Barriers to Hand Washing with Soap Among Health Care Workers

Barriersto Hand Washing with Soap Among Health Care Workers

Tableof Contents

1.0 Introduction 3

1.1Thesis statement 3

1.2 Problem Statement 3

1.3 Purpose/Significance 4

2.0 Feasibility of the study 4

4.0 Literature Review 5

5.0 Behavior Change Framework 8

5.1 FOAM Behaviour Change Framework 8

6.0 Research Hypothesis 9

6.1 Research questions 9

7.0 Methodology 9

7.1 Research Design 9

7.2 Research sample 9

7.3 Data collection 10

7.3.1 Interviews 10

7.3.2 Questionnaires 10

7.3.3 Participative observation 10

7.4 Data Analysis and Presentation 11

8.0 The Proposed Study Budget 11

8.1 Time Table for the proposed study 12

9.0 Appendices 13

10.0 References 15


Withthe increase in Health Care-associated Infections (HCAIs), handhygiene is currently considered as the most significant strategy toreduce such infections (Marra, Guastelli and Pereira et al., 2010).Many healthcare providers and nursing practitioners are going back toexamining simple practices such as hand washing in an effort toreduce HCAIs. Various studies (Manning, 2010 Galiani andOrsola-Vidal, 2010 Sax, et al., 2007) have supported the argumentthat hand hygiene, if properly implemented and reinforced cansignificantly reduce the risks of cross-transmission among healthcaregivers and facilities. By ensuring that a care giver`s hands are freefrom germs, the risk for infection is low. However, despite handwashing being a simple task, several studies have revealed that manycaregivers are not compliant with the practice.

Accordingto Galiani and Orsola-Vidal (2010), hands are a common platform fortransmitting infectious diseases especially for people working orvisiting healthcare settings. Within most healthcare settings, peopleare at a higher risk of frequently coming into contact with surfacescontaminated with microbes, hence increasing the probability ofcross-contamination (Storr and Clayton-Kent, 2004). Past studies suchas the one carried out by Schmidt, Aunger and Coombes, et al., (2009)have researched on the various barriers hindering hand washing as aneffective strategy to prevent HCAIs and identified lack of exposureand lack of infrastructure as some of the challenges.

1.1Thesisstatement:Hand washing is an important practice which when implementedsignificantly reduce HCAIs.

1.2Problem Statement

Handhygiene compliance has been difficult to achieve especially amonghealthcare providers as a result of the working environment, tightwork schedules, tedious processes and task requirements. VariousStudies in this field have revealed evidence that supports hands as acommon mode of transmitting diseases in health care settings.According to Chagpar, Banez and Lopez, et al., (2010), despite peoplebeing aware of the importance of hand hygiene, they tend to overlookthe practice and end up contracting various diseases spread throughdirect contact. World Health Organization (WHO) has establishedvarious guidelines in relation to hand hygiene, but the implementedguidelines have always faced numerous challenges among caregivers andhealth care workers. The consistency of this problem has necessitatedthe current study to find out the barriers to hand hygiene and comeup with effective strategies to overcome these obstacles to reduceinfections.


Thecurrent study is highly significant since it will identify thevarious barriers to hand hygiene and come up with effectivestrategies to enhance compliance with the simple task. According toGaliani and Orsola-Vidal, (2010), studies to understand factorsinfluencing hand washing behavior are highly significant in improvingcompliance that has remained extremely low for decades. The resultsof this study aims at encouraging hand washing not only in healthcare setting but also in other places such as schools and homes,which in turn will drastically reducing infections transmittedthrough hand contact. The health center picked for this study willdirectly benefit from reduced infections and improved health not onlyfor the caregivers but also the patients and other people visitingthe centers.

2.0Feasibility of the study

Thecurrent study is feasible based on the fact that there are previoussimilar studies that were successfully carried out. The study alsorequires few materials and takes a short period of time making iteconomical. The health center chosen is within reach and hence fewexpenses in terms of transportation will be incurred. The study willutilize simple methods such as observation and questionnaires incollecting data making the study more feasible.

4.0Literature Review

Studiesto find out barriers to hand washing for enhanced patient safety andreduced infections started back in the 18th century. Manning (2010)reviewed one of the earliest studies that provided evidence that handhygiene can significantly reduce puerperal fever and maternalmortality. The study carried out back in the 1840s involved twoclinics, one of them attended by medical students and the other bymidwives. The clinic attended by medical students had a mortalityrate of 10% as a result of puerperal fever and the other attended bymidwives had a death rate of 2%. After the demise of a medicaltrainee in 1887 who was cut by an infected blade with puerperalfever, scholars concluded that contagion through hands was the basicreason for increased mortality rate in that facility. Following thisdeath, the implementation of a hand washing policy drasticallyreduced mortality as a result of puerperal fever by ten folds.However, there were challenges with the implementation of the policyespecially in the clinic attended my midwives. Some of the identifiedchallenges were the lack of interest, lack of awareness about theimportance of hand washing and overlooking hand washing due to verytight schedules. The study was successful since it came up with apractical solution to infections during an era in which lacked aclear elaboration of the germ theory of disease, (Manning, 2010).

