Hand Hygiene Behaviour
Modifying healthcare worker (HCW) hand hygiene behaviour is a complex task. Generally, adherence of HCWs to recommended hand hygiene procedures is poor, with mean baseline rates ranging from 5% to 81%, with an overall average of about 40%.
Current models and theories that help to explain human behaviour, particularly as they relate to health education, can be classified on the basis of being directed at the individual (intrapersonal), interpersonal, or community levels:
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Hand hygiene behaviour will vary significantly among HCWs within the same institution or unit as individual features could play a role in determining behaviour. Intrapersonal factors are individual characteristics that influence behaviour such as knowledge, attitudes, beliefs and personality traits.
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In the majority of instances, handwashing practices involve a ritualised behaviour performed mainly for self-protection against infection with harmful microorganisms. The development of handwashing beliefs and practices is believed to first occur during early childhood and continues thereafter with little modification.
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An individual's hand hygiene behaviour is not homogenous and can be classified into at least two types of practice. Inherent hand hygiene practice, which drives the majority of community and HCW hand hygiene behaviour, occurs when the 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. This inherent practice appears to require subsequent handwashing with soap and water.
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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 healthcare 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.
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Interpersonal factors include intrapersonal processes and primary groups i.e. family, friends and peers, who provide social identity, support and role definition. HCWs can be influenced by or are influential in their social environments. Behaviour is often influenced by peer group pressure, which indicates that responsibilities for each HCW's individual groups should be clearly recognised and defined.
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Community factors are social networks and norms that exist either formally or informally between individuals, groups and organisations. In the hospital, the community level would be the ward.
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. Yet these clinicians are possibly the peer facilitators of hand hygiene compliance for nurses with different groups acting as peer facilitators for other HCWs.
A number of interventions incorporated in a long-term program are required to ensure sustained improvements to hand hygiene compliance.
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Whilst the introduction of alcohol-based hand rub is likely to influence hand hygiene practice by decreasing the effort required to wash hands, without an associated behavioural modification program that acts on elective hand hygiene intent, a sustained increase in hand hygiene compliance is unlikely.
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