Iranian healthcare workers' perspective on hand hygiene: a qualitative study.

JIPH-340; No. of Pages 8

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Journal of Infection and Public Health (2014) xxx, xxx—xxx

Iranian healthcare workers’ perspective on hand hygiene: A qualitative study Mary-Louise McLaws a, Saman Farahangiz b, Charles J. Palenik c, Me hrdad Askarian d,∗ a

School of Public Health & Community Medicine, UNSW Medicine, UNSW Australia, Sydney, Australia Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran c Department of Oral Biology, Infection Control Research and Services, Indiana University School of Dentistry, Indianapolis, IN, USA d Department of Community Medicine, Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran b

Received 19 February 2014 ; received in revised form 15 April 2014; accepted 24 May 2014

KEYWORDS Hand hygiene; Healthcare workers; Iran; Qualitative study

Summary Background: Hand hygiene (HH) has been identified as one of the simplest, but most important, methods to prevent cross-infection in healthcare facilities. In spite of this fact, the HH compliance rate remains low among healthcare workers (HCWs). Several factors may affect HH behavior. In this study, we aimed to assess various aspects of HH from the perspective of HCWs. Method: This qualitative study was conducted in two hospital settings in Shiraz, Iran. Eight focus group discussions (FGDs) and six in-depth interview sessions were held with ICU and surgical ward nurses, attending physicians, medical and nursing students and supporting staff. Each FGD and interview was transcribed verbatim, open codes were extracted, and thematic analysis was conducted. Results: Three themes emerged from the thematic analysis including: ‘‘the relationship between personal factors and HH compliance,’’ ‘‘the relationship between environmental factors and HH compliance’’ and ‘‘the impact of the health system on HH adherence, including the role of adequate health systems, administrative obligations and the effect of surveillance systems.’’

∗ Corresponding author at: Department of Community Medicine, Shiraz University of Medical Sciences, P.O. Box: 71345-1737, Shiraz, Iran. Tel.: +98 917 1125577; fax: +98 711 2354431. E-mail addresses: [email protected] (M.-L. McLaws), [email protected] (S. Farahangiz), [email protected], [email protected] (M. Askarian).

http://dx.doi.org/10.1016/j.jiph.2014.05.004 1876-0341/© 2014 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: McLaws M-L, et al. Iranian healthcare workers’ perspective on hand hygiene: A qualitative study. J Infect Public Health (2014), http://dx.doi.org/10.1016/j.jiph.2014.05.004


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M.-L. McLaws et al. Conclusion: Several factors played a significant role in improving HCWs HH compliance, such as the regular adherence to health system tenets. HH compliance may be improved through application of realistic policies and better supervision. In addition, appropriate education may positively affect HH behavior and attitudes. © 2014 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.

Introduction

Materials and methods

Hand cleanliness is the single most important factor in preventing the spread of pathogens and antibiotic resistance in healthcare settings. Patients can acquire healthcare-associated infections (HAIs) during diagnosis and treatment. HAIs can be devastating and may result in disease complications, long term disability and increased morbidity and mortality [1]. HAIs affect millions of patients worldwide each year and can result in higher healthcare costs [2,3]. Therefore, HAI prevention must be a top priority. Hand hygiene (HH), either by washing hands with water and soap or by using alcohol-based hand rubs, is one of the simplest, but most important, methods to prevent cross-infection and to decrease the rate of HAIs [4—6]. In spite of this fact, the rate of HH compliance by HCWs remains traditionally low, between 40 and 45% [7]. However, rates have increased to 65% when a facility makes a strong effort to improve proper practices [8]. To increase HCWs’ HH compliance, various policies have been developed, guidelines issued and promotional campaigns made worldwide. Several issues can affect HH compliance rates [9,10]. Studies indicate that HCWs’ knowledge, beliefs and attitudes influence adherence to HH guidelines [9,11,12]. Self-reported factors for poor HH adherence include: (1) hand-washing agents cause irritation and dryness; (2) running water and sinks are inconveniently located or in short supply; (3) there is a lack of soap and paper towels; (4) too busy/insufficient time; (5) understaffing/overcrowding; (6) the patients’ needs take priority and (7) the low risk of acquiring an infection from patients [8,11,13—16]. Following a literature review, we determined that no qualitative study regarding HCWs HH has been performed in Iran. Therefore, the objective of this study was to assess various aspects of HH from the perspective of HCWs in Iran.

