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SJIF Impact Factor: 3.476 ISSN: 2455-7838(Online)
EPRA International Journal of Research and Development (IJRD)
Volume: 1 | Issue: 4 | June | 2016

Rooswidiawati Dewi1
1Master of Public Health Science, Faculty of Medicine,

Lambung Mangkurat University, Banjarbaru 70714,

Kalimantan Selatan, Indonesia

Ari Yunanto2
2Master of Public Health Science, Faculty of Medicine,

Lambung Mangkurat University, Banjarbaru 70714,

Kalimantan Selatan, Indonesia

Syamsul Arifin3
3Master of Public Health Science, Faculty of Medicine,

Lambung Mangkurat University, Banjarbaru 70714,

Kalimantan Selatan, Indonesia

ABSTRACT
Hand hygiene is the best way to reduce Healthcare Associated Infections (HAIs). According to the WHO hand hygiene
compliance paramedics worldwide for less than <50%. This study aims to determine some of the factors that influence hand
hygiene compliance behavior on paramedics before and after implementation of Multimodal Hand Hygiene Improvement
Strategy. This research method is Pre Experimental design with one group pretest-posttest design. The sampling technique used
purposive sampling. Total sample of 40 people. Measuring devices in the form of questionnaires and observation. The results
showed a relationship between knowledge, attitudes, subjective norms, perceived behavior control, percevied susceptibility,
perceived severity, perceived benefits and perceived barriers to hand hygiene compliance before and after the implementation of
Multimodal Hand Hygiene Improvement Strategy except for age and gender. There is a significant difference before and after
implementation of Multimodal Hand Hygiene Improvement Strategy of the knowledge, attitudes, subjective norms, perceived
behavior control, percevied susceptibility, perceived severity, perceived benefits except perceived barrier and hand hygiene
compliance. Knowledge is the most influential variable on hand hygiene compliance.
KEYWORDS:Hand hygiene compliance, Multimodal Hand Hygiene Improvement Strategy

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INTRODUCTION people. The sampling technique used purposive

World Health Organization (WHO) in sampling. Exclusion criteria of this research are
Shinde and Mohite1 states that Healthcare nurse or midwife willing to become respondents in
Associated Infections (HAIs) is a major public the research and educated diploma nursing or
health problem in many countries. The incidence midwifery. The inclusion criteria of this study
HAIs in developing countries is estimated to range are; nurse or midwife will not or are taking time off
between 5.7 up to 19.1% with an average of and have not been trained hand hygiene. Based on
10.1%. The incidence of wound infection is a case these criteria the number of samples to 40
HAIs most common in middle income countries people. The dependent variable in this study is the
and low with a ratio of 1.2 up to 23.6 per 100 compliance behavior hand hygiene while
surgical procedures, or approximately independent variables were age, sex, knowledge,
11.8%.2 According to the WHO 3 hand hygiene is attitudes, subjective norms, perceived behavior
one of the effective measures to break the chain of control, percevied susceptibility, perceived severity,
transmission infection. According to experts in perceived barriers and perceived benefits. The
Creedon 4 hand hygiene compliance paramedics instrument used was a questionnaire and a check
score rarely exceeds 50%. In developing countries, list hand hygiene compliance
a failure in the implementation of hand hygiene is either handrub and handwash and My Five For
triggered by a shortage of funds to provide the Hand Hygiene Moment. Validity and reliability
necessary facilities. But when the existing funds, the using Pearson Product Moment Correlation
next obstacle is of most concern is the behavior of technique and Cronbach’s Alpha. The trial
the paramedics that are not in accordance with the questionnaire was conducted weeks to August 2nd,
procedure. Based on the preliminary study on 2015. The results of validity and reliability of the
February 16th, 2015, found a lack facilities to whole question is valid and reliable for arithmetic
support the implementation of the hand and r alpha r> r table is 0.444. Intervention is the
hygiene like a broken sink, lack of hand rub and implementation strategy of multimodal hand
tissue fluids and the lack of socialization as well as hygiene improvement comprising: a) education and
education and training, including infection training on hand hygiene; b) reminders in the
prevention and control hand hygiene. Therefore, workplace in the form of posters 6 hand hygiene
the researchers want to implement Multimodal measures and Five For Hand Hygiene Moment c)
Hand Hygiene Improvement Strategy of WHO to changes in the system by ensuring facilities such as
improve compliance with hand hygiene in the alcohol-based handrub liquids, antiseptic soap and
paramedics. The aims of this study was to tissue in each room. Data analysis consisted of
determine some of the factors that influence univariate, bivariate and multivariate. Limitations of
compliance behavior in the hand hygiene this study is the number of respondents by sex in
paramedics before and after implementation of the this study are not as large so that the difference in
Multimodal Hand Hygiene Improvement Strategy in hand hygiene compliance among paramedics men
Inpatient Ratu Zalecha Hospital 2015. and women can not be known. Intervention and
METHODS observations made in a short time. Another variable
The research design was pre that may affect such experience, workload, role
experimental with one group pretest-posttest models, motivation, feedback, workload, working
design. The population in this study are all nurses time can not be observed.
in the ICU, nursery, and surgery room in Ratu
Zalecha Martapura Hospital as many as 73

