- Email: [email protected]
Predicting hand hygiene among Iranian health care workers using the theory of planned behavior
American Journal of Infection Control 40 (2012) 336-9
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Predicting hand hygiene among Iranian health care workers using the theory of planned behavior Mary-Louise McLaws DipTropPubHlth, MPH, PhD a, Najmeh Maharlouei MD b, Farideh Yousefi MD c, Mehrdad Askarian MD d, * a
School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran College of Education and Psychology, Shiraz University, Shiraz, Iran d Department of Community Medicine, Shiraz University of Medical Sciences, Shiraz, Iran b c
Key Words: Handwashing Predictive behavioral model Compliance
Background: This study was conducted to identify significant predictors of handwashing associated with hospital elective (clean) and hospital inherent (dirty) contacts. Methods: This cross-sectional survey of 1,700 health care workers was based on the theory of planned behavior. Data were aggregated into components according to the theory and tested for predictors of hospital elective and hospital inherent handwashing using multiple logistic regression analysis. The a value was set at 0.05, and odds ratios (ORs) for significant predictors were adjusted by interquartile range. All wards studied were in private and government hospitals associated with the University of Medical Sciences, Shiraz, Iran between April and September 2008. Results: Of the 1,200 healthcare workers surveyed 1,077 (90%), of whom 83% were nurses, returned a completed survey. Hospital elective handwashing practice was positively influenced by community elective practice (adjusted OR [aOR], 2.1; P < .000), hospital inherent practice (aOR, 1.6; P < .000), perception that handwashing required little effort (aOR, 1.1; P ¼ .039), and subjective norms (nursing peers) (aOR, 1.1; P ¼ .025) and negatively influenced by poor attitudes regarding handwashing (aOR, 0.91; P ¼ .01). Hospital inherent handwashing practice was positively influenced by hospital elective practice (aOR 2.5; P < .000), community inherent practice (aOR, 1.5; P ¼ .001), subjective norms (infection control practitioners) (aOR, 1.4; P ¼ .001, and attitudes (aOR, 1.1; P ¼ .001) and negatively influenced by poor subjective norms (nurses) (aOR, 0.74; P < .000). Conclusion: Community-based handwashing practices exerted a strong influence on handwashing compliance in the hospital. Given this interdependence between community and hospital handwashing, a campaign to improve awareness of the benefit of community handwashing may improve clinicians’ compliance. Crown Copyright Ó 2012 Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc. All rights reserved.
Health careeassociated infections (HAIs) are associated with increased morbidity, mortality, hospitalization,1-4 and patient distress and with longer patient recovery times.4 More than 1.4 million patients worldwide are estimated to suffer an HAI at any given time.5 Between 5% and 10% of patients admitted to high-resourced health care systems acquire one or more infections during hospitalization.5,6
* Address correspondence to Mehrdad Askarian, MD, Professor of Community Medicine, Shiraz University of Medical Sciences, PO Box 71345-1737, Shiraz, Iran. E-mail address: [email protected] (M. Askarian). This study was funded by the Vice-Chancellor for Research, Shiraz University of Medical Sciences. Conflict of interest: None to report.
HAIs are the 11th-leading cause of death in the United States.2 The risk of HAI in low-resourced health care settings is between 2 and 20 times higher than the US rate.5 Between 1999 and 2000, the incidence of HAI in the surgical department of a teaching hospital in Shiraz was 18%, and the estimated annual cost of this level of infection was approximately 120 billion Rials (wUS $150,000).7 Regardless of the level of health service resources, hand hygiene compliance has an inverse influence on the rate of HAI8 and is a costeffective method of preventing infection transmission.9-11 Contacts between nurses with contaminated hands and their patients are generally considered the main route of infectious spread between wards. Although nurses recognize hand hygiene as an important HAI prevention measure, their practice varies
0196-6553/$36.00 - Crown Copyright Ó 2012 Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc. All rights reserved. doi:10.1016/j.ajic.2011.04.004
M.-L. McLaws et al. / American Journal of Infection Control 40 (2012) 336-9
337
depending on such factors as the level of health service resources,12-16 ward,14 professional level of nursing,17 working conditions,17 and type of patient contact.14,18 Notwithstanding these compliance barriers, hand hygiene rates are typically <50%.1,2,12,13 Iranian health care workers (HCWs) have acceptable knowledge and attitudes about hand hygiene, but poor selfreported hand hygiene practice.19 A study of Australian HCWs’ cognition for hand hygiene using a survey based on the theory of planned behavior (TPB)20 examined compliance with 2 types of patient contacts: hospital elective behavior, in which hands are visually clean and HCWs may elect to comply or not comply, and hospital inherent behavior, in which hands are physically dirty or contacts trigger an emotional or inherently high level of compliance.18 Accordingly, the TPB can be used to predict intention to comply with hospital elective or hospital inherent contacts from several intermediate variables, including attitude toward handwashing associated with clean or dirty contacts, subjective norms (ie, perception of peer group pressure to undertake clean or dirty handwashing), perceived control (ie, perception of effort to perform the clean or dirty handwashing behaviors), similar handwashing practices in the community, and the opposite hospital handwashing practice (ie, hospital elective for predicting hospital inherent practice and vice versa). Iranian HCWs are expected to practice handwashing before and after patient contacts. In the present work, we used a statistical model with a pretested survey18 to examine barriers to and factors facilitating HCWs’ compliance with hospital elective and hospital inherent patient contacts.