This qualitative study was conducted in one public teaching hospital and 1 private hospital in Shiraz, Iran, between August and October 2012. The hospitals did not have specific hand hygiene or infection control policies and both hospitals provide limited hand hygiene training seminars for staff. We used a purposive sampling method driven by the objectives of the study to include staff from critical points of care, such as ICU and surgery. Our sample consisted of 80 HCWs; 16 intensive care unit (ICU) nurses, 14 surgical ward nurses, 24 support staff, 6 attending physicians, 20 medical students (interns working in ICUs and surgical wards) and 6 nursing students. All 80 HCWs completed an FGD session. Data collection involved eight focus group discussions (FGDs) and six in-depth, one-on-one interviews. Due to the physicians’ work schedules, they did not participate in the FGDs. Instead, in-depth interviews were held with participating physicians. Announcements for participation in the FGD were coordinated with hospital administrators and educational supervisors, and participation was voluntary. FGD sessions for each group of participants of the same profession, department and hospital were carried out separately in a location chosen by the participants and hospital administrators (see Table 1). One facilitator conducted all FGD sessions using a semi-structured interview format while a colleague took notes and made audio-recordings. Interviews included open-ended questions, which lead to fostering new ideas directed by participant responses (Appendix 1). Each interview continued until no new responses/perceptions came forward from the participants. This point is referred to as data saturation and indicates that further continuation of the FGD will not provide new information. Every FGD session began with a standard introduction, which consisted of meeting the researchers, a brief description of the study’s aims and procedures and


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Workers’ perspective on hand hygiene

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Table 1 Description of focus group discussions and the participants. FGD

Participants

Male

Female

Total

FGD1 FGD2 FGD3

ICU nurses Cleaning staff Surgical ward nurses ICU and surgical ward nurses Medical students (interns) Medical students (interns) Nursing students Cleaning staffs

3 7 0

9 8 7

12 15 7

0

11

11

5

4

9

6

5

11

5 5

1 4

6 9

FGD4 FGD5 FGD6 FGD7 FGD8

FGD: focus group discussion.

an assurance of participant confidentiality. Before beginning, participants provided an oral informed consent. Then, the facilitator began by asking a set of prepared open-ended questions and encouraging participation. Each FGD session lasted approximately 60 min and upon completion of the FGD, the participants were given refreshments. No monetary incentive was offered. For in-depth interviews with physicians, we contacted surgeons, anesthesiologists and other ICU physicians by phone and made appointments with those willing to cooperate. The specialties represented by the participating physicians included two general surgeons, two anesthesiologists, a neurosurgeon and a neurologist. The specialties of the participating attending physicians were intentionally selected from ICU and surgical wards. We aimed to interview two surgeons, four ICU physicians and any other specialty physician; however, six physician interviews resulted in data saturation. Each interview lasted approximately 45—60 min. The interviews used the same semistructured interview format and list of open-ended questions as were used during the FGDs. All FGD and interview audiotape recordings were transcribed verbatim into Farsi and English by the facilitator and colleague immediately after each session. The facilitator and colleague who attended each FGD and interview reviewed the transcripts separately to extract open codes and to identify the themes. All authors then interpreted the thematic analysis.