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RESULT
Univariate analysis:-
Table 4.1. Frequency Distribution of Respondents by Independent and Dependent Variable
Before After
Variable
N % N %
Age
Early adulthood 32 80 32 80
Middle adulthood 8 20 8 20
Gender
Male 14 35 14 35
Female 26 65 26 65
Knowledge
Poor 27 67.5 12 30
Good 13 32.5 28 70
Attitude
Poor 21 52.5 11 27.5
Good 19 47.5 29 72.5
Subjective norms
Poor 18 45 8 20
Good 22 55 32 80
Perceived Behavior Control
Poor 19 47.5 8 20
Good 21 52.5 32 80
Perceived Susceptibility
Poor 21 52.5 12 30
Good 19 47.5 28 70
Perceived Severity
Poor 16 40 10 25
Good 24 60 30 75
Perceived Barrier
Poor 15 37.5 14 35
Good 25 62.5 26 65
Perceived Benefit
Poor 14 35 10 25
Good 26 65 30 75
Hand Hygiene Compliance
Disobedient 25 62.5 12 30
Obedient 15 37.5 28 70

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Analysis Bivariat:-
Table 4.2. The Relationship of Age and Gender on Hand Hygiene Compliance on Paramedics Before
and After Implementation of Strategy Multimodal Hand Hygiene Improvement in Ratu Zalecha
Hospital Martapura 2015
Hand Hygiene Compliance OR
Variable p-value
Disobedient (%) Obedient (%) Total % (CI95%)
Age
Before
Early adulthood 21 65.6 11 34.4 32 100 0.444 -
Middle 4 50 4 50 8 100
adulthood
After
Early adulthood 10 31.3 22 68.8 32 100
Middle 2 25 6 75 8 100 1.000 -
adulthood
Gender
Before
Male 9 64.3 5 35.7 14 100 1.000 -
Female 16 61.5 10 38.5 26 100
After
Male 6 42.9 8 57.1 14 100 0.281 -
Female 6 23.1 20 76.9 26 100

Table 4.3. Relations Knowledge, Attitude, Subjective Norm and Perceived Behavior Control with
Hand Hygiene Compliance on a Paramedic Before and After Implementation of Strategy
Multimodal Hand Hygiene Improvement in Ratu Zalecha Hospital Martapura 2015
Hand Hygiene Compliance OR
Variable p-value
Disobedient (%) Obedient (%) Total % (CI95%)
Knowledge
Before
Poor 19 70.4 8 29.6 27 100 0.175 -
Good 6 46.2 7 53.8 13 100
After
Poor 8 66.7 4 33.3 12 100 0.002 12.000
Good 4 14.3 24 85.7 28 100
Attitude
Before
Poor 14 66.7 7 33.3 21 100 0.745 -
Good 11 57.9 8 42.1 19 100
After
Poor 7 63.6 4 36.4 11 100 0.008 8.400
Good 5 17.2 24 82.8 29 100
Subjective norms
Before
Poor 14 77.8 4 22.2 18 100 0.104 -
Good 11 50 11 50 22 100
After
Poor 5 62.5 3 37.5 8 100 0.039 5.952
Good 7 21.9 25 78.1 32 100
Perceived Behavior
Control
Before
Poor 13 68.4 6 31.6 19 100 0.527 -
Good 12 57.1 9 42.9 21 100
After
Poor 5 62.5 3 37.5 8 100 0.039 5.952
Good 7 21.9 25 78.1 32 100

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Table 4.4. Relationships Perceived Susceptibility, Perceived Severity, Perceived

Barrier and Perceived Benefit with Hand Hygiene Compliance in Paramedic Before and
After the Implementation of Strategy Multimodal Hand Hygiene in Ratu Zalecha Hospital
Martapura 2015
Hand Hygiene Compliance OR
Variable p-value
Disobedient (%) Obedient (%) Total % (CI95%)
Perceived
Susceptibility
Before
Poor 17 81 4 19 21 100 0.013 5.844
Good 8 42.1 11 57.9 19 100
After
Poor 7 58.3 5 41.7 12 100 0.021 6.440
Good 5 17.9 23 82.1 28 100
Perceived Severity
Before
Poor 13 81.3 3 18.8 16 100 0.056 4.333
Good 12 50 12 50 24 100
After
Poor 6 60 4 40 10 100 0.041 6.000
Good 6 17.9 24 82.1 28 100
Perceived Barrier
Before
Poor 12 80 3 20 15 100 0.101 -
Good 13 52 12 48 25 100
After
Poor 8 57.1 6 42.9 14 100 0.011 7.333
Good 4 15.4 22 84.6 26 100
Perceived Benefit
Before
Poor 10 71.4 4 28.6 14 100 0.502 -
Good 15 57.7 11 42.3 26 100
After
Poor 6 60 4 40 10 100 0.041 6.000
Good 6 20 24 80 26 100

