An E-Learning Program Improves Patients' Knowledge After Lung Transplantation

Abstract

Background:

Adherence to immunosuppressive medicine in lung transplant recipients is associated with improved long-term survival. Patient education and support from health care providers are key components. We investigated e-learning as a tool to improve lung transplant recipients' knowledge of post-transplant care such as hygiene, self-monitoring, travel precautions, vaccinations, and the importance of adherence to medication.

Objective:

To compare the effect of e-learning and conventional patient education with respect to level of knowledge and drug adherence. A single-center open randomized controlled trial design was used.

Methods:

Lung transplant recipients were randomized to an e-learning program or standard care. One month before a scheduled follow-up visit, the intervention group received a link by e-mail to a 15-min e-learning program. At the follow-up visit, all lung transplant recipients completed two drug adherence questionnaires (Basel Assessment of Adherence with Immunosuppressive medication Scales [BAASIS] and Transplant Adherence Questionnaire [TAQ]) and a questionnaire testing their knowledge of post-transplant care.

Results:

Fifty lung transplant recipients were randomized with 24 recipients in each group completing the study. Recipient adherence measured by BAASIS showed a tendency toward improved drug adherence in the intervention group compared with the control group (71% vs. 55%, p = 0.23). TAQ showed no difference between the two groups (p = 1.0). Recipients in the intervention group had a significantly higher number of correct answers to questions about transplant-friendly lifestyle (median 11 vs. 10, p = 0.02).

Conclusion:

A 15-min e-learning program is a simple and effective tool to improve lung transplant recipients' knowledge of post-transplant care.

Introduction

Lung transplantation is the ultimate treatment for severe chronic lung failure. Short-term survival of patients undergoing lung transplantation has increased during the past 20 years, but long-term survival has, however, remained unchanged with a median survival of 5.9 years in 2017.¹ The most frequent cause of reduced survival is chronic rejection.¹

Adherence to medication and a high level of self-care regarding hygiene, home monitoring, travel precautions, and vaccinations are important factors for long-term survival.^2

–5 Several studies show that adherence to immunosuppressive therapy regarding taking, dosing, and timing of medication is important. Even minor deviations from the prescribed immunosuppressive regimen, that is, taking <98% of the tablets or variability in timing of medication of >2 h, are related to increased risk of acute rejection, graft loss, and poor kidney function.^6

–10 Furthermore, transplant recipients tend to be less adherent over time^11,12; despite knowing this risk, nonadherence is common.⁶

Several factors influence patient adherence: the number of drugs, the number of daily doses, and whether the drugs are free of charge or not, but also family relations and patients' coping ability play a role.^12,13 Challenges related to adherence among lung transplant recipients are similar to recipients of other solid organs. In addition, lung transplant recipients have to monitor their pulmonary function at home, which is difficult to remember for many patients.^3,6 Strategies to maximize adherence to both drugs and home monitoring are thus highly warranted. These strategies should be based on caregiver support with continuous and repeated efforts to improve adherence through education and supportive interventions.

Despite continuous patient education at follow-up visits, many patients remain nonadherent with respect to blood sampling, medication, and home monitoring.^14,15 A recent study showed self-reported nonadherence to immunosuppressive medication in 27.4% of lung transplant recipients.¹⁶

All patients and their caregivers, enrolled in the Danish lung transplant program, are provided with a booklet made by the Danish transplant center at Rigshospitalet, Copenhagen. The booklet contains information about necessary precautions after lung transplantation and is handed out during recovery after transplantation. Before discharge from hospital and at every outpatient visit after lung transplantation, the patients receive repeated education of important topics, including sun protection, hygiene, the importance of taking and timing medication and blood sampling, peak flow home monitoring, symptoms, and how to react to these symptoms.¹⁷ In a previous Danish study, individual interviews with five lung transplant recipients pointed at the importance of timing of patient education.¹⁷ The aforementioned findings are supported by a mixed-method study from 2014, where lung transplant patients expressed a wish for education immediately before and after transplantation. However, there was a subset of topics that patients were interested in reviewing again.¹⁸