Results Three themes emerged (Table 2) with nearly all themes from the nurses, medical and nursing

students and supporting staff being consistent, although, they were not in line with international hand hygiene practices. However, the physicians expressed sound hand hygiene views. Most participants frequently expressed concerns about the time required to complete HH before and after patient contact. Only the attending physicians were aware of the WHO ‘‘Five Moments for Hand Hygiene’’ for the protection of the patient, while other HCWs mentioned HH that were — self-protecting — after touching a patient or their environment and after exposure to bodily fluids. Providing care to high risk patients, such as those who are immunocompromised or positive for HIV, HBV or HCV, often requires strict adherence to HH tenets. The noted themes included ‘‘relationships between personal factors, such as attitudes, knowledge and HH compliance’’, ‘‘relationships between environmental factors, including heavy workloads, unavailability of the HH facilities, and emergency situations and HH compliance’’ and ‘‘the impact of the health system on adherence to HH.’’

Theme I: ‘‘The relationship between personal factors and HH compliance’’ Many HCWs’ believed that the hands are a prime vector for transmission of infection in hospitals. Participants stressed the importance of HH and agreed on its role in the prevention of transmission of infection. One attending physician (Interview 5) stated, ‘‘If we want to measure the impact of the ways for preventing nosocomial infections, [high] hand hygiene is the best.’’ Conversely, there were a few participants who did not have a strong understanding of the importance of HH. One nurse (FGD1) said, ‘‘Is it necessary to wash my hands for each contact to patients? I don’t think so.’’ There were several opinions that associated HH nonadherence with cultural beliefs, including feelings of ‘‘patients being upset’’ or that complying with ‘‘HH while examining patients’’ was disrespectful to the patient. An attending physician (Interview 4) reported, ‘‘It is a cultural issue. Some physicians think that if they wash their hands, patients would have a bad feeling about that.’’ Participants also explained that there are many reasons for poor adherence to HH recommendations. Physicians stated their principal reason for performing HH was to protect their patients, while other participants adhered to HH guidelines for both their patients’ and their own safety. Some cleaning staff reported that their primary reason



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M.-L. McLaws et al. Table 2

Themes and subthemes concerning HH and related factors from HCWs points of view.

Theme/subtheme

Description

Theme 1 Subtheme Subtheme Subtheme Subtheme Subtheme Subtheme Subtheme

1.1 1.2 1.3 1.4 1.5 1.6 1.7

Relationship between personal factors and HH compliance Attitude toward the importance of hand hygiene The main reason for hand hygiene is patient and practitioner personal protection Interrelationship of knowledge and performance Belief in the role of behavioral factors in adherence to HH Belief in noncompliance of other staff groups Staff indolence as a reason for noncompliance Being allergic to hand hygiene materials as one of the barriers

Theme 2 Subtheme Subtheme Subtheme Subtheme

2.1 2.2 2.3 2.4

Relationship between environmental factors and HH compliance Unavailability of HH facilities as a compliance barrier Emergency situations are reasons for noncompliance Heavy workloads are reasons for noncompliance The role ward type plays in HH compliance

Theme 3 Subtheme Subtheme Subtheme Subtheme

3.1 3.2 3.3 3.4

The impact of health system on HH adherence Inadequate health systems and HH noncompliance Beliefs in the role of supervision and obligation Attitude toward surveillance system Role education plays in HH compliance

HH: hand hygiene.

for performing HH was to protect their family and themselves from infections. There was no clear relationship between knowledge and performing HH. Noncompliance occurred in spite of having the correct knowledge and incorrect HH performance occurred due to a lack of knowledge. Participants believed that most HCWs were aware of the role that HH plays in infection prevention, yet many do not adequately perform HH. One nurse (FGD1) stated, ‘‘Despite the fact that this knowledge (the importance of HH) exists, it’s still not done.’’ Participants expressed a belief that some HCWs perform HH incorrectly or inappropriately because they do not have sufficient knowledge. A second nurse (FGD1) said, ‘‘One may suppose that he/she has done the best hand washing, but if we evaluate performance scientifically it might not be the appropriate method.’’ A medical student (FGD5) perceived that ‘‘many staff members do not know how to wash their hands.’’ Factors that help formulate a person’s perceptions, beliefs and appreciation for correct HH can play a role in HH compliance. HCWs often have different approaches in their attempt to comply with HH guidelines. Participants believed that interpreting and/or adhering to HH recommendations is often a personal decision that is heavily influenced by individual behavioral factors. One physician (Interview 2) stated, ‘‘My view to [HH] is different from other HCWs, who don’t wash their hands, also he told ‘‘It has become my habit.’’ One nurse (FGD4) expressed similar views,