Multivariate Analysis
Table 4.5. Multivariate Analysis of Several Factors That Influence Hand Hygiene
Compliance After Implementation of Strategy Multimodal Hand Hygiene Improvement on
Ratu Zalecha Hospital Martapura 2015
Variable Koef.Regresi Std. Error t value P Value
Constant -0823 0.411 -2.004 0,053
Knowledge .500 0.173 2,885 0.007
Attitude 0,201 0,154 1.331 0,199
Subjective norms 0,201 0,118 1.699 0.099
Perceived Severity .110 .058 1,911 0.065
Perceived Susceptibility .213 0.107 1.985 0.055
R .778
R Square 0.606 F Count 10.439
Adjusted R Square 0,548 probability F 0000

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Variable knowledge have the greatest Foote 21 and Al Khalwadeh 13, Snow et al 8, Al-
regression coefficient, meaning that the variable Hussami et al 14. The results of different studies
knowledge is the most dominant variable in indicated Sax et al 10.
influencing hand hygiene compliance compared to Relationships Between Knowledge with
other variables. Based on the value of Adjusted R Hand Hygiene Compliance on Paramedics
Square (R2) obtained coefficient of determination Before and After Implementation of Strategy
R2 is 0.606. This shows the percentage of variation Multimodal Hand Hygiene:-
of the dependent variable that can be explained by The results of the study before
the independent variables of 60.6%. While the implementation Strategy Multimodal Hand Hygiene
remaining 39.4% is influenced by other Improvement showed no significant correlation
independent variables outside the research model. between knowledge with hand hygiene
DISCUSSION compliance. After application of the Strategy
The Relationship Between Age With Hand Multimodal Hand Hygiene Improvement bivariate
Hygiene Compliance on Paramedics Before analysis results show the different things that there
and After Implementation of Strategy is a significant relationship between knowledge with
Multimodal Hand Hygiene:- hand hygiene compliance.
Noncompliance hand hygiene in middle age One component of the Multimodal Strategy
respondents likely due to they are accustomed to of the WHO Hand Hygiene Improvement of
routine work without doing hand hygiene so that it education and training. Information that
becomes a habit. This condition causes them to be continuous and sustainable to the paramedics will
resistant to any change. According to influence behavior change. Good knowledge of
Erasmus5 paramedics early adulthood to make their hand hygiene practices in accordance with WHO
colleagues who are more mature as a reference guidelines and compliance are essential to reduce
work. If the senior paramedic disobedient with hand the number HAIs. Compliance behavior based
hygiene practices so they tend to mimic the knowledge will be more durable than behavior
behavior. bedasarkan knowledge. The results of this study are
The results showed no significant consistent with results from studies conducted
correlation between age with hand hygiene Creedon 4, Foote 21, Al Khawaldeh et al 13, Rezaee et
compliance before and after the al 22. Green (1980) in Notoatmodjo 23 states that
intervention. Paramedics age does not always there is a positive relationship between the
describe their experiences related hand hygiene knowledge acquired someone to behavioral
and HAIs. The results are consistent with the theory change. Knowledge and compliance of good hand
advanced by some researchers who claim that age washing practices in accordance with WHO
does not affect the actions of a person because of guidelines on health workers are essential for
factors such as a person's attitude intermediaries reducing HAIs. Paramedics who already have
and other factors that affect a person's will. 6 The knowledge of the importance of hand hygiene in
results in line with research Philomene 7, Snow et al preventing the incidence of HAIs would be
8
, Quiros Lin & Larson 9, Sax et al 10, Tai et subservient to the practice. The results of this study
al 11, Mitchell 12, Al Khawadeh et al 13, the results of differ from research by Ward 24, Situngkir 25,
this study contradicts the studies conducted Al Rabbani et al 26, Cole 27, De Wandel et al 28, Huis et
Hussami 14, Ryan 15. al 29 high level of knowledge, influence social or
Relationships Between Sex with Hand moral perception, consciousness, traffic control
Hygiene Compliance Before and After measures and their facilities do not always lead to
Implementation of Strategy Multimodal increased adherence to hand hygiene.
Hand Hygiene Improvement:- Relationship Between Attitude With Hand
Although it has been exposed to information Hygiene Compliance on Paramedics Before
about hand hygiene but when observation and After Implementation of Strategy
respondents still found women respondent who Multimodal Hand Hygiene:-
wear a ring when performing hand hygiene The results of the study before
practices. In the male respondents disobedience implementation strategy Multimodal Hand Hygiene
perform hand hygiene due to improper Improvement showed no significant relationship
practices. The bivariate analysis both before and between attitudes towards hand hygiene
after implementation of Strategy Multimodal Hand compliance. After application of the strategy
Hygiene Improvement showed no significant Multimodal Hand Hygiene Improvement of the
relationship between sex with hand hygiene results of the analysis showed a significant
compliance. According to Ajzen (1985) in Hassan et relationship between attitudes towards hand
al16 demographic characteristics and personality hygiene compliance.
have not a direct effect on a person's behavior. The The results are consistent with research
results are consistent with research Van de Quiros et al 9 that shows a strong correlation
Mortel 17, Korniewicz & El-Masri 18, between a positive attitude towards compliance
Mitchell , Mortada & Zalat , Philomene7 and
19 20 paramedics Hand Hygiene. The same is shown