In 2014, a randomized controlled trial showed that computer-based education was noninferior to conventional education and that computer-based education was a simple effective tool to improve adherence to immunosuppressive medication.¹⁹

e-Learning has several advantages compared with conventional education. It is cost-effective and it is possible for the patients to gain information at their own pace and to go through the educational program when needed. Randomized studies in other patient groups have shown that e-learning at home after receiving conventional education significantly increased patients' knowledge. Patients with hemophilia increased their practical skills as well as their knowledge of the disease.²⁰ Patients with overactive bladder demonstrated increased knowledge, fewer symptoms, and increased empowerment after going through an e-learning program.²¹ A study of two education methods in pretransplant patients showed a significantly higher knowledge of post-transplant care, less anxiety about transplant surgery, and a higher satisfaction with the education method for patients receiving computer-based multimedia education compared with conventional education.²²

Few studies have compared a conventional education program with an e-learning program in lung transplant recipients. The aim of this study was to investigate e-learning as a way to increase patients' knowledge of post-transplant care and increase adherence to immunosuppressive treatment.

Methods

Design

This was a single-center open randomized controlled intervention study. The study was approved by the Central Denmark Region Committee on Health Research Ethics (ID 1-16-02-497-14) and informed consent was obtained.

The E-Learning Program

An e-learning program was developed covering transplant topics from existing patient education materials used at transplant centers in Denmark. Topics included the importance of lung function monitoring by regular peak flow measurement, recognition of symptoms of rejection or infection, early contact to the transplant center in case of changes, adherence to immunosuppressive medication and blood tests, and knowledge of lifestyle recommendations, including sun protection, food, and vaccination (Table 1). The duration of the e-learning program was limited to 15 min to ensure focused attention from the patient.

Table 1.

Topics Included in the e-Learning Program for Lung Transplant Recipients

SLIDE	TOPICS
1	Introduction. The program contains both images and sound
2	The importance of taking and timing immunosuppressive medication and blood tests
3	Ciclosporin, Tacrolimus: How to take the medication. What to do if you miss a dose
4	Other medications and side effects
5	Hygiene: At home, in public areas, if a family member gets sick
6	Oral hygiene: Frequency of dentist visits and use of antibiotics before dental treatment
7	Sun protection. The importance of skin self-examination
8	Diet and fluid intake
9	Work and hobbies
10	Traveling and vaccinations
11	Exercise
12	Home monitoring: Peak flow, symptoms of rejection or infection, importance of early contact to a transplant physician in case of changes, etc.

The e-learning program was developed by a transplant nurse (T.B.G.) and administered by e-mail to transplant recipients 1 month before participants in the intervention group had their next scheduled appointment at the transplant center. The program was developed as a PowerPoint presentation with voice-over narration.

The e-learning program was tested in three focus groups. Three lung transplant recipients from the Danish transplant center at Rigshospitalet in Copenhagen, Denmark, participated in the first focus group interview, and lung transplant nurses from Rigshospitalet and Aarhus University Hospital participated in the second and third interview (Fig. 1). The aim of the focus group interviews was to clarify if the e-learning program was sufficiently clear and understandable to patients, and to ensure the relevance of the topics. The interviews resulted in adding sections about sexuality and exercise. After the interviews, the e-learning program was approved by a lung transplant physician (E.B.) and a dermatology specialist. The e-learning program is shown as Supplementary Data S1.

Fig. 1.

Development of the e-learning program.

Participants

Inclusion

All lung transplant recipients attending the post-transplant follow-up program at Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Denmark, between January 2016 and August 2016 were invited to participate.

Eligible patients had received a lung transplantation >6 months before inclusion, they were >16 years of age, had access to a computer at home and an e-mail address, were able to speak Danish, and had a life expectancy of >6 months.

Patients were randomized in groups of 10 by random drawing of closed envelopes.

Information on age, gender, educational level, marital status, and time since transplantation was registered at the time of inclusion. Patients gave informed consent to participate in the e-learning program. One month before a scheduled follow-up visit, patients in the intervention group could access the e-learning program from home.

Follow up

At a follow-up visit after 1 month, all patients were asked to fill out three different questionnaires. All questionnaires were self-reported. Patients in the intervention group confirmed that they had seen the e-learning program and answered questions about their satisfaction with the e-learning program. The patients were treated by staff at the transplant center who were unaware of the randomization to either the intervention or the control group.

