WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE
17.2 Hand gestures in different religions and cultures
Hand use and specific gestures take on considerable
significance in certain cultures. 771 The most common popular
belief about hands, for instance in Hindu, Islam, and some
African cultures, is to consider the left hand as “unclean”
and reserved solely for “hygienic” reasons, while it is thought
culturally imperative to use the right hand for offering, receiving,
eating, for pointing at something or when gesticulating.
In the Sikh and Hindu cultures, a specific cultural meaning is
given to the habit of folding hands together either as a form of
greeting, as well as in prayer.
There are many hand gestures in Mahayana and Tibetan
Buddhism. In Theravada Buddhist countries, putting two hands
together shaped like a lotus flower is representative of the flower
offered to pay respect to the Buddha, Dhamma (teaching)
and Sangha (monk). Walking clockwise around the relic of
the Buddha or stupa is also considered to be a proper and
positive form of respect towards the Buddha. Washing hands
in a clockwise movement is suggested and goes well with the
positive manner of cheerful and auspicious occasions.
Studies have shown the importance of the role of gesture
in teaching and learning and there is certainly a potential
advantage to considering this for the teaching of hand hygiene,
in particular, its representation in pictorial images for different
cultures. 772,773 In multimodal strategies to promote hand hygiene,
posters placed in key points in health-care settings have been
shown to be very effective tools to remind HCWs to cleanse
their hands. 58,60 Efforts to consider specific hand uses and
gestures according to local customs in visual posters, including
educational and promotional material, may help to convey the
intended message more effectively and merits further research.
17.3 The concept of “visibly dirty” hands
Both the CDC guidelines 58 and the present <strong>WHO</strong> guidelines
recommend that HCWs wash their hands with soap and water
when visibly soiled. Otherwise, handrubbing with an alcoholbased
rub is recommended for all other opportunities for hand
hygiene during patient care as it is faster, more effective, and
better tolerated by the skin.
Infection control practitioners find it difficult to define precisely
the meaning of “visibly dirty” and to give practical examples
while schooling HCWs in hand hygiene practices. In a
transcultural perspective, it could be increasingly difficult to
find a common understanding of this term. In fact, actually
seeing dirt on hands can be impeded by the colour of the skin:
it is, for example, more difficult to see a spot of blood or other
proteinaceous material on very dark skin. Furthermore, in some
very hot and humid climates, the need to wash hands with
fresh water may also be driven by the feeling of having sticky or
humid skin.
According to some religions, the concept of dirt is not strictly
visual, but reflects a wider meaning which refers to interior and
exterior purity. 774,775 In some cultures, it may be difficult to train
HCWs to limit handwashing with soap and water to some rare
situations only. For instance, external and internal cleanliness
is a scripturally enjoined value in Hinduism, consistently
listed among the cardinal virtues in authoritative Hindu texts
(Bhagavadgita, Yoga Shastra of Patanjali). Furthermore, in
the Jewish religion, the norm of washing hands immediately
after waking in the morning refers to the fact that during the
night, which is considered one sixtieth of death, hands may
have touched an impure site and therefore implies that dirt
can be invisible to the naked eye. Therefore, the concept of
dirt does not refer only to situations in which it is visible. This
understanding among some HCWs may lead to a further need
to wash hands when they feel themselves to be impure and this
may be an obstacle to the use of alcohol-based handrubs.
The cultural issue of feeling cleaner after handwashing rather
than after handrubbing was recently raised within the context of
a widespread hand hygiene campaign in Hong Kong and might
be at the basis of the lack of long-term sustainability of the
excellent results of optimal hand hygiene compliance achieved
during the Severe Acute Respiratory Syndrome pandemic (W H
Seto, personal communication).
From a global perspective, the above considerations highlight
the importance of making every possible effort to consider the
concept of “visibly dirty” in accordance with racial, cultural and
environmental factors, and to adapt it to local situations with an
appropriate strategy when promoting hand hygiene.
17.4 Use of alcohol-based handrubs and alcohol
prohibition by some religions
According to scientific evidence arising from efficacy and
cost–effectiveness, alcohol-based handrubs are currently
considered the gold standard approach. For this purpose, <strong>WHO</strong>
recommends specific alcohol-based formulations taking into
account antimicrobial efficacy, local production, distribution,
and cost issues at country level worldwide (see also Part I,
Section 12).
In some religions, alcohol use is prohibited or considered an
offence requiring a penance (Sikhism) because it is considered
to cause mental impairment (Hinduism, Islam) (Table I.17.1). As
a result, the adoption of alcohol-based formulations as the gold
standard for hand hygiene may be unsuitable or inappropriate
for some HCWs, either because of their reluctance to have
contact with alcohol, or because of their concern about
alcohol ingestion or absorption via the skin. Even the simple
denomination of the product as an “alcohol-based formulation”
could become a real obstacle in the implementation of <strong>WHO</strong>
recommendations.
In some religions, and even within the same religious affiliation,
various degrees of interpretation exist concerning alcohol
prohibition. According to some other faiths, on the contrary, the
problem does not exist (Table I.17.1). In general, in theory, those
religions with an alcohol prohibition in everyday life demonstrate
a pragmatic vision which is followed by the acceptance of
the most valuable approach in the perspective of optimal
patient-care delivery. Consequently, no objection is raised
against the use of alcohol-based products for environmental
cleaning, disinfection, or hand hygiene. This is the most
common approach in the case of faiths such as Sikhism and
Hinduism. For example, in a fundamental Hindu textbook, the
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