describes hand hygiene compliance associated with physically dirty or sticky hands or when hands have made contact previously described by nursing staff as microbiologically dirty or emotionally sensitive (eg, axillae, groin, genitals). A detailed description of the survey items and its development is available elsewhere.18 Pilot testing of the questionnaire with 50 Iranian HCWs demonstrated high reliability (r ¼ 0.92). Responses to items for the outcomes hospital elective handwashing and hospital inherent handwashing were measured on a 5-point scale (1, always; 2, mostly, 3, sometimes; 4, occasionally; 5, never). Responses to items measuring the predictive components were measured using a 7-point Likert-type scale (ranging from 1, strongly agree to 7, strongly disagree). Items worded in the negative had the scores reversed. Paired items for attitudes (ie, attitudinal beliefs and evaluation of beliefs), subjective norms (ie, normative beliefs and motivational beliefs), and perceived peer behavior (ie, perceived peer behaviors and evaluation of the behaviors) were multiplied before being summed. There were 12 paired items for attitudes, 2 paired items for subjective normative (SN) nurse colleagues, 2 paired items for SN physician colleagues, 2 paired items for SN administrators, 3 paired items for SN infection control practitioners (ICPs), 5 items for effort required, 6 paired items for perceived peer behavior, 16 items for community elective contact, and 4 items for community inherent contact. There were 13 items for the hospital elective outcome component and 10 items for the hospital inherent outcome component. The summed score for each component was divided to revert the range to the original 1-7 or 1-5 score.
METHODS
Assessment of construct validity of the components and development of the models
Design and setting A questionnaire was distributed to 1,000 nursing staff members and 200 medical and nursing students in 18 private and 10 government hospitals in Shiraz, Iran between April and September 2008. Evening shifts were more likely to be staffed by junior staff and supervised by a small team of senior staff; therefore, participants were identified using a random sample of every third HCW available on all wards during all shifts (morning, afternoon, and evening). A standardized verbal description of the study and its aims was provided to each participant, and each participant provided oral consent to participate before the anonymous, selfadministered questionnaires were distributed. Approximately 90% of the distributed questionnaires were completed and returned to one of the authors (N.M.). Data collection The questionnaire (available from M.-L.M.) was previously tested18 and was translated into Persian by 2 community medicine specialists and a psychologist, who verified the questionnaire’s face and content validity. Items measuring the original components of the TPB and a new component included the respondent’s perception of the positive and negative effects of handwashing and an evaluation of the behavior (attitudes), belief that 4 peer groups expected the HCW to comply and motivation to please the peer (subjective norms), effort and control to comply (effort required), and effect of role modeling (perceived peer behavior). The original application of the TPB has one outcome component; we modeled 2 separate self-reported hand hygiene behaviors, hospital elective and hospital inherent.18 The elective hand hygiene component described compliance associated with clean contacts, including patient environments, obtaining a pulse reading where the HCW elects to perform hand hygiene or not. Inherent hand hygiene
The internal consistency of all components was evaluated using Cronbach’s a coefficient. Values were 0.78 for hospital inherent, 0.87 for hospital elective, 0.31 for community inherent, 0.80 for community elective, 0.83 for attitudes, 0.78 for SN nurse colleagues, 0.81 for SN physician colleagues, 0.82 for SN administrators, 0.78 for SN ICPs, 0.75 for effort required, and 0.86 for perceived peer behavior. Potential predictors were entered using backward linear regression to model 2 separate outcomes, hospital elective and hospital inherent hand hygiene behaviors. The variables entered included 9 independent variables plus the opposite outcome as a potential predictor; hospital inherent behavior was included as a potential predictor for hospital elective model and vice versa. According to the TPB, demographic variables are not predictive of behavior in adults. The mean age of the study participants was 29.4 7.1 years; age, categorized by interquartile range (IQR), was entered into the models but was not significant. The majority (82.6%; 890/ 1,077) of participants were nursing staff, followed by nursing students (4.2%; 45/1,077) and medical students/trainees (13.2%, 142/1,077). Professional category was not a significant predictor for either model. There were no significant first-order interaction terms or collinearity in either model. Because the IQRs on a Likert-type scale for each predictor differed, the odds ratios (ORs) for significant predictors were standardized by multiplying the b coefficient by the IQR to provide an adjusted OR (aOR). The use of aORs allows for direct comparisons of the influence of each predictor on the dependent variable. The 95% confidence intervals (CIs) were adjusted by weighting the b value and standard error by the IQR. PASW Statistics 18 Core system software (http://www.spss.com/software/statistics/) was used for all statistical tests, including multiple logistic regression analysis. Because we were testing self-reported behavior, a was set at 0.06.