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Philomene 7 which shows that hand hygiene strongest predictor of a student as a mentor in
compliance is done via method Self Reported by hand hygiene practices.
nursing students positively correlated with Relationship Between Perceived Behavior
attitude. According Ekwere TA & Okafor Control With Hand Hygiene Compliance on
IP 30 attitude toward hand hygiene positively Paramedics Before and After
influence Hand hygiene practices. Implementation of Strategy Multimodal
Relationship Between Subjective Norm With Hand Hygiene:-
Hand Hygiene Compliance on Paramedics Statistical test results before and after
Before and After Implementation of Strategy implementation of Strategy Multimodal Hand
Multimodal Hand Hygiene:- Hygiene Improvement find a significant association
Statistical test results before the between perceived behavior control with hand
implementation of Strategy Multimodal Hand hygiene compliance. Someone who feels able and
Hygiene Improvement showed no significant successfully perform a particular practice tends to
relationship between subjective norms and hand repeat the behavior. The ability to perform a
hygiene compliance. After the application of the behavior is certainly supported by the availability of
strategy Multimodal Hand Hygiene Improvement facilities, knowledge and a positive attitude.
found a significant relationship between subjective The results of this study are consistent with
norms and hand hygiene compliance. Sax et al 10, Hassan et al 16, Tai et al 11, Kortteisto et
Individuals tend to behave according to what al 34, Philomene.7 According to Pessoa-
others expected to do. Someone who is in a social Silva 31 perceived behavior control and subjective
environment tend to behave the same with peers or norm is the most prominent predictor of intention
others, as well as with a paramedic. Praise or to comply with hand hygiene practices are
positive feedback from senior staff or colleagues good. According DERSCH 35 perceived behavior
can trigger a more positive attitude than a control associated with the ability to know what to
paramedic on the behavior of the Hygiene Hand.31 do in certain circumstances, which is based on
The belief that supervisors and hospital education and training. Research Mc Laws et
administrators expect adherence to the practice of al 33, Al Hussami et al 14 and Al
hygienist hand and pressure from peers as well as 13
Khalwadeh conducted on nursing students
the presence of role model reportedly has a big showed perceived behavior control and intention
effect on the attitude towards hygiene Hand were significant predictors of hygienic hand
paramedics.32 behavior. Perceived behavior control is a predictor
The results of this study are consistent with of the most prominent of its intention to comply
Sax et al 10, Hassan et al 16, Mc Laws et with hand hygiene practices good.31
al . According Kortteisto et al 34 that subjective
33
Relationship Between Perceived
norm is the strongest factor. Paramedics who feel Susceptibility With Hand Hygiene
their subjective norm has no intention to comply Compliance on Paramedics Before and After
with hand hygiene than paramedics who do not feel
Implementation of Strategy Multimodal
their subjective norms. Subjective norm is a model
Hand Hygiene:-
that has a positive role.35 According to Lankford et Statistical test results before and after
al (2001) in Kamunge 36 found that compliance with implementation of Strategy Multimodal Hand
hand hygiene of health workers is influenced role Hygiene Improvement show a statistically
model. Focus Group Discussion (FGD) conducted significant relationship between perceived
Pittet et al 37 showed that hand hygiene practices susceptibility with hand hygiene compliance. In this
conducted paramedics influenced by co-workers study, respondents were given the intervention in
and vice versa. According to Sax et al10, Snow et the form knowledge of HAIs. It aims to sensitize the
al 8, Tai et al 11, and Ryan 15 that hand hygiene paramedics that they are very vulnerable to HAIs
compliance levels tend to be higher paramedic events. Individual perceived susceptibility to poor
supervisor or co-workers if they have a hand health condition or a disease varies. The results of
hygiene compliance. This is due to the close this study indicate a relationship between perceived
relationship and cooperation often compared with susceptibility with hand hygiene compliance. The
the head of the room. Pesoa-Silva 31 found that the higher the perceived risk, the higher the chances of
intention to perform hand hygiene among someone engaging in behaviors that lower the
paramedics at the neonatal unit influenced the risk.The results are consistent with research
opinion of others. According to Maskerine & Loeb 39, Ghanbari et al 40,
White 38 paramedics considers coworkers as Carpenter 41 and Mortada & Zalat 20. According to
references to the most outstanding performance in Kurniawan et al 42, perceived susceptibility on
support of hand hygiene. Other references are paramedic most dominant influence in the
supervisors, patients, and representatives of the application of standard precautions. Another study
Infection Prevention and control team in the conducted by Silva et al 43 also concludes that if
hospital. Research Snow et al 8 found that the individuals feel a susceptibility to a disease, the
related potential to participate in preventive health