Questionnaires

Adherence to medication intake was assessed using the Basel Assessment of Adherence with Immunosuppressive Medication Scale (BAASIS) and the Transplant Adherence Questionnaire (TAQ),^3,10,23 which were completed by all participants. Both questionnaires are validated in patients with HIV; the BAASIS questionnaire has also been validated in renal transplant patients.^24
–26

The BAASIS questionnaire

The BAASIS questionnaire measures patients' taking, skipping, timing (>2 h from prescribed time) and dose reduction of drugs during the previous 4 weeks. BAASIS comprises four questions with a 6-point response scale ranging from never (0 points) to every day (5 points).^3,10 Scores 1–5 on any of the four items, (1) taking, (2) skipping, (3) timing, and (4) dose reduction, are considered as nonadherence. A score of 0 for each item is considered adherent. Overall adherence is scored in percentage on a visual analog scale.

The TAQ questionnaire

The TAQ questionnaire measures patients' taking, skipping, and timing of drugs during the past 4 days.^3,23 TAQ comprises six questions and patients are considered adherent if all doses are taken correctly.

Post-transplant care questionnaire

A new questionnaire examining patients' knowledge of post-transplant care and insight into the treatment was developed for the purpose of this study. It included questions related to the topics in the e-learning program (Supplementary Data S2). The questionnaire comprises 13 multiple choice questions and has been face validated²⁷ among lung transplant recipients from the transplant unit at Rigshospitalet, Copenhagen, Denmark.

Statistical Analysis

Data are presented as mean and standard deviation, median and range if continuous, or as frequencies if categorical. The number of patients with available data (n) was used in the calculation of summary statistics. Comparison was performed using the independent t-test, the Wilcoxon rank sum, or the chi-squared test as appropriate. The significance threshold was set at 0.05.

All analyses were performed using STATA statistical software (version 12.1; StataCorp, College Station, TX).

Results

A total of 48 patients completed the study. Fifty lung transplant recipients gave informed consent; one participant died and one withdrew consent. No patients declined participation. Demographic data and immunosuppressive treatment are presented in Table 2. No difference was seen with respect to age, gender, marital status, educational level, employment status, time since transplantation, and type of lung transplantation.

Table 2.

Baseline Demographics

	INTERVENTION GROUP, N = 25	CONTROL GROUP, N = 25
Gender, male/female	12/13	14/11
% male	48	56
Age, years
Mean (SD)	53 (12)	54 (11)
Time since LTX, months
Mean (SD)	128 (85)	114 (52)
Single lung transplant	8	7
Double lung transplant	17	18
Education (n)
None	9	3
Skilled worker	4	8
Technicians	4	8
Associate professionals	8	5
Academic level/professionals	0	1
Employment status
Employed partly or full time	5	6
Retired	20	18
Student	0	1
Marital status
Married/cohabiting	13	14
Living alone	12	11
Immunosuppressive treatment
Cyclosporine	15	11
Tacrolimus	10	14
Everolimus	2	3
Mycophenolate	10	10
Azathioprine	10	10
Prednisolone	25	25

LTX, lung transplantation; SD, standard deviation.

Adherence to Immunosuppressive Medication

A total of 71% of patients in the intervention group were adherent compared with 55% in the control group (p = 0.23) (Table 3).

Table 3.

Results of the BAASIS and TAQ questionnaires

	INTERVENTION GROUP, N = 24	CONTROL GROUP, N = 24	p
BAASIS
Adherent (%)	17 (71)	13 (55)
Nonadherent (%)	7 (29)	11 (45)	0.23
TAQ
Adherent (%)	23 (96)	23 (96)
Nonadherent (%)	1 (4%)	1 (4)	1.0

BAASIS, Basel Assessment of Adherence with Immunosuppressive Medication Scales; TAQ, Transplant Adherence Questionnaire.

The most frequent aberration in the control group was timing that is, taking the drugs >2 h away from the prescribed time. This was reported by a significantly higher proportion of patients in the control group than in the intervention group (11 patients [46%] vs. 3 patients [13%], p = 0.012). Two patients in the intervention group (8%) reported that this happened more than once a week; nine patients in the control group (38%) reported the same (p = 0.017).

No difference in adherence according to BAASIS was seen between patients with time since transplant above median compared with patients with time since transplant below median (p = 0.12).

