Hand hygiene.pdf

and community factors must be considered and investigated when designing behavioural
interventions 537,541,552 .
Research into hand hygiene using behavioural theory has primarily focused on the individual,
though this may be insufficient to effect sustained change. O’Boyle and colleagues 543
investigated the possible association of cognitive factors with hand hygiene compliance,
the first-ever attempt using a well-established behavioural model. However, none of the
three major factors was strongly predictive of intention, and while intention related to selfreported
estimates of compliance, the relationship was not strong (r=0.38) nor did intention
to wash hands predict observed handwashing behaviour. In a neonatal ICU, a perceived
positive opinion of a senior staff member towards hand hygiene and the perception of
control over hand hygiene behaviour were independently associated with the intention to
perform hand hygiene among HCWs 544 . Perceived behavioural control and intention were
significant predictors of hand hygiene behaviour in another study 558 .
Focus group data 542 suggested that hand hygiene patterns are likely to be firmly established
before the age of 9 or 10 years, probably beginning at the time of toilet training. They
are patterns of a ritualized behaviour carried out to be, in the main, self-protective from
infection. However, the drivers to practise hand cleansing both in the community and in the
health-care setting are not overtly microbiologically based and appear seriously influenced
by the emotional concepts of “dirtiness” and “cleanliness” 542,562 . This same behaviour pattern
has previously been recognized in developing countries 563 , and Curtis & Biran have
postulated that the emotion of disgust in humans is an evolutionary protective response
to environmental factors that are perceived to pose a risk of infection 564 . Yet in most communities,
this motivation results in levels of hand hygiene that are, in microbiological terms,
suboptimal for ideal protection 565,566 .
An individual’s hand hygiene behaviour is not homogenous and can be classified into at
least two types of practice 542 . Inherent hand hygiene practice, which drives the majority of
community and HCW hand hygiene behaviour, occurs when hands are visibly soiled, sticky
or gritty. Among nurses, this also includes occasions when they have touched a patient
who is regarded as “unhygienic” either through appearance, age or demeanour, or after
touching an “emotionally dirty” area such as the axillae, groin or genitals 542 . This inherent
practice appears to require subsequent handwashing with water or with soap and water.
The other element to hand hygiene behaviour, elective hand hygiene practice, represents
those opportunities for hand cleansing not encompassed in the inherent category. In HCWs,
this component of hand hygiene behaviour would include touching a patient such as taking
a pulse or blood pressure, or having contact with an inanimate object around a patient’s
environment. This type of contact is similar to many common social interactions such as
shaking hands, touching for empathy, etc. As such, it does not trigger an intrinsic need to
cleanse hands, though in the health-care environment may lead to hand contamination with
the risk of cross-transmission of organisms. It therefore follows that it is this component of
hand hygiene which is likely to be omitted by busy HCWs.
Compliance with hand cleansing protocols is most frequently investigated in nurses as this
group represents the majority of HCWs in hospitals. However, it is also well documented that
doctors are usually less compliant with practices recommended for hand hygiene than are
other HCWs 262,454,485 . Yet these clinicians are possibly the peer facilitators of hand hygiene
compliance for nurses 542 with different groups acting as peer facilitators for other HCWs
263. Behavioural modelling 542 suggests that the major influence on nurses’ handwashing
practices in hospitals is the translation of their community attitudes into the health-care setting.
Thus, activities which would lead to inherent community handwashing similarly induce
inherent handwashing in the health-care setting. The perceived protective nature of this