‘‘Even if we are busy we must wash our hands, it is a conscionable matter.’’ An issue expressed by some staff groups was that others were noncompliant, while they were compliant. For example, nurses believed that physicians usually have low HH compliance, while medical students complained that nurses did not adhere to HH guidelines. One medical student (FGD5) stated, ‘‘I have never seen nurses perform hand hygiene for a procedure like IV line insertion.’’ Some participants believed that ‘‘personal behavior’’ was a cause for nonadherence or, as a physician (Interview 4) believed, ‘‘Laziness is one of the reasons’’ that prevents HCWs from ‘‘[doing] the right thing’’. Other participants believed that skin conditions, including allergies to HH materials, were reasons for noncompliance, which was one nursing student’s (FGD7) perception, who said, ‘‘Most liquid soaps are not kind to our skin.’’

Theme 2: ‘‘The relationship between environmental factors and HH compliance’’ Conditions in the working environment were frequently mentioned as factors affecting HH compliance. For example, unavailability of HH resources was a barrier to proper HH adherence. This was a common complaint by governmental hospital staff members. Others referred to measures taken by hospital administrators to improve these conditions, which raised HCWs’ satisfaction



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Workers’ perspective on hand hygiene with their resources and hence their HH compliance. One nurse at the public hospital (FGD4) said, ‘‘Sometimes we want to wash our hands, but liquid soap does not exist at all.’’ Resources at the public hospital were perceived to facilitate compliance, with a medical student (FGD5) reporting that, ‘‘Last year they installed pedals for sinks instead of water taps, it was very effective, and we didn’t have to touch the taps and [that] helped us to do our job more rapidly.’’ In emergency situations, staff believed that they did not have the time to perform proper HH. Time restriction resulted in the inappropriate use of gloves by some staff members instead of HH. Different ideas about glove use existed; for example, HCWs did not perform HH before and after glove use and did not change gloves between patients. One nurse (FGD3) said, ‘‘We don’t have the time to wash our hands in emergencies; [instead] we have to change gloves one after another.’’ Participants complained strongly that their heavy workloads served as a major HH obstacle. They suggested that sufficient staff levels in each work shift would improve HH compliance. Using alcohol based hand rubs (ABHR) has decreased the time taken for HH, especially during busy periods. However, one nursing student (FGD7) stated that, ‘‘While a nurse cares for 20 patients during a shift, she doesn’t always have the time to wash her hands for each patient.’’ Some participants believed the type of hospital ward affected HH compliance. Although all wards are required to follow the same HH guidelines and indications, some believe that HCWs in intensive care units (ICUs) are required to have the highest level of HH compliance. Staff from wards such as NICU, ophthalmology and burn units were concerned about HH compliance, and one medical student (FGD6) believed that in ‘‘some wards, like NICU, it is routine to [perform hand hygiene] but it isn’t the same in internal medicine wards.’’ One nurse (FGD1) expressed that, ‘‘According to the ward that I work in, I have to use both ABHR and water and soap.’’