Five patients (21%) in the intervention group reported more serious deviations from the prescribed regimen, all stating that they had omitted a dose of immunosuppressive medication during the past 4 weeks, but only on a single occasion. Four patients in the control group (17%) reported the omission of a dose of immunosuppressive medication during the past 4 weeks. Three of these patients reported that the omission had only occurred once, but one patient reported skipping a dose four times. No so-called “drug holidays” were reported, that is, skipping several doses in a row. No patients reported to have taken less than the prescribed dose.

No patients in the intervention group failed more than one item. Seven patients (29%) in the control group failed in only one item. Four patients (17%) in the control group reported nonadherence in more than one of the four items of nonadherence.

Patients' Knowledge of Post-Transplant Care

Patients in the intervention group had a significantly higher number of correct answers to the author-constructed questionnaire on patients' knowledge of transplant-related topics compared with patients in the control group (median 11 vs. 10, p = 0.02).

A total of 88% of the patients in the intervention group found the e-learning program relevant and 71% wished to review the program annually as a reminder. A total of 25% reported that participating in the e-learning program had resulted in lifestyle changes. Among the patients, 63% would have liked to receive the e-learning program earlier and 88% believed that other lung transplant recipients would benefit from the e-learning program.

Discussion

Our study investigated the benefits of an e-learning program on knowledge of post-transplant care among lung transplant recipients. Assuming that more correct answers and better timing of immunosuppressive medicine in those who received the e-learning program compared with those who received standard education was not caused by bias or a chance finding, our study is the first to show that an e-learning program increases lung transplant recipients' knowledge of post-transplant care. Patients randomized to the e-learning program had significantly more correct answers and the majority of recipients found it relevant and wished to repeat it annually. Our results also suggest that the e-learning program might improve adherence compared with standard patient education provided at every follow-up visit. Thus, patients in the intervention group had better timing and failed in fewer items of nonadherence.

Nonadherence to the immunosuppressive drug regimen was high in our population, as 38% of the patients were nonadherent (29% in the intervention group and 45% in the control group). This is higher than previous reports of nonadherence where rates to the immunosuppressive medication adherence ranged from 13% to 37%.^2,5 We found no relationship between the time from transplantation and drug adherence, possibly due to the limited number of patients. We found some indications, although statistically nonsignificant, toward better adherence in the intervention group suggesting that a regular brush-up of patients' knowledge of post-transplant care can be ensured by a 15-min e-learning program. The lack of a statistical significance may be caused by a type two error. However, we found that the e-learning program resulted in improved adherence with regard to timing of the medication.

Nonadherence may be difficult to discover. The gold standard is the use of an electronic pill count that may provide a less biased estimate than self-reported questionnaires.²⁸ However, electronic pill counts are considered impractical and unrealistic in daily clinical use.⁹ Several self-report instruments such as BAASIS and TAQ have been developed with the purpose of examining nonadherence. It has been suggested that self-report instruments, together with clinical judgement and blood sample analyses are key components for assessment of adherence in clinical practice.² In our study, we used the BAASIS and TAQ questionnaires and were able to show a trend for better adherence in the intervention group measured with BAASIS but no difference in TAQ. The BAASIS questionnaire measures adherence for a period of 4 weeks compared with 4 days in TAQ. Focusing on the previous 4 days only, probably results in less recall bias, but the longer time span assessed with BAASIS may provide a more truthful picture of patient behavior.

Computer-based education has been shown to be noninferior compared with conventional education.¹⁹ e-Learning programs have resulted in increased patient knowledge in nontransplant patients, increased empowerment, and reporting of fewer symptoms.²¹ Among health care personnel, a significantly higher adherence to alcohol-based hand rubbing has been demonstrated.²⁹ The advantages of e-learning are obvious as it is cost-effective compared with nurse-led conventional education. It also allows patients to go through the program at their own pace and to repeat it as needed. We did not include caregivers in the e-learning program although they may play a critical role in the education and support of transplant recipients. Involvement of caregivers may be advantageous and should be addressed in further studies.

In this study, we found a small, although statistically significant, difference between patients who used the e-learning program compared with those who followed the conventional education program. Our transplant recipients generally received the e-learning program well and they recommended it for an annual brush-up and as a part of the general education provided for all transplant recipients. Our e-learning program was developed by one of our transplant nurses (T.B.G.); it is short (15 min) and easily administered by e-mail to transplant recipients. Thus, it can easily be implemented at other transplant clinics.