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M.-L. McLaws et al. / American Journal of Infection Control 40 (2012) 336-9 Community Elective Behavior
AOR 2.1 (95%CI 1.8-2.4) P <0.000
Hospital Inherent Behavior
AOR 1.6 (95%CI 1.4-1.7) P <0.000
Hospital Elective Behavior
R2 0.58 P <0.000
Hospital Elective Hand Hygiene
Community Inherent Behavior
AOR 1.5 (95%CI 1.2-1.9) P =0.001
Subjective normsInfection Control Practitioners
AOR 1.4 (95%CI 1.2-1.8) P=0.001
Effort required
AOR 1.1 (95%CI 1.0-1.1) P=0.039
Subjective normsnurses
AOR 1.1(95%CI 1.02-1.3) P =0.025
Attitudes
Attitudes
AOR 0.91(95%CI 0.8-0.9) P=0.01
Subjective normsnurses
Fig 1. Modeling of hospital elective hand hygiene elective behavior describing compliance with clean contacts, with which HCWs perceive that they can elect to comply or not.
AOR 2.5 (95%CI 2.0-3.0) P <0.000
R2 0.49 P <0.0001
Hospital Inherent Hand Hygiene
AOR 1.1 (95%CI 1.04-1.2) P =0.001 AOR 0.74 (95%CI 0.64-0.87) P<0.000
Fig 2. Modeling of hospital inherent hand hygiene elective behavior describing compliance with clean contacts, with which HCWs perceive that they can elect to comply or not. Inherent behavior describes compliance with contacts with which HCWs perceive to have been associated with emotionally dirty spots or with sticky or dirty hands.
RESULTS Hospital elective hand hygiene behavior Our final model identified 5 significant predictors for compliance after contacts that HCWs incorrectly elected to comply or not. This model accounts for 58% of the variance in hand hygiene behavior with this classification of patient contacts (Fig 1). The strongest predictor was community elective behavior (aOR, 2.1; 95% CI, 1.8-2.4; P < .000); HCWs were 2.1 times more likely to comply with hospital elective contacts if they comply with this community practice. HCWs who reported hand hygiene with hospital inherent contacts were 1.6 times more likely (aOR, 1.6; 95% CI, 1.4-1.7; P < .000) to comply with hospital elective contacts. With the perception of low effort required to undertake hand hygiene, HCWs were 1.1 times more likely (aOR, 1.1; 95% CI, 1.0-1.1; P ¼ .039) to comply with hospital elective contacts. HCWs were 1.1 times more likely (aOR, 1.1; 95% CI, 1.02-1.3; P ¼ .025) to comply with hospital elective contacts if they believed their nursing colleagues (SN nurses) expected them to comply. Poor attitudes toward hospital elective compliance adversely affected compliance with hospital elective contacts (aOR, 0.91; 95% CI, 0.85-0.96; P ¼ .01). Hospital inherent hand hygiene behavior The final model for compliance with hospital inherent contacts consisted of 5 significant predictors that accounted for 49% of the variance for this hand hygiene behavior (Fig 2). Hospital elective behavior exerted the greatest influence on hospital inherent behavior (aOR, 2.5; 95% CI, 2.0-3.0; P < .0001). HCWs who complied with community inherent behavior were 1.5 times more likely (aOR, 1.5; 95% CI, 1.2-1.9; P ¼ .001) to comply with hospital inherent contacts. HCWs who believed that the ICP (SN ICP) expected them to comply with hospital inherent contacts were 1.4 times more likely (aOR, 1.4; 95% CI, 1.2-1.8; P ¼ .001) to comply than those without a perception of ICP peer pressure. Conversely, HCWs were less likely (aOR, 0.74; 95% CI, 0.64-0.87; P < .000) to comply with hospital inherent contacts if they perceived that nursing colleagues (SN nurses) did not expect compliance with hand hygiene. Those HCWs who reported good attitudes towards hand hygiene were 1.1 times more likely to comply with hospital inherent contacts (aOR, 1.1; 95% CI, 1.04-1.2; P < .000). DISCUSSION At the time of this study, Iranian HCWs had not yet been introduced to “My Five Moments for Hand Hygiene”21 or alcohol-based hand rub, but they were expected to undertake handwashing