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behaviors. According Maskerine & Loeb 39, the shortage of paramedics cause a high workload
41 44
Carpenter and Lee et al , health officials will and this is contributing to disobedient on hand
adhere to the hand hygiene if they believe that they hygiene practices. This study also showed a
are susceptible to certain infections and will significant reduction of nosocomial infection rates
acquire or pass it on to someone else if it does when paramedics reduced workload. 50
not. Instead paramedics who do not consider Relationship Between Perceived
themselves vulnerable to HAIs events would not act Benefit With Hand Hygiene Compliance on
to make prevention by applying standard Paramedics Before and After
45
precautions. Redding & Rossi in Orji et al , Implementation of Strategy Multimodal
generally people often underestimate their Hand Hygiene
vulnerability to disease. Statistical test results showed a statistically
Relationship Between Perceived Severity significant relationship between perceived
With Hand Hygiene Compliance on benefit with hand hygiene compliance on
Paramedics Before and After paramedics before and after implementation of
Implementation of Strategy Multimodal Strategy Multimodal Hand Hygiene
Hand Hygiene:- Improvement. Hand hygiene compliance in
Results of bivariate analysis showed a paramedical influenced by a belief in the benefits of
statistically significant relationship the practice itself. If a person believes and will feel
between perceived severity with hand hygiene the benefits of hand hygiene meal will adopt the
compliance on paramedics before and after behavior and vice versa.
implementation of Strategy Multimodal Hand The results are consistent with research
Hygiene Improvement. Paramedics will obedient to Sax et al 10, da Silva et al 43, Ghanbari et al 40,
perform hand hygiene if they know the severity Mortada & Zalat 20. According to Kurniawan 42 there
caused HAIs. is a significant relationship between perceived
The results are consistent with research benefit with paramedics compliance in applying
conducted Mortada & Zalat 20, Lee et al. 44 According standard precautions. Hand hygiene is the most
to Kurniawan et al 42 perceived severity of influential aspect in 43 infection control, infection
paramedic most dominant influence in the control can help reduce the prevalence of
application of standard precautions. The results of MRSA. According to paramedics, patient protection
this study differs indicated by Lau et al 46 and is the most prominent benefits of hand hygiene
Erasmus 5 where there is no relationship between practices. 38 Health workers will recognize and
perceived severity standard precautions behavior. perform hand hygiene practices as a personal duty
Relationship Between Perceived for their own health benefits. Most paramedics
Barriers With Hand Hygiene Compliance on stressed the need for self-protection from
Paramedics Before and After pathogens for patients and their families as a major
Implementation of Strategy Multimodal accelerator of their hand hygiene
Hand Hygiene:- practices.50 Prevention of cross infection is the
According to Rosenstock (1974) in main advantage of hand hygiene compliance. 5 The
41 results of this study are not consistent with research
Carpenter when people believe to an act that is
considered effective in reducing a negative impact Jang. 51
but at the same time also see that this action is not Effect of Knowledge, Attitude, Subjective
uncomfortable, expensive, painful, and or Norm, PerceivedSusceptibility and Perceived
challenge, then it is likely they are to adopt Severity of With Hand Hygiene Compliance
measures prevention-step most likely not on Paramedics Before and After
happen. The negative aspects of an action is an Implementation of Strategy Multimodal
obstacle in the act. If the benefits of a high action Hand Hygiene
and resistance is weak, then an action is possible After observing the results of the bivariate
and vice versa. According Nazary et al 47 the analysis and multivariate analysis of the
paramedics access to facilities can improve hand development of this research is that hand hygiene
hygiene compliance. According to Creedon et compliance on paramedics strongly influenced by
al 4 easy access to obtain liquid hand rub causes the the level of knowledge without ignoring other
practice of hand antisepsis increased by 20%. The factors such as attitudes, subjective
results of this study conflict with Hossein 48 which norms, perceived behavioral control, perceived
only half of the health workers who are committed susceptibility, perceived severity, perceived
to doing hand hygiene if all the facilities are benefits and perceived barriers.
provided. Knowledge is a factor that affects the
According Ariyaratne et al 49 most person's behavior changes. Based on their
paramedics felt the lack of time as barriers to hand knowledge, someone will figure out the benefits and
hygiene but the obstacle is addressed by using take an attitude to perform an action. O'Brien et
gloves not to practice techniques of effective hand al 52 stated that the right knowledge is the starting
hygiene. Research Pessoa-Silva et al 31 showed that point to improve the practice and inculcate the