Strengths and Limitations

The strength of the study is the randomized controlled design and the validation of the e-learning program by focus group interviews among patients and health professionals. However, there are several limitations to the study. It included a relatively small number of participants and only subjective self-reported data on adherence were used. Owing to the lack of a standardized validated questionnaire that measures patients' skills and knowledge of post-transplant care, a new questionnaire was developed for this study. This new questionnaire was only face validated. Self-reported measures can lead to bias that may be different between the intervention and the control group. Caregivers were not included in the study. Furthermore, self-reported adherence was not supported by objective measures, for instance, trough serum levels of immunosuppressive medication. Other parameters of interest are prevalence of chronic lung allograft dysfunction, hospitalization, renal function, quality of life, and survival.

Conclusions

A simple and patient-friendly 15-min e-learning program improves lung transplant recipients' skills and knowledge of post-transplant care. This study shows a tendency toward better adherence to immunosuppressive medication. E-Learning seems to be a valid and important supplement to standard education at every lung transplant follow-up visit. However, more research is warranted.

Footnotes

Authors' Contributions

T.B.G. and E.B. conceived the study idea and T.B.G. developed the e-learning program. T.B.G. collected the data. C.H. and O.H. performed the data analysis. E.B. organized the writing, and all authors critically revised the article for intellectual content and approved the final version before submission.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Data S1

Supplementary Data S2

References

The International Society for Heart and Lung Transplantation. A Society that Includes Basic Science tFHaALD. Overall Lung Transplantation Statistics 2019. Available at: https://ishltregistries.org/registries/slides.asp (last accessed on August 1, 2020 ).

Dew

, DiMartini

, De Vito Dabbs

, Zomak

, De Geest

, Dobbels

, Myaskovsky

, Switzer

, Unruh

, Steel

, Kormos

, McCurry

. Adherence to the medical regimen during the first two years after lung transplantation. Transplantation, 2008; 85:193–202.

Dobbels

, Berben

, De Geest

, Drent

, Lennerling

, Whittaker

, Kugler

. The psychometric properties and practicability of self-report instruments to identify medication nonadherence in adult transplant patients: A systematic review. Transplantation, 2010; 90:205–219.

Vlaminck

, Maes

, Evers

, Verbeke

, Lerut

, Van Damme

, Vanrenterghem

. Prospective study on late consequences of subclinical non-compliance with immunosuppressive therapy in renal transplant patients. Am J Transplant, 2004; 4:1509–1513.

Bertram

, Fuge

, Suhling

, Tudorache

, Haverich

, Welte

, Gottlieb

. Adherence is associated with a favorable outcome after lung transplantation. PLoS One, 2019; 14:e0226167.

De Geest

, Dobbels

, Fluri

, Paris

, Troosters

. Adherence to the therapeutic regimen in heart, lung, and heart-lung transplant recipients. J Cardiovasc Nurs, 2005; 20(5 Suppl):S88–S98.

Lennerling

, Forsberg

. Self-reported non-adherence and beliefs about medication in a Swedish kidney transplant population. Open Nurs J, 2012; 6:41–46.

Dharancy

, Giral

, Tetaz

, Fatras

, Dubel

, Pageaux

. Adherence with immunosuppressive treatment after transplantation: Results from the French trial PREDICT. Clin Transplant, 2012; 26:E293–E299.

Denhaerynck

, Schäfer-Keller

, Young

, Steiger

, Bock

, De Geest

. Examining assumptions regarding valid electronic monitoring of medication therapy: Development of a validation framework and its application on a European sample of kidney transplant patients. BMC Med Res Methodol, 2008; 8:5.

10.

De Geest

, Abraham

, Moons

, Vandeputte

, Van Cleemput

, Evers

, Daenen

, Vanhaecke

. Late acute rejection and subclinical noncompliance with cyclosporine therapy in heart transplant recipients. J Heart Lung Transplant, 1998; 17:854–863.

11.

Chisholm

, Vollenweider

, Mulloy

, Jagadeesan

, Wynn

, Rogers

, Wade

, DiPiro

. Renal transplant patient compliance with free immunosuppressive medications. Transplantation, 2000; 70:1240–1244.

12.

Laederach-Hofmann

, Bunzel

. Noncompliance in organ transplant recipients: A literature review. Gen Hosp Psychiatry, 2000; 22:412–424.

13.