before and after patient contacts. Therefore, we used the classification of patient contact for hand hygiene into elective and inherent in an attempt to understand compliance, because this approach has been successful elsewhere where before and after patient contact compliance was practiced.18 It was not surprising that a corresponding community handwashing practice was strongly predictive of compliance with hospital elective and hospital inherent contacts. A similar relationship was found in a high-resourced health care system;18 however, unexpectedly, self-reported compliance with hospital elective contacts was predictive of hospital inherent contacts and vice versa (aOR, 1.6), suggesting that good hand hygiene practice associated with any type of contact reinforces all hand hygiene practices. The influence of the ICP was limited to only those hand hygiene practices for dirty (ie, hospital inherent) contacts, whereas the influence of nursing colleagues extended to compliance with both dirty and clean (ie, hospital elective) contacts. The influence of peer groups was unlike that identified in West countries, where only physicians and administrators were found to influence nursing staff compliance.18 In the present study, neither physicians nor administrators provided role models for Iranian HCWs. Hand hygiene associated with hospital elective (ie, clean) contacts benefit from a perception that hand hygiene compliance required little effort, and hospital inherent (ie, dirty) contacts trigger the same need for hand hygiene in Iran as in the West.18 Therefore, the consistent availability of alcohol-based hand rub for clean contacts would continue to improve compliance by facilitating the influence of perceived (low) effort required. Of all of the significant predictors for both types of hand hygiene contacts studied, community-based hand hygiene behavior was found to have the strongest influence on hospital-based behavior. Thus, a community hand hygiene awareness campaign would gain additional benefits by improving hospital-based behavior. Hospitalbased awareness campaigns focusing on improving compliance with perceived clean contacts also will benefit compliance with dirty hospital inherent contacts.
References 1. Moret L, Teque B, Lombrail P. Should self-assessment methods be used to measure compliance with hand washing recommendations? A study carried out in a French university hospital. Am J Infect Control 2004;32:385-90. 2. Raboud J, Saskin R, Wong K, Moore C, Parucha G, Bennett J, et al. Patterns of hand washing behavior and visits to patients on a general medical ward of health care workers. Infect Control Hosp Epidemiol 2004;25:198-202. 3. Sharir R, Teitler N, Lavit L, Raz R. High-level handwashing compliance in a community teaching hospital: a challenge that can be met. J Hosp Infect 2001;49:55-8.
M.-L. McLaws et al. / American Journal of Infection Control 40 (2012) 336-9 4. Stout A, Retchie K, Macpherson K. Clinical effectiveness of alcohol-based products in increasing hand hygiene compliance and reducing infection rates: a systematic review. J Hosp Infect 2007;66:308-12. 5. Pittet D, Donaldson L. Clean Care Is Safer Care: a worldwide priority. Lancet 2005;366:1264-5. 6. Pittet D. Infection control and quality health care in the new millennium. Am J Infect Control 2005;33:258-67. 7. Askarian M, Rostami-Gooran N. National nosocomial infection surveillance systemebased study in Iran: additional hospital stay attributable to nosocomial infections. Am J Infect Control 2003;31:465-8. 8. Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect 2009;73:305-15. 9. Akyol AD. Hand hygiene among nurses in Turkey: opinion and practices. J Clin Nurs 2007;16:431-7. 10. Lawton RM, Turon T, Cochran RL, Cardio D. Prepackaged hand hygiene educational facilitate implementation. Am J Infect Control 2006;34:152-4. 11. Pittet D, Donaldson SL. Clean Care Is Safer Care: the first global challenge of the WHO World Alliance for Patient Safety. Infect Control Hosp Epidemiol 2005; 26:891-4. 12. Marjadi B, McLaws ML. Hand hygiene in rural Indonesia: barriers beyond sinks, hand rubs and in-service training. J Hosp Infect 2010;76:256-60.
