Review Reports - Effectiveness of Nudge Tools to Promote Hand Disinfection among Healthcare Professionals and Visitors in Health Institution: The Slovenian Pilot Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

In the present study, the authors investigate the effects of nudging tools in the hand hygiene of healthcare professionals and the visitors of a hospital. Although, this is an interesting study, the presentation needs improvement. In particular,

- - The aims of the study are not clearly presented in the abstract or the last paragraph of the Introduction section.

- -nA comparison of all five categories (Registered nurses, Medical technicians, Doctors, Cleaners) with regard to the number of all opportunities for hand disinfection in all four weeks (Table 5) is presented in lines 234-256. The statistical analysis used for calculating the p-values should be mentioned in the Materials & Methods section. An additional Table for presenting these data is recommended.

- - The paragraphs in the Results since the paragraphs [3.1 The first week of observation (without nudge tools), 3.2 The second week of observation (posters with a picture and an inscription), 3.3 Third week of observation (scent citrus), 4.3 Fourth week of observation (flashing lights)- this should be 3.4] are very descriptive of the data presented in Tables 1-4, which are also presented in Table 5 and Figures 2-5. The Results and Discussion may be combined in one section.

- - The data in Tables 1-4 are also presented in Table 5 and Figures 2-5 (the numbering should be 1-4), which is a redundancy and, therefore should be deleted. The data of the figures are also presented in Table 5. I would suggest to combine these figures in one figure as a bar chart for the per week of observation by individual categories (Registered nurses, Medical technicians, Doctors, Cleaners) of observed persons.

Author Response

The authors wish to thank all reviewers for their valuable time to comment on the manuscript in such a constructive way.

Regarding comments raised after our submission, please find below list of changes made. Our changes are also visible in the revised version of the manuscript where deleted text and text which was moved to another location inside the manuscript are visible as track changes.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

Overall I think this paper is a very interesting paper in looking into how nudge tools help in improving hand hygiene compliance in the hospital. The use of different methods are innovative and cost-effective if these are demonstrated to be useful in the study. The English in this paper is well-written, however I have several comments that the authors may want to look into during their revision:

Major comments:

1. Significant repetition of content was observed in the result session. The content of the first paragraph of each intervention session, the corresponding table, as well as the bar chart, basically presents the same content. The authors should review the content of the Result session again to reduce repetition, for example, Figure 2, 3, 4, and 5 can be combined together. Similarly, Table 1, 2, 3, and 4 are unnecessary when Table 5 is present. There is no need for the text to repeat the content of the Table.

2. The statistical method and software used in analyzing the data should be included in the Methodology section in the manuscript, especially when there were occasions where two or more groups were compared in the Result session. The p-value cutoff of statistical significance should also be mentioned.

3. I would like to know whether the study was performed in a single ward or not. One significant limitation in this study is that the interventions were performed in a particular sequence, i.e. you cannot differentiate whether the change in hand hygiene practice was due to a single intervention or due to the effect of several interventions combined in sequence together. Based on the result provided, I do not know whether the change in hand hygiene compliance is due to a single intervention or not. A better study design would be having 3 wards, with each ward having interventions under different sequences, for example Ward A starting with poster first, Ward B starting with citrus smell first, and Ward C starting with flashing light first, in order to better understand the significance of each intervention.

4. The reason for insignificant results observed after intervention could be due to the low number of individuals in each group observed. This should be included in the limitation section.

5. The comparison of total number of opportunities for hand hygiene in Lines 234 - 237 is not useful. The difference is likely due to the low number of participants in each group. It provides no added value in performing statistical test on this parameter.

Minor comments:

1. It is better for the authors to present the schedule of the intervention graphically, as it is difficult the understand the schedule of interventions.

2. It would be great if the authors could provide photos of the intervention, especially on the use of posters and flashing lights, so that readers understand what types of interventions were given by the research group.