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EPRA International Journal of Research and Development (IJRD) |ISSN:2455-7838 (Online)|SJIF Impact Factor : 3.476

right attitude for the prevention of infection. The 9. Quiros D, Lin S. Larson E. Attitudes toward practice
level of knowledge of the individual influence on guidelines Among the intensive care unit personnel: A
attitudes toward a behavior. Someone with high cross-sectional anonymous survey.
knowledge will be a behavior will have a positive 10. Sax H, IlkerUc K, Richet H, Allegranzi B, Pittet D.
Determinants of good adherence to hand hygiene
attitude toward a behavior and tends to be obedient Among healthcare workers who have extensive exposure
in applying the behavior. to hand hygiene campaigns. Infection control and
According to Al Khalwadeh 13, Al Hussami et hospital epidemiology [serial on the Internet]. 2007
al , Mc Laws et al 33 that personal attitude and
14
[cited 2015 Aug 23]; 28 (11): 1267-1274
responsible is a significant predictor of 11. Tai J, Mok E, Ching P, W Seto, Pittet D. Nurses and
intentions. Attitudes can be improved by increasing physicians' perceptions of the importance and impact of
one's knowledge through educational programs. An healthcare-associated binfections and hand hygiene:
individual with perceived amulti-center exploratory study in Hong Kong. Clinical
and Epidemiological Study. [serial on the Internet]
susceptibility and perceived severity is high against
2009 [cited 2015 Nov 15] ; 37 (4): 320-333
a disease tend to have a strong knowledge. These 12. Mitchell BG , Say R, Wells A, Wilson M, L Cloete,
conditions explain the variation of individual's Matheson L. Australian graduating nurses â €
perception of a disease. Knowledge of the disease ™ knowledge, intentions and beliefs on infection
has the potential to modify the perceptions of prevention and control: a cross-sectional study. BMC
individuals (Haefner & Kirsch, 1970) in Glanz K et Nursing [serial on the Internet] 2014 [cited 2015 Nov
al 53. 9] 13; 43
Conclusion 13. Al-Khawaldeh OA, Al-Hussami M, Darawad M.
(2015) Influence of nursing students Handwashing
The results showed a relationship between
knowledge, beliefs, and attitudes on their Handwashing
knowledge, attitudes, subjective norms, perceived compliance.Health [serial on the Internet] 2015 [cited
behavior control, percevied susceptibility, perceived 2015 Nov 20]; 7 (5 ): 572-579
severity and perceived barriers and perceived 14. Al-Hussami M, Darawad M, Almhairat II. (2011)
benefits of compliance with hand hygiene before Predictors of compliance practice Handwashing Among
and after implementation of Strategy Multimodal healthcare professionals. Healthcare Infection [serial on
Improved hygiene Hands except for age and sex. the Internet] 2011 [cited 2015 October 01 [cited 2015
Knowledge is variable the most dominant in Oct 01]; 16 (2) 78-84/handwashing_2.pdf
influencing hand hygiene compliance without 15. Ryan CE. Determinants of hand hygiene Among
registered nurses caring for Critically Ill infants in the
ignoring other factors.
neonatal intensive care unit. Thesis. University of
REFFERENCE Windsor in 2012 [cited 2015 Des 23]
1. BM Shinde, Mohite VR. Study to assess knowledge, 16. ZM Hassan, Wahsheh MA, Hindawi
attitude and practices of five moments of hand hygiene OS. Understanding hand hygiene behavior Among
Among nursing staff and students at a tertiary care Jordanian nurses registered an application of the
hospital at Theory of Planned Behavior.Journal of Infectious
Karad. International Journal of Science and Research. Diseases in Clinical Practice . [ Serial on the Internet]
2014 [cited 2015 Oct 10]; 3 (2): 311-321. 2009 [cited 2015 Aug 27]; 17 (3): 150-156
2. WHO [homepage on the Internet]. Report on the 17. van de Mortel TF, Apostolopoulou EA,
burden of endemic health care-associated infection PetrikkosGL. A comparison of the hand hygiene
worldwide a systematic review of the literature. [Serial knowledge, beliefs, and practices of Greek nursing and
on the Internet] 2011 [cited 2015 May 10]; medical students.Southern Cross University.2010 [cited
3. WHO [ homepage on the Internet]. WHO guidelines December 18, 2015]
on hand hygiene in health care. First global patient 18. Korniewicz DM, El-Masri M. Exploring The Factors
safety challenge clean care is safer care. [ Serial on the Associated With Hand Hygiene Compliance of Nurses
Internet].2009. [cited 2015 Nov 14] During Routine Clinical Practice. Applied Nursing
4. Creedon, US. Infection control: behavioral healthcare Research . [ Serialon the internet]. 2010 [cited 23
worker issues for clinical governance. An December 2015]; 23 (2 ): 86-90
International Journal . [ Serial on the 19. Mitchell BG , Say R, Wells A, Wilson M, L Cloete,
Internet]. 2006 [cited 2015 May 24] ; 11 (40): 316- Matheson L. Australian graduating nurses â €
325 ™ knowledge, intentions and beliefs on infection
5. Erasmus, V.Compliance to hand hygiene guidelines in prevention and control: A Cross-Sectional Study. 2014
hospital care a stepwise behavioral [cited 2015 Nov 9]; 13: 43
approach . Thesis . 2012 [cited 14 December 2015] 20. Mortada EM , Zalat MM. Assessment of compliance to
Erasmus Universiteit Rotterdam. standard precautions Among surgeons in university
6. Smet, B, Psychology health. Jakarta. Grasindo.2004 hospitals Zagazig, Egypt, using the Health Belief
7. Philom à ne compliance U.Handwashing Among Model.Journal of the Saudi Society for Medical
nurses and Midwives caring for newborn babies in Research Original . [ Serial on the Internet]. 2014
health facilities Rwamagana, Rwanda. Thesis. (2014) [cited 2015 Des 21]; 9 (): 6-14
[cited 19 Sept 2015] University of the Western Cape. 21. Foote A. Exploring self-perceived hand hygiene
8. Snow M, White GL Jr, Alder SC, Stanford practices in undergraduate nursing Among
JB. Mentor's hand hygiene practices influence student's students.Thesis.University of Windsor. 2014 [cited
hand hygiene rates.American Journal of 2015 Sept 22]
Infection Control. [Serial on the Internet]. 2006 [cited 22. Rezaee R , Danaei M, Askarian M. The efficacy of
2015 October 2]; 34 (1): 18-24. teaching hand hygiene to medical students: an