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13. Owusu-Ofori A, Jennings R, Burgess J, Prasad PA, Acheampong F, Coffin SE. Assessing hand hygiene resources and practices at a large African teaching hospital. Infect Control Hosp Epidemiol 2010;31:802-8. 14. Whitby M, McLaws ML. Handwashing in healthcare workers: accessibility of sink location does not improve compliance. J Hosp Infect 2004;58:247-53. 15. Fitzpatrick KR, Pantle AC, McLaws ML, Hughes CF. Culture change for hand hygiene: Clean Hands Save Lives Part II. Med J Aust 2009;191:S13-7. 16. Randle K, Clarke M, Storr J. Hand hygiene compliance in health care workers. J Hosp Infect 2006;64:205-9. 17. Pittet D. Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerg Infect Dis 2001;7:234-40. 18. Whitby M, McLaws ML, Ross MW. Why healthcare workers don’t wash their hands: a behavioural explanation. Infect Control Hosp Epidemiol 2006;27:484-92. 19. Askarian M, Memish ZA, Khan AA. Knowledge, practice, and attitude among Iranian nurses, midwives, and students regarding standard isolation precautions. Infect Control Hosp Epidemiol 2007;28:241-4. 20. Ajzen I. The theory of planned behaviour. Organ Behav Hum Dec Proc 1991;50: 179-211. 21. World Health Organization. Guidelines on hand hygiene in health care, 2009 First Global Patient Safety Challenge: Clean Care Is Safer Care. Available from: www.who.int/patientsafety/events/05/HH_en.pdf. Accessed November 2010.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Predicting hand hygiene among Iranian health care workers using the theory of planned behavior Mary-Louise McLaws DipTropPubHlth, MPH, PhD a, Najmeh Maharlouei MD b, Farideh Yousefi MD c, Mehrdad Askarian MD d, * a
School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran College of Education and Psychology, Shiraz University, Shiraz, Iran d Department of Community Medicine, Shiraz University of Medical Sciences, Shiraz, Iran b c
Key Words: Handwashing Predictive behavioral model Compliance
Background: This study was conducted to identify significant predictors of handwashing associated with hospital elective (clean) and hospital inherent (dirty) contacts. Methods: This cross-sectional survey of 1,700 health care workers was based on the theory of planned behavior. Data were aggregated into components according to the theory and tested for predictors of hospital elective and hospital inherent handwashing using multiple logistic regression analysis. The a value was set at 0.05, and odds ratios (ORs) for significant predictors were adjusted by interquartile range. All wards studied were in private and government hospitals associated with the University of Medical Sciences, Shiraz, Iran between April and September 2008. Results: Of the 1,200 healthcare workers surveyed 1,077 (90%), of whom 83% were nurses, returned a completed survey. Hospital elective handwashing practice was positively influenced by community elective practice (adjusted OR [aOR], 2.1; P < .000), hospital inherent practice (aOR, 1.6; P < .000), perception that handwashing required little effort (aOR, 1.1; P ¼ .039), and subjective norms (nursing peers) (aOR, 1.1; P ¼ .025) and negatively influenced by poor attitudes regarding handwashing (aOR, 0.91; P ¼ .01). Hospital inherent handwashing practice was positively influenced by hospital elective practice (aOR 2.5; P < .000), community inherent practice (aOR, 1.5; P ¼ .001), subjective norms (infection control practitioners) (aOR, 1.4; P ¼ .001, and attitudes (aOR, 1.1; P ¼ .001) and negatively influenced by poor subjective norms (nurses) (aOR, 0.74; P < .000). Conclusion: Community-based handwashing practices exerted a strong influence on handwashing compliance in the hospital. Given this interdependence between community and hospital handwashing, a campaign to improve awareness of the benefit of community handwashing may improve clinicians’ compliance. Crown Copyright Ó 2012 Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc. All rights reserved.