Dew

, Roth

, Thompson

, Kormos

, Griffith

. Medical compliance and its predictors in the first year after heart transplantation. J Heart Lung Transplant, 1996; 15:631–645.

14.

Griva

, Neo

HLM

, Vathsala

. Unintentional and intentional non-adherence to immunosuppressive medications in renal transplant recipients. Int J Clin Pharm, 2018; 40:1234–1241.

15.

Cossart

, Staatz

, Campbell

, Isbel

, Cottrell

. Investigating barriers to immunosuppressant medication adherence in renal transplant patients. Nephrology, 2019; 24:102–110.

16.

Drick

, Seeliger

, Fuge

, Tudorache

, Greer

, Welte

, Haverich

, Gottlieb

. Self-reported non-adherence to immunosuppressive medication in adult lung transplant recipients—A single-center cross-sectional study. Clin Transplant, 2018; 32:e13214.

17.

Graarup

J OD

. Knowledge about life with new lungs. Sygeplejersken, 2012; 7:62–67.

18.

Davis

, Ryszkiewicz

, Schenk

, Peipert

, Lasee

, Miller

, Richardson

, Ridolfi

, Trulock

, Patterson

, Waterman

. Lung transplant or bust: Patients' recommendations for ideal lung transplant education. Prog Transplant, 2014; 24:132–141.

19.

Suhling

, Rademacher

, Zinowsky

, Fuge

, Greer

, Warnecke

, Smits

, Bertram

, Haverich

, Welte

, Gottlieb

. Conventional vs. tablet computer-based patient education following lung transplantation a randomized controlled trial. PLoS One , 2014; 9:e90828.

20.

Mulders

, De Wee

, Vahedi Nikbakht-van de Sande

MCVM

, Kruip

MJHA

, Elfrink

, Leebeek

FWG

. E-learning improves knowledge and practical skills in haemophilia patients on home treatment: A randomized controlled trial. Haemophilia, 2012; 18:693–698.

21.

Ruiz

, Tunuguntla

, Cifuentes

, Andrade

, Ouslander

, Roos

. Development and pilot testing of a self-management internet-based program for older adults with overactive bladder. Urology, 2011; 78:48–53.

22.

Gerity

, Silva

, Reynolds

, Hoffman

, Oermann

. Multimedia education reduces anxiety in lung transplant patients. Prog Transplant, 2018; 28:83–86.

23.

Chesney

, Ickovics

, Chambers

, Gifford

, Neidig

, Zwickl

, Wu

. Self-reported adherence to antiretroviral medications among participants in HIV clinical trials: The AACTG Adherence Instruments. AIDS Care, 2000; 12:255–266.

24.

Wallston

, Wallston

. Locus of control and health: A review of the literature. Health Educ Monogr, 1978; 6:107–117.

25.

De Geest

, Burkhalter

, Bogert

, Berben

, Glass

, Denhaerynck

. Describing the evolution of medication nonadherence from pretransplant until 3 years post-transplant and determining pretransplant medication nonadherence as risk factor for post-transplant nonadherence to immunosuppressives: The Swiss Transplant Cohort Study. Transpl Int, 2014; 27:657–666.

26.

Marsicano

EDO

, Fernandes

NDS

, Colugnati

, Grincenkov

FRDS

, Fernandes

NMDS

, De Geest

, Sanders-Pinheiro

. Transcultural adaptation and initial validation of Brazilian-Portuguese version of the Basel assessment of adherence to immunosuppressive medications scale (BAASIS) in kidney transplants. BMC Nephrol, 2013; 14:108.

27.

Mokkink

, Terwee

, Patrick

, Alonso

, Stratford

, Knol

, Bouter

, de Vet

HCW

. The COSMIN study reached international consensus on taxonomy, terminology, and definitions of measurement properties for health-related patient-reported outcomes. J Clin Epidemiol, 2010; 63:737–745.

28.

Waterhouse

, Calzone

, Mele

, Brenner

. Adherence to oral tamoxifen: A comparison of patient self-report, pill counts, and microelectronic monitoring. J Clin Oncol, 1993; 11:1189–1197.

29.

Laustsen

, Bibby

, Kristensen

, Møller

, Thulstrup

. E-learning may improve adherence to alcohol-based hand rubbing: A cohort study. Am J Infect Control Am J Infect Control, 2009; 37:565–568.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.06 MB

1.55 MB

0.00 MB