www.eprajournals.com Volume: 1| Issue: 4| June 2016 84

EPRA International Journal of Research and Development (IJRD) |ISSN:2455-7838 (Online)|SJIF Impact Factor : 3.476

interventional study. International Journal of 37. Pittet D, Simon A, Hugonnet S, CL Pessoa-Silva,

Academic Research in Business and Social Sciences. Sauvan V, Perneger TV. Hand Hygiene Among
[Serial on the Internet] 2014 [cited 2015 Des 27]; 4 ( Physicians: Performance, Beliefs, and Perceptions Ann
9) 151-159 Intern Med . [Serial on the Internet]. 2004 [cited
23. Notoatmodjo, S . Health Promotion Theory and 2015 February 2]; 141 (1)
Application. Jakarta. PT. Rineka Reserved. 2005 38. White KM, Jimmieson NL, PL Obst, Graves N,
24. DJ Ward. The role of education in the prevention and Barnett A, Cockshaw W, P Gee, Haneman L, Page K,
control of infection: a review of the literature. Nurse Campbell M, Ma rtin E, Paterson D. Using a theory of
Educ Today . [ Serial on the Internet]. 2011 [cited planned behavior framework to explore hand hygiene
2015 Nov 20]; 31 (1): 9-17 beliefs at the â € ~ 5 critical moments â € ™ Among
25. Situngkir SF. Factors that influence adherence of Australian hospital-based nurses. BMC Health
health workers in the implementation of handwashing Services Research.[serial on the int ernet] 2015 [cited
in poly teeth RSCM Jakarta. Thesis. Post graduate 2015Agt 27]; 15:59
program Faculty of Medicine, University of Gadjah 39. Maskerine, C. and Loeb, M. Improving adherence to
Mada. 2014 hand hygiene Among health care workers.The Journal
26. Rabbani IS , Pateda V, Wilar R, of Continuing Education in the Health Professions.
Rampengan. Relations Knowledge Against [Serial on the Internet] 2006 [cited 2015 Aug 10]; 26
Handwashing Behavior Health Officer in the Child (3): 224-251
Health Department, Prof. Dr BLUDsDR. Kandau 40. MK Ghanbari, Farazi AA, Shamsi M Khorsandi
Journal E-Clinic. [Serial on the intenet] 2014 [cited M and Esharti B. Measurement of the Health Belief
2015 Oct 21] 2 (1) Model (HBM) Hand Hygiene Among Nurses in the
27. Cole, M. Using a motivational paradigm to improve Hospitals.World Applied Sciences Journal . [ Serial on
Handwashing compliance.Nurse Education in the Internet] 2014 [cited 2015 Aug 10]; 31 (5): 811-
Practice . [ Serial on the Internet]. 2006 [cited 2015 818
Des 07]; 6 (3): 156-162 41. Carpenter CJ.A meta-analysis of the effectiveness of
28. De Wandel D, L Maes, Labeau S, Vereecken C, Blot S. health belief model of variables in predicting
behavioral determinants of hand hygiene compliance in behavior. Health Communication. [Serial on the
intensive care units. American Journal of Critical Care. Internet] 2010 [cited 2015 Sept 21]; 25 (8): 661-669
[Serial on the Internet] .2010 [cited 2015 Sept 42. Kurniawan R, Ibrahim K. Sugwignyo P
17]; 19 (3): 230-239 (2011). Predictors of Adherence Nurse In
29. Huis A, van Achterberg T, de Bruin M, Grol1R, Implementation of Standard Precautions in the ER
Schoonhoven L, Hulscher M. A systematic review of and ICU. Magazine Nursing Unpad [serial on the
hand hygiene improvement strategies: a behavioral Internet] 2011 [cited 2015 July 22]; 12 (2)
approach . 43. da Silva, AM, de Carvalho MJ, de Silva CSR, de
30. Ekwere TA, IP Okafor. (2013) . Hand hygiene Almeida CED, Simones CL. Methicillin-resistant
knowledge and practices Among healthcare providers in Staphylococcus aureus: Knowledge and factors related
a tertiary hospital, South West Nigeria. International to the nursing team â € ™ s adherence to preventive
Journal of Infection Control. [serial on the Internet] measures.Revista Latino- Americana de
2013 [cited 2015 Aug 17]; 9 (4) Enfermagem. [serial on the Internet] .2010 [cited
31. Pessoa â € Silva CL, Posfay â € Barbe K, Pfister R, 2015 Oct 24]; 18 (3): 346-351
Touveneau S, Perneger T, Pittet D , ( 2005) .Attitudes 44. SS Lee, Jeong Se Park SJ, Chung MJ, Lee JH, Kang
and perceptions toward hand hygiene Among HJ, Lee JA, Kim YK. Improved Hand Hygiene
healthcare workers caring for Critically Ill Compliance is Associated with the Change of
neonates.Infect Control Hosp Epidemiol 2005, 26 (3): Perception toward Hand Hygiene Among Medical
305-311. Personnel. Infect Chemother [serial on the Internet]
32. Nicol PW, RE Watkins, RJ Donovan, Wynaden D, 2014 [cited 2015 Des 9]; 46 (3): 165-171
Cadwallader H. (2009) The power of vivid experience 45. Orji R, J Vassileva, Mandryk R. Towards an Effective
in hand hygiene compliance. J Hosp Infect. 2009 May ; Health Interventions Design: An Extension of the
72 (1): 36-42. Health Belief Model. Journal of Public Health
33. McLawsML, Maharlouei N, Yousefi F, Askarian Informatics. [Serial on the Internet] 2012 [cited 2015
MD. Among Iranian predicting the hand hygiene of Sept 19]; 4 (3): 4321
health care workers using the theory of planned 46. Lau JT, Griffiths S, Choi KC, HY Tsui. Widespread
behavior. American Journal of Infection public misconception in the early phase of the H1N1
Control . [serial on the Internet] 2012 [cited 21Sept influenza pandemic. Journal of Infection. [Serial on
21] the Internet]. 2009 [cited 2015 Aug 24]; 59 (2): 122-
34. Kortteisto T. Kaila M, Komulainen J, M ä ntyranta 127
T, P. Rissanen Healthcare professionals' intentions to
use clinical guidelines: a survey using the theory of 47. Nazari R, Ahmadi MH , Dadashzade M, Asgari P.
planned behavior. Implementation Science [serial on Study of hand hygiene behavior Among nurses in
the Internet] 2010 [cited 2015 Aug 1 ] Critical Care Units. Iranian Journal of Critical Care
35. DERSCH S . ( 2009) .Hand Hygiene In the Nursing. [Serial on the Internet] 2011 [cited 2015
Undergraduate Nursing Education In Alberta. Thesis Aug 11]; 4 (2;) 95-98
Faculty of Health Sciences University of 48. Husein R, Khakoo R, Hobbs G. Hand hygiene practices
Lethbridge download November 23, 2015 in adult versus pediatric Intensive Care Units at a
36. Kamunge EW. Exploring Knowledge, Attitudes and university hospital before and after
Practices of Registered Nurses Regarding the spread of intervention. Scandinavian Journal of Infectious
nosocomial Infections.Dissertation Seton Hall Diseases [serial on the Internet] .2007 [cited 2015 Des
University.2013 15]; 39 (6-7): 566-570

