infect Control Hosp Epidemiol 2014;35(10):1277–1285

Original Article
© 2014 by The Society for Healthcare Epidemiology of America. All rights reserved.

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