Theme 3: ‘‘The impact of the health system on HH adherence’’ Participants discussed several issues relating to the Iranian national health system that could contribute to HH compliance; many felt that the national health system inadequately supported HH. Generally, staff thought that if the health system authorities were more concerned about HH, then compliance would improve. A medical student

5 (FGD5) said, ‘‘Unfortunately some issues like hand hygiene are not considered at all because they [the healthcare authorities] are not concerned.’’ Some attending physicians understood the importance of HH from their experience working in other countries and strongly believed that they had role models there. When we asked about role modeling, most of them believed in the positive effect of peer or staff role models. For example, nurses and interns identify physicians as their role models. Additionally, some nurses and cleaning staff believed that their colleagues could have a significant impact by serving as role models. All physicians felt they were leaders of HH and should serve as role models to other staff members, and the physicians indicated that they would warn noncompliant HCWs. Staff believed head supervisors in the ward and hospital administrators are responsible for HH compliance, including its improvement among HCWs. It was suggested that hospital administrators should provide better HH supervision. A nursing (FGD7) and a medical student (FGD6) agreed that ‘‘there must be an obligation.’’ A physician (Interview 4) suggested that ‘‘supervision in the system is necessary.’’ There were a few participants who thought that HH obligations would have negative effects. One nurse (FGD4) said, ‘‘One must do [HH] with interest and concern; obligation must not exist.’’ There was a general feeling that an absence of efficiency existed in the current hospital surveillance systems. Physicians, in particular, emphasized the important role of a functioning surveillance system. ‘‘If we had a good [HH] surveillance system, our [HH] condition would not be like this,’’ said a physician (Interview 2). Education was believed to be an effective means for improving HH compliance. Participants believed that periodic or continuous training by hospital authorities should be repeated at specified times and contain encouraging posters, reminders and other training assistance techniques. A cleaning staff member (FGD2) said, ‘‘One of the most important things that we have had is training’’, and a physician (Interview 4) believed that ‘‘if the training was repeated periodically and there was a reminder, it would be surely effective.’’

Discussion There are various determinants for HH practice success [11—14,17—19], and our participants identified many elements affecting compliance that are common among HCWs globally. We could



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M.-L. McLaws et al.

categorize those influential factors into three groups—–personal factors, environmental factors and health system-related factors. This is the first qualitative study in Iran investigating the views of HH from the perspective of staff members with direct patient contact. Overall, HCWs from this study spoke positively about HH and recognized the importance of HH in infection prevention. HCWs expressed adequate HH knowledge. Studies have found that an HCW’s attitude has little effect on compliance [20,21]. According to the HCWs in this study, the level of HH compliance was not optimal, which supports the phenomenon that low compliance persists despite knowledge [12,15] and a positive attitude toward HH. This finding contrasts with that of Pittet et al. and other studies that reported positive attitudes were more likely to improve or predict compliance [7,9,10]. However, in previous studies, different aspects of attitude were assessed [7,9,10], while we only investigated attitudes in general toward the role and importance of HH. The thoughts of participants that incorrect performance and/or noncompliance may be due to knowledge insufficiency were also observed by Jang et al., Barret et al., and Mathur [11,14,22]. Generally, our participants believed that HH compliance was influenced by a variety of factors, as has been reported elsewhere [19,23], yet an understanding of habit formation and HH compliance was not expressed. Nursing staff in this study reported higher HH compliance for themselves than for physicians. Physicians’ attitudes toward HH revealed the lowest compliance rate among all HCWs studied [24]. This observation was also identified as a risk factor for nonadherence by Pittet et al. and Rosenthal et al. [16,25]. The compliance of HCWs in this study was based on a perception that their own professional group had superior HH performance; however, compliance data were not collected. Human behavior is complex, and if ‘laziness’ is perceived as an undesirable cause for noncompliance, then it could be used in the form of peer pressure to improve compliance and conformity to a social norm that ‘noncompliance is lazy’. Nicol et al. considered that staff fatigue influences HH performance, and, while participants in the present study mentioned workload, they did not speak about fatigue [19]. Other studies have also reported an association between heavy workload and emergency situations with lower HH compliance [9,11—17]. Environmental factors were major barriers to HH compliance. The WHO acknowledges the importance of HH resources, such as accessibility to water, soap and ABHR, for compliance [2]. A study