www.eprajournals.com Volume: 1| Issue: 4| June 2016 85

EPRA International Journal of Research and Development (IJRD) |ISSN:2455-7838 (Online)|SJIF Impact Factor : 3.476

49. Ariyaratne MHJD, Gunasekara TDCP, Kottahachchi 51. Jang J, Wu S, Kirzner D, Moore C, Youssef G, Tong
J , Kudavidanage BP, Fernando SSN. Knowledge, A , McGeer A. (2010). Focus group study of hand
attitudes and practices of hand hygiene Among the final hygiene practice Among healthcare workers in a
year of medical and nursing students at the University teaching hospital in Toronto, Canada. Infection
of Sri Jayewardenepura Sri Lankan. Journal of Control and Hospital Epidemiology . [ Serial on the
Infectious Diseases. [Serial on the Internet] 2012 Internet]. 2010 [cited 2015 Sept 01]; 31 (2): 144-150
[cited 2015 Oct 12]; 3 (1): 15-25 52. O â € ™ Brien, Richards J, Walto KE, MGA Phillips,
50. Salmon S, Tran HL, B ù IDP. Beginning the journey H. Humphreys Survey of teaching / learning of
of hand hygiene compliance monitoring at a 2,100-bed healthcare-associated infections in UK and Irish
tertiary hospital in Vietnam. American Journal of medical schools.Journal of Hospital Infection. [Serial
Infection Control. [Serial on the Internet] 2014 [cited on the Internet] 2009 [cited 2015 Aug 27]; 73 (2):
2015 Nov 10]; 42 (1): 71-73 171-175.
53. Glanz K, Rimer KB , Viswanath K. (2008). Health
Behavior and Health Education; Theory. Research and
Pratice.Edisi 4.Jhon Wiley & Sons , Inc .

www.eprajournals.com Volume: 1| Issue: 4| June 2016 86