3. There were occasions where the "." in numbers were changed to ",". Please correct them.

Author Response

The authors wish to thank all reviewers for their valuable time to comment on the manuscript in such a constructive way.

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

Reviewer’s Comments and Suggestions for Authors

Journal: Hygiene, MDPI

Manuscript ID: hygiene-2926747

Type: Article

Title: Effectiveness of nudge tools to promote hand disinfection among healthcare professionals and visitors in health institution: The Slovenian case study

Authors: Neža Podvratnik, Andrej Ovca and Mojca Jevšnik

The authors of the manuscript Manuscript ID: hygiene-2926747 conducted open observation of employees and visitors with participation for four weeks. The actual state of hand disinfection was determined on the basis of observation, without introducing any changes; then separately introduced three nudge tools, posters with an inscription and a picture, the scent of citrus and flashing lights. The obtained results were analyzed with the help of the SpeedyAudit Lite application, and the effectiveness of each nudge tool and the adequacy of hand disinfection by categories of persons were compared. The results showed that employees and visitors or parents of children did not disinfect their hands consistently. All three nudge tools had a positive effect on employees (in total).

This manuscript was written clearly, and the authors have described the main limitations of this study. The essential revisions should be completed as below.

Major revisions

(1) In the Abstract section: the authors should reconstruct the Abstract, and present the major results and conclusions of this study. Moreover, the significance of the results should be elucidated.

(2) In the Introduction section, the aim of this study should be described. What did the authors do in this study?

(3) In the Materials and Methods section, the references of the methods used in this study should be cited. Moreover, I suggest the authors to make a flow chart of the investigation strategy for “The Process of observation”.

(4) In the Results section, I suggest the authors to add a subtitle to present the comparison of all five categories with regard to the number of all opportunities for hand disinfection in all four weeks.

(5) The Conclusions section is redundant, please reconstruct this section, shorten it, and present the major results and conclusions of this manuscript.

(6) Figures 2-5: the X and Y axes are missing. Please modify.

(7)Please add the citation information on Page 1.

(8) Please check the References section, and format each of the references according to the guidance of the journal for authors.

Author Response

The authors wish to thank all reviewers for their valuable time to comment on the manuscript in such a constructive way.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have fulfilled the requiremets for publication and revised the manuscript, accordingly

Author Response

Dear reviewer!

Thank you for your second review and your reply.

Kind regards,

Authors

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have addressed most of my comments in my previous review. Here are some of the minor comments:

1. The authors may consider emphasizing in the manuscript title that this is a pilot study.

2. With the addition of the flow chart, the authors should note that the week 1, week 2, week 3, and week 4 mentioned in the bar chart will be different from that in the flow chart. Please review and make sure the weeks are consistent throughout the whole manuscript.

3. It might be better not to quote references in the abstract, but quote references in the main text instead.

Author Response

Dear reviewer!

Thank you for your second review and your reply. We have taken all your comments into account and corrected the manuscript according to each comment.

Kind regards,

Authors

Reviewer 3 Report

Comments and Suggestions for Authors

Reviewer’s Comments and Suggestions for Authors

(Second round)

Journal: Hygiene, MDPI

Manuscript ID: hygiene-2926747-R1

Type: Article

Title: Effectiveness of nudge tools to promote hand disinfection among healthcare professionals and visitors in health institution: The Slovenian case study

Authors: Neža Podvratnik, Andrej Ovca and Mojca Jevšnik

The authors have revised the manuscript Manuscript ID: hygiene-2926747, according to my comments and suggestions.

A minor revision is to remove the subtitle “The aim of study”, but reconstruct a single paragraph as “The aim of this study was: (1) to determine the actual status ...; (2) to select and introduce ...; and (3) to give suggestions ... .

Author Response

Dear reviewer!

Thank you for the second review of the manuscript. We corrected and remove the subtitle “The aim of study”. We have also reconstruct The aim of this study in 3 points as suggested.

Kind regards,

Authors