Health careeassociated infections (HAIs) are associated with increased morbidity, mortality, hospitalization,1-4 and patient distress and with longer patient recovery times.4 More than 1.4 million patients worldwide are estimated to suffer an HAI at any given time.5 Between 5% and 10% of patients admitted to high-resourced health care systems acquire one or more infections during hospitalization.5,6
* Address correspondence to Mehrdad Askarian, MD, Professor of Community Medicine, Shiraz University of Medical Sciences, PO Box 71345-1737, Shiraz, Iran. E-mail address: [email protected] (M. Askarian). This study was funded by the Vice-Chancellor for Research, Shiraz University of Medical Sciences. Conflict of interest: None to report.
HAIs are the 11th-leading cause of death in the United States.2 The risk of HAI in low-resourced health care settings is between 2 and 20 times higher than the US rate.5 Between 1999 and 2000, the incidence of HAI in the surgical department of a teaching hospital in Shiraz was 18%, and the estimated annual cost of this level of infection was approximately 120 billion Rials (wUS $150,000).7 Regardless of the level of health service resources, hand hygiene compliance has an inverse influence on the rate of HAI8 and is a costeffective method of preventing infection transmission.9-11 Contacts between nurses with contaminated hands and their patients are generally considered the main route of infectious spread between wards. Although nurses recognize hand hygiene as an important HAI prevention measure, their practice varies
0196-6553/$36.00 - Crown Copyright Ó 2012 Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc. All rights reserved. doi:10.1016/j.ajic.2011.04.004
M.-L. McLaws et al. / American Journal of Infection Control 40 (2012) 336-9
337
depending on such factors as the level of health service resources,12-16 ward,14 professional level of nursing,17 working conditions,17 and type of patient contact.14,18 Notwithstanding these compliance barriers, hand hygiene rates are typically <50%.1,2,12,13 Iranian health care workers (HCWs) have acceptable knowledge and attitudes about hand hygiene, but poor selfreported hand hygiene practice.19 A study of Australian HCWs’ cognition for hand hygiene using a survey based on the theory of planned behavior (TPB)20 examined compliance with 2 types of patient contacts: hospital elective behavior, in which hands are visually clean and HCWs may elect to comply or not comply, and hospital inherent behavior, in which hands are physically dirty or contacts trigger an emotional or inherently high level of compliance.18 Accordingly, the TPB can be used to predict intention to comply with hospital elective or hospital inherent contacts from several intermediate variables, including attitude toward handwashing associated with clean or dirty contacts, subjective norms (ie, perception of peer group pressure to undertake clean or dirty handwashing), perceived control (ie, perception of effort to perform the clean or dirty handwashing behaviors), similar handwashing practices in the community, and the opposite hospital handwashing practice (ie, hospital elective for predicting hospital inherent practice and vice versa). Iranian HCWs are expected to practice handwashing before and after patient contacts. In the present work, we used a statistical model with a pretested survey18 to examine barriers to and factors facilitating HCWs’ compliance with hospital elective and hospital inherent patient contacts.
describes hand hygiene compliance associated with physically dirty or sticky hands or when hands have made contact previously described by nursing staff as microbiologically dirty or emotionally sensitive (eg, axillae, groin, genitals). A detailed description of the survey items and its development is available elsewhere.18 Pilot testing of the questionnaire with 50 Iranian HCWs demonstrated high reliability (r ¼ 0.92). Responses to items for the outcomes hospital elective handwashing and hospital inherent handwashing were measured on a 5-point scale (1, always; 2, mostly, 3, sometimes; 4, occasionally; 5, never). Responses to items measuring the predictive components were measured using a 7-point Likert-type scale (ranging from 1, strongly agree to 7, strongly disagree). Items worded in the negative had the scores reversed. Paired items for attitudes (ie, attitudinal beliefs and evaluation of beliefs), subjective norms (ie, normative beliefs and motivational beliefs), and perceived peer behavior (ie, perceived peer behaviors and evaluation of the behaviors) were multiplied before being summed. There were 12 paired items for attitudes, 2 paired items for subjective normative (SN) nurse colleagues, 2 paired items for SN physician colleagues, 2 paired items for SN administrators, 3 paired items for SN infection control practitioners (ICPs), 5 items for effort required, 6 paired items for perceived peer behavior, 16 items for community elective contact, and 4 items for community inherent contact. There were 13 items for the hospital elective outcome component and 10 items for the hospital inherent outcome component. The summed score for each component was divided to revert the range to the original 1-7 or 1-5 score.