Inthe 1950s, another successful study was carried out to determine themode of transmitting S. aureus in nurseries. Mortimer and otherssuccessfully identified direct contact as the primary way ofcommunicating S. aureus causing the deaths of many babies innurseries (1966). They identified that hand washing was an effectivestrategy for reducing the rate at which children acquired thisdiseases. However, barriers to hand washing were identifiedespecially among mothers and caregivers in the nurseries. Many of themothers did not have the knowledge on the importance of hand washingand so many of them ignored the practice before handling theirbabies. The caregivers despite knowing the importance some of thetime ignored the practice.

HealthCareworkers (HCWs) consider hand washing a simple practice that canprevent the spread of various infections in healthcare settings andhomes (Galiani and Orsola-Vidal, 2010 Luby and Halder, 2008).Furthermore, they view hand hygiene as an effective strategy ofprotecting themselves from the high risks of infection exposure(Manning, 2010). However, the study carried out by Chagpar, Banez andLopez, et al., (2010) indicate that compliance with hand washingpractices has been difficult to achieve. World Health Organization(WHO) has implemented various strategies to improve hand hygiene suchas carrying out hand washing campaigns implementing easier processesof hand washing such as alcohol-based hand sanitizers among othersbut still compliance with this practice remain small.

Tofind out factors which can be used in motivating people andcaregivers in embracing hand hygiene, O`Boyle et al (2001b) utilizedthe theory of Planned Behavior to come up with internal factors thatmotivate hand hygiene. The researchers looked at factors such as:certainty in the effectiveness of hand hygiene in reducing HospitalAcquired Infections (HAIs), social pressure surrounding the practiceof hand washing and the supposed simplicity of adding hand washinginto the tight schedules of HCWs. The study found out that the threefactors significantly influenced a person`s willingness to complywith hand washing practice. The researchers concluded that handwashing is more of a behavioral activity, and hence strategies toincrease compliance should focus more on changing behavior thanfocusing so much on implementing policies (Galiani and Orsola-Vidal,2010 Manning, 2010). O`Boyle and others concluded by recommendingfurther studies to investigate a fourth factor (intensity ofactivity) that could have some influence on hand washing compliance.

Chagpar,Banez and Lopez et al., (2010), support O`Boyle`s argument byextending their model to find out external factors that influencehand hygiene. The researchers hypothesized factors such as the designof environments and the simplicity processes as some of the externalfactors which could have a considerable influence on the perceivedease of introducing hand hygiene into the already tight workflows ofcaregivers and HCWs. Marra, Guastelli and Pereira, et al., (2010),identified another type of barrier that they referred to as processbarrier discouraging people from hand washing activity. Processbarriers are the complications in relation to the routines put inplace by various healthcare institutions that discourage hand hygienepractices. For instance, while, in a patient`s room, an HCW may checkthe patient`s vital signs, monitor urine output and provide hands oncare to the patient. According to five moments of hand hygiene, handwashing should occur before entering the patient`s environment, afterthe risk of exposure to body fluids and after getting out of thepatient`s environment (Sax et al., 2007).

Apolicy advocating HCWs to wear gloves was found to” tiresome” forworkers to wash hands for all the recommended moments, as gloves haveto be removed and put in a waste bin, hands washed and gloves wornagain before care could be continued (Marra, Guastelli and Pereira,et al., 2010). Many HCWs were unable to comply with the suggestedguidelines due to the additional time needed to complete the processof handwashing. Due to such barriers, strategies such as handsanitizers were recommended to ease the process to improvecompliance. However, Manning points out that, implementations tochange behavior and motivate people to embrace hand hygiene is toenhance compliance with hand washing practices (2010).

5.0Behavior Change Framework

Thestudy will utilize a framework of four parameters to identify thefactors that influence hand washing behavior: Focus, Opportunity,Ability and Motivation (FOAM). Figure 1 below elaborates theparameters. Focus refers to the fact that any strategy to change handwashing behavior should clearly point out the exact actions thatshould be undertaken and by whom. Opportunity refers to theprobability that the behavior occurs and includes the resourcesneeded to carry out the work. Ability involves the individual andappropriate factors that make the act of a given action feasible.Motivation explains the psycho-social factors associated with thedegree to which executing the preferred actions is in the person`sbest interest (Galiani &amp Orsola-Vidal, 2010). Infection controlinterventions in the past have made use of this framework and itoriginates from the work carried out by Rothschild. The framework isappropriate for the current study as it takes into considerationdifferent aspects that will help gain knowledge on hand washingbehavior.

5.1FOAM Behavior Change Framework





Target Behavior

Target population


Product attributes

Social norms


Social Support

Beliefs and attitudes

Outcome expectations




6.0Research Hypothesis

Ifbarriers such as environmental obstacles, attitudinal/beliefbarriers, process barriers and lack of sensitization are minimized,hand washing will improve among health care workers in hospitalsetting.

6.1Research questions

1.What are the barriers to hand washing behavior among health carepersonnel in health care environment?

2.Which approaches should be employed to overcome the highlightedbarriers to improve hand washing behavior?