conducted in eight Mediterranean countries recognized that the lack of available HH resources was a major barrier to compliance [13]. The differences in perception between HCWs from public and private facilities were minimal and related to HH resources. Physicians in the public hospital spoke about the difficulty of obtaining sufficient amounts of the WHO formulation of ABHRs due to current economic sanctions, but this has not been verified. Some participants believed that certain departments, such as ICUs, must have higher HH compliance. However, critical units have been associated with low compliance [9,16]. This belief is in accordance with Rosenthal et al., who found a higher compliance rate in NICUs than in adult wards [25]. The idea that NICU patients require superior HH efforts could be used to emphasize the importance of HH in other wards by highlighting that all patients would benefit from decontaminated hands. The participants noted the role of health system authorities in providing resources to improve HCW compliance, and this issue has also been reported by HCWs in other healthcare systems [26]. The role of policy makers and the effect of organizational authorities on infection prevention are universally acknowledged as important influences on HH compliance [12,18]. Physicians’ awareness of being observed has a positive impact on compliance and confirms this study’s HCWs’ belief that the supervisor has an important role in adherence to HH [9]. In this study, training and education was claimed to play an important role in improving HH compliance and is supported elsewhere as a pivotal influencer [19,26]. Hospital administrators can incorporate an HH audit system for rapid feedback and continuous interactive education until high compliance is reached. The limitations of our study are inherent in the qualitative design and small sample size, as well as the potential for participants to express opinions of the group rather than their own. In addition, it was difficult to arrange interviews with busy physicians. However, our investigation reveals that adherence to HH policies can be improved with increased resources, the application of peer pressure to change social norms and the emphasis that all patients deserve high HH compliance.

Financial support The vice-chancellor for research at Shiraz University of Medical Sciences 4063 funded this project.



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Workers’ perspective on hand hygiene

Conflicts of interest None declared.

7 Question 12

13

Ethical approval Not required.

14

Acknowledgments

15

The data collection, transcription and review by Saman Farahangiz were undertaken in partial fulfillment of the requirements for certification as a specialist in community medicine at Shiraz University of Medical Sciences in Shiraz, Iran. The authors thank Dr. Sulmaz Ghahramani, resident of community medicine, Shiraz University of Medical Sciences, for her contribution in the focus group discussions as the facilitator’s assistant.

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Appendix 1. : The list of questions prepared for the focus group discussions and in-depth interviews Question 1 2 3 4 5 6 7 8

9

10

11

What is your opinion about the importance of hand hygiene in practice? In what extent? What do you know about WHO 5-Moment for hand hygiene? When do you wash your hands in a clinical practice? What is your main and primary reason for practicing hand hygiene? What patients or circumstances make you wash your hands? When do you wash your hands for your patient’s safety? When do you wash your hands for your own protection? How often do you wash your hands or use alcohol based hand rubs? Do you think that it is enough to prevent cross-infection? Do you think it is necessary to use alcohol based hand rubs besides hand-washing? Why? Do you have access to these facilities in the hospital that you work? Do you think that it is necessary to practice hand hygiene in the situations that you wear gloves? Why? What do you think of other health-care worker groups’ compliance with hand hygiene?

17

Do you believe that their compliance with hand hygiene has an impact on yours? Can you tell me how? What would you do if see one of your colleagues (or a staff of other groups) not washing their hands or do it in a wrong way, when it is critical for a patient’s safety? What do you think of implementing a surveillance system for hand hygiene at the hospital? What are the obstacles of right and frequent hand hygiene in the facility you’re working? Do you have any opinion to remove those barriers? What opinions do you have for the hospital administration to improve hand hygiene in your facility?