METHODS
Assessment of construct validity of the components and development of the models
Design and setting A questionnaire was distributed to 1,000 nursing staff members and 200 medical and nursing students in 18 private and 10 government hospitals in Shiraz, Iran between April and September 2008. Evening shifts were more likely to be staffed by junior staff and supervised by a small team of senior staff; therefore, participants were identified using a random sample of every third HCW available on all wards during all shifts (morning, afternoon, and evening). A standardized verbal description of the study and its aims was provided to each participant, and each participant provided oral consent to participate before the anonymous, selfadministered questionnaires were distributed. Approximately 90% of the distributed questionnaires were completed and returned to one of the authors (N.M.). Data collection The questionnaire (available from M.-L.M.) was previously tested18 and was translated into Persian by 2 community medicine specialists and a psychologist, who verified the questionnaire’s face and content validity. Items measuring the original components of the TPB and a new component included the respondent’s perception of the positive and negative effects of handwashing and an evaluation of the behavior (attitudes), belief that 4 peer groups expected the HCW to comply and motivation to please the peer (subjective norms), effort and control to comply (effort required), and effect of role modeling (perceived peer behavior). The original application of the TPB has one outcome component; we modeled 2 separate self-reported hand hygiene behaviors, hospital elective and hospital inherent.18 The elective hand hygiene component described compliance associated with clean contacts, including patient environments, obtaining a pulse reading where the HCW elects to perform hand hygiene or not. Inherent hand hygiene
The internal consistency of all components was evaluated using Cronbach’s a coefficient. Values were 0.78 for hospital inherent, 0.87 for hospital elective, 0.31 for community inherent, 0.80 for community elective, 0.83 for attitudes, 0.78 for SN nurse colleagues, 0.81 for SN physician colleagues, 0.82 for SN administrators, 0.78 for SN ICPs, 0.75 for effort required, and 0.86 for perceived peer behavior. Potential predictors were entered using backward linear regression to model 2 separate outcomes, hospital elective and hospital inherent hand hygiene behaviors. The variables entered included 9 independent variables plus the opposite outcome as a potential predictor; hospital inherent behavior was included as a potential predictor for hospital elective model and vice versa. According to the TPB, demographic variables are not predictive of behavior in adults. The mean age of the study participants was 29.4 7.1 years; age, categorized by interquartile range (IQR), was entered into the models but was not significant. The majority (82.6%; 890/ 1,077) of participants were nursing staff, followed by nursing students (4.2%; 45/1,077) and medical students/trainees (13.2%, 142/1,077). Professional category was not a significant predictor for either model. There were no significant first-order interaction terms or collinearity in either model. Because the IQRs on a Likert-type scale for each predictor differed, the odds ratios (ORs) for significant predictors were standardized by multiplying the b coefficient by the IQR to provide an adjusted OR (aOR). The use of aORs allows for direct comparisons of the influence of each predictor on the dependent variable. The 95% confidence intervals (CIs) were adjusted by weighting the b value and standard error by the IQR. PASW Statistics 18 Core system software (http://www.spss.com/software/statistics/) was used for all statistical tests, including multiple logistic regression analysis. Because we were testing self-reported behavior, a was set at 0.06.
338
M.-L. McLaws et al. / American Journal of Infection Control 40 (2012) 336-9 Community Elective Behavior
AOR 2.1 (95%CI 1.8-2.4) P <0.000
Hospital Inherent Behavior
AOR 1.6 (95%CI 1.4-1.7) P <0.000
Hospital Elective Behavior
R2 0.58 P <0.000
Hospital Elective Hand Hygiene
Community Inherent Behavior
AOR 1.5 (95%CI 1.2-1.9) P =0.001
Subjective normsInfection Control Practitioners
AOR 1.4 (95%CI 1.2-1.8) P=0.001
Effort required
AOR 1.1 (95%CI 1.0-1.1) P=0.039
Subjective normsnurses
AOR 1.1(95%CI 1.02-1.3) P =0.025
Attitudes
Attitudes
AOR 0.91(95%CI 0.8-0.9) P=0.01
Subjective normsnurses
Fig 1. Modeling of hospital elective hand hygiene elective behavior describing compliance with clean contacts, with which HCWs perceive that they can elect to comply or not.
AOR 2.5 (95%CI 2.0-3.0) P <0.000
R2 0.49 P <0.0001
Hospital Inherent Hand Hygiene
AOR 1.1 (95%CI 1.04-1.2) P =0.001 AOR 0.74 (95%CI 0.64-0.87) P<0.000
Fig 2. Modeling of hospital inherent hand hygiene elective behavior describing compliance with clean contacts, with which HCWs perceive that they can elect to comply or not. Inherent behavior describes compliance with contacts with which HCWs perceive to have been associated with emotionally dirty spots or with sticky or dirty hands.