7.0Methodology7.1Research Design

Acase study covering The Wilkes-Barre General Hospital MedicalSurgical and Critical Care Units will be conducted. The case study ispreferred since it will enable the collection of in-depth data on thebehavior of the participants within the study resulting in valid andviable conclusions. The results obtained from the case study will beextrapolated to cover all healthcare settings all over the world.

7.2Research sample

Asstated in the research design, the participants of this study will behealth care workers recruited from Wilkes-Barre Area Hospital. Fromthis health center, forty willing workers twenty of which should befemales and the other twenty men will be recruited for the study. Therecruitment will utilize following selection criteria in selectingthe participants:

• Theparticipant should have at least two-year experience in a health caresetting

• Theparticipant should have some knowledge about the importance of handhygiene in infection control

• Dueto the study`s actions, the study will not be open to people withdisability hindering limbs (hands) movement.

7.3Data collection

Thewhole study will take within a period of two and half to threemonths. Data collection will consume one and half to two months ofthe study`s time. Three main methods of data collection will be usedinterviews, questionnaires, and participant observation.


Eachparticipant will undergo a short interview. The interview will last10 to 15 minutes. The interview will comprise questions to reveal theattitudes towards hand washing. The interview will also aim to getfirst-hand data on the beliefs surrounding hand washing andstrategies which health care workers consider to be effective inenhancing compliance.


Questionnairesstructured with both closed and open-ended questions will be issuedto each of the participants. The questions will mainly focus onperceived barriers to hand washing and strategies which whenimplemented can enhance compliance to reduce infections. Thequestionnaires will be issued after the interviews. This method ofdata collection aims at giving the health care workers more freedomto expose their beliefs and personal attitudes which hinder them fromcomplying to hand hygiene practices.

7.3.3Participative observation

Thismethod of data collection aims at collecting unbiased data andinformation on behavioral factors influencing hand washing practice.Two people will be sourced and compensated accordingly to interactwith the participants and collect data on what they observe as theyparticipate together with the study sample.

7.4Data Analysis and Presentation

Thematicanalysis will be used in analyzing the collected data. The datacollected will be examined and patterns (themes) recorded. Theresults of every research question will be examined to draw patternsthat will be used in describing phenomenon. The identified themeswill then make the groupings for analysis. Six steps will be followedto allocate codes, which will be used for identifying themes. Thefirst step is becoming accustomed with the collected data so as toproduce preliminary codes, which makes the second step. The next stepwill be exploring for themes emerging from the codes and thenevaluating the identified themes. The fifth step is classifying andnaming themes and lastly generating the final report. The themesresulting from the data analysis will then be presented throughcharts, diagrams and graphs to make its interpretation simple andclear.

8.0 TheProposed Study Budget

of Expenses




Costfor hand washing materials: $250.65

Transportationof the materials: $158.70

Salaryfor the two field officers: $240.00

HealthCenters License fee for carrying out the study: $278.78

Detaileddescription of the expenses

• Travel:Regional Express Train trip to and fro Hurtsboro: $ 20.02, 10 trips =$ 200.20

• Accommodations:Hurtsboro Youth Hostels in Hurtsboro: approx $30.00/night 6 nights =$300.00

• Food:$ 28.04/day, 14 days total = $ 448.56

• Costfor hand washing materials: A packet of hand washing soap for each ofthe two health centers: $15.32/packet, 2 packets =$ 30.64. 3 handalcohol-based sanitizers for each of the two health centers:$12.07/sanitizer, 6 sanitizers = $72.42. 20 Packets of hand tissuesfor each hospital: $ 3.20/packets, 40 packets = $ 120.80.

• Transportationcost for the hand washing materials: Regional Express Train trip toHurtsboro $ 158.70

• Salaryfor two field officers: $60.00 per day per person for two days = $240.00

• Licensefee to carry out the study in the two health facilities: HurtsboroMedical Centre: $198.40, Bullock Health Department being a publicfacility was a bit cheaper: $ 80.38

TotalExpenditure = $ 1876.89

8.1Time Table for the proposed study



Proposed Start&nbspdate&nbsp

Proposed End&nbspdate



14th September 2015

22nd September 2015



24th September 2015

25th September 2015



28th September 2015

1st October 2015

Collection&nbspof data


3rd October 2015

20th November 2015



23rd November 2015

8th December 2015



Appendix1: Interview for Health Care Workers

1.From your perspective, what is the importance of hand washing?

2.What are some of the social factors that influence your hand washingbehavior?

3.From your working environment, do you find hand washing a tedioustask to perform? If yes give reasons

4.Do you perceive hand-washing process a workload to your current tightwork schedule? If yes elaborate

5.What changes should be implemented to make hand washing processeasier to perform?

6.What are some of the strategies that you think can be effective inenhancing compliance to hand washing?

Appendix2: Questionnaire for Health Care Workers

1.In order of importance give reasons why hand washing is a crucialpractice in health care settings




2.Do you hold any beliefs that hinder you from observing hand hygiene?If yes name them




3.What are some of the barriers to hand hygiene practices?





4.What are some of the strategies which should be implemented toenhance hand washing behavior?






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