References [1] US Centers for Disease Control and Prevention. Healthcare acquired infection. Available at: http://www.cdc.gov/HAI/ burden.html [accessed June 2013]. [2] WHO guidelines on hand hygiene in health care. First global patient safety challenge: clean care is safer care; 2009. Available at: http://www.who.int/gpsc/5may/tools/ who guidelines-handhygiene summary.pdf [accessed June 2013]. [3] Pittet D, Donaldson L. Clean care is safer care: a worldwide priority. Lancet 2006;366:1246—7. [4] Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000;356:1307—12. [5] Capretti MG, Sandri F, Tridapalli E, Galletti S, Petracci E, Faldella G. Impact of a standardized hand hygiene program on the incidence of nosocomial infection in very low birth weight infants. Am J Infect Control 2008;36:430—5. [6] Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep 2002;51:1—45. [7] Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010;31:283—94. [8] Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol 2000;21:381—6. [9] Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 2004;141:1—8. [10] McLaws ML, Maharlouie N, Yousefi F, Askarian M. Predicting hand hygiene among Iranian healthcare workers using the theory of planned behavior. Am J Infect Control 2012;40(4):336—9. [11] Jang JH, Wu S, Kirzner D, Moore C, Youssef G, Tong A, et al. Focus group study of hand hygiene practice among



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M.-L. McLaws et al.

[12]

[13]

[14] [15]

[16]

[17]

[18]

[19]

healthcare workers in a teaching hospital in Toronto, Canada. Infect Control Hosp Epidemiol 2010;31:144—50. Joshi SC, Diwan V, Tamhankar AJ, Joshi R, Shah H, Sharma M, et al. Qualitative study on perceptions of hand hygiene among hospital staff in a rural teaching hospital in India. J Hosp Infect 2012;80:340—4. Borg MA, Benbachir M, Cookson BD, Ben Redjeb S, Elnasser Z, Rasslan O, et al. Health care worker perceptions of hand hygiene practices and obstacles in a developing region. Am J Infect Control 2009;37:855—7. Barrett R, Randle J. Hand hygiene practices: nursing students’ perceptions. J Clin Nurs 2008;17:1851—7. Malekmakan L, Haghpanah S, Askarian M, Jowkari M, Moalaee M. Hand hygiene in Iranian health care workers. Am J Infect Control 2008;36:602—3. Pittet D. Compliance with hand disinfection and its impact on hospital-acquired infections. J Hosp Infect 2001;48(Suppl. A):S40—6. Marjadi B, McLaws ML. Hand hygiene in rural Indonesian healthcare workers: barriers beyond sinks, hand rubs and in-service training. J Hosp Infect 2010;76:256—60. Yuan CT, Dembry LM, Higa B, Fu M, Wang H, Bradley EH. Perceptions of hand hygiene practices in China. J Hosp Infect 2009;71:157—62. Nicol PW, Watkins RE, Donovan RJ, Wynaden D, Cadwallader H. The power of vivid experience in hand hygiene compliance. J Hosp Infect 2009;72:36—42.

[20] Jenner EA, Fletcher BC, Watson P, Jones FA, Miller L, Scott GM. Discrepancy between self-reported and observed hand hygiene behaviour in healthcare professionals. J Hosp Infect 2006;63:418—22. [21] Creedon SA. Healthcare workers’ hand decontamination practices: compliance with recommended guidelines. J Adv Nurs 2005;51:208—16. [22] Mathur P. Hand hygiene: back to the basics of infection control. Indian J Med Res 2011;134:611—20. [23] O’Boyle CA, Henly SJ, Larson E. Understanding adherence to hand hygiene recommendations: the theory of planned behavior. Am J Infect Control 2001;29: 352—60. [24] Pyne E. Physician attitudes toward hand hygiene in the acute care setting. Wisconsin Medical Society Fellowship; 2010. June—August. [25] Rosenthal VD, Pawar M, Leblebicioglu H, Navoa-Ng JA, Villamil-Gómez W, Armas-Ruiz A, et al. Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach over 13 years in 51 cities of 19 limited-resource countries from Latin America, Asia, the Middle East, and Europe. Infect Control Hosp Epidemiol 2013;34:415—23. [26] Allegranzi B, Sax H, Pittet D. Hand hygiene and healthcare system change within multi-modal promotion: a narrative review. J Hosp Infect 2013;83(Suppl. 1):S3—10.

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