RESULTS Hospital elective hand hygiene behavior Our final model identified 5 significant predictors for compliance after contacts that HCWs incorrectly elected to comply or not. This model accounts for 58% of the variance in hand hygiene behavior with this classification of patient contacts (Fig 1). The strongest predictor was community elective behavior (aOR, 2.1; 95% CI, 1.8-2.4; P < .000); HCWs were 2.1 times more likely to comply with hospital elective contacts if they comply with this community practice. HCWs who reported hand hygiene with hospital inherent contacts were 1.6 times more likely (aOR, 1.6; 95% CI, 1.4-1.7; P < .000) to comply with hospital elective contacts. With the perception of low effort required to undertake hand hygiene, HCWs were 1.1 times more likely (aOR, 1.1; 95% CI, 1.0-1.1; P ¼ .039) to comply with hospital elective contacts. HCWs were 1.1 times more likely (aOR, 1.1; 95% CI, 1.02-1.3; P ¼ .025) to comply with hospital elective contacts if they believed their nursing colleagues (SN nurses) expected them to comply. Poor attitudes toward hospital elective compliance adversely affected compliance with hospital elective contacts (aOR, 0.91; 95% CI, 0.85-0.96; P ¼ .01). Hospital inherent hand hygiene behavior The final model for compliance with hospital inherent contacts consisted of 5 significant predictors that accounted for 49% of the variance for this hand hygiene behavior (Fig 2). Hospital elective behavior exerted the greatest influence on hospital inherent behavior (aOR, 2.5; 95% CI, 2.0-3.0; P < .0001). HCWs who complied with community inherent behavior were 1.5 times more likely (aOR, 1.5; 95% CI, 1.2-1.9; P ¼ .001) to comply with hospital inherent contacts. HCWs who believed that the ICP (SN ICP) expected them to comply with hospital inherent contacts were 1.4 times more likely (aOR, 1.4; 95% CI, 1.2-1.8; P ¼ .001) to comply than those without a perception of ICP peer pressure. Conversely, HCWs were less likely (aOR, 0.74; 95% CI, 0.64-0.87; P < .000) to comply with hospital inherent contacts if they perceived that nursing colleagues (SN nurses) did not expect compliance with hand hygiene. Those HCWs who reported good attitudes towards hand hygiene were 1.1 times more likely to comply with hospital inherent contacts (aOR, 1.1; 95% CI, 1.04-1.2; P < .000). DISCUSSION At the time of this study, Iranian HCWs had not yet been introduced to “My Five Moments for Hand Hygiene”21 or alcohol-based hand rub, but they were expected to undertake handwashing
before and after patient contacts. Therefore, we used the classification of patient contact for hand hygiene into elective and inherent in an attempt to understand compliance, because this approach has been successful elsewhere where before and after patient contact compliance was practiced.18 It was not surprising that a corresponding community handwashing practice was strongly predictive of compliance with hospital elective and hospital inherent contacts. A similar relationship was found in a high-resourced health care system;18 however, unexpectedly, self-reported compliance with hospital elective contacts was predictive of hospital inherent contacts and vice versa (aOR, 1.6), suggesting that good hand hygiene practice associated with any type of contact reinforces all hand hygiene practices. The influence of the ICP was limited to only those hand hygiene practices for dirty (ie, hospital inherent) contacts, whereas the influence of nursing colleagues extended to compliance with both dirty and clean (ie, hospital elective) contacts. The influence of peer groups was unlike that identified in West countries, where only physicians and administrators were found to influence nursing staff compliance.18 In the present study, neither physicians nor administrators provided role models for Iranian HCWs. Hand hygiene associated with hospital elective (ie, clean) contacts benefit from a perception that hand hygiene compliance required little effort, and hospital inherent (ie, dirty) contacts trigger the same need for hand hygiene in Iran as in the West.18 Therefore, the consistent availability of alcohol-based hand rub for clean contacts would continue to improve compliance by facilitating the influence of perceived (low) effort required. Of all of the significant predictors for both types of hand hygiene contacts studied, community-based hand hygiene behavior was found to have the strongest influence on hospital-based behavior. Thus, a community hand hygiene awareness campaign would gain additional benefits by improving hospital-based behavior. Hospitalbased awareness campaigns focusing on improving compliance with perceived clean contacts also will benefit compliance with dirty hospital inherent contacts.
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