A Structural Model of Hand Hygiene Compliance Factors among Hospital Nurses in Jember, Indonesia

Introduction: Healthcare-associated infections (HAIs) are a global epidemic that has yet to be addressed. The occurrence of nosocomial infections is strongly associated with hand hygiene compliance. With an increase in the latter, the occurrence of nosocomial infections decreases. The percentage of people who wash their hands is still low–between 35 % and 55.3 % in Indonesia and 54.7 % worldwide.
Objective: To evaluate a structural model of hand hygiene compliance determinants among nurses in Indonesian hospitals. Perceived behavioral control, facility factors, and knowledge factors are some of the determinant factors.
Materials and methods: The population in the study was nurses at Jember Regency hospitals in Indonesia. The sampling technique included a total sample of 116 nurses. The inclusion criteria used are nurses who provide direct service to the patient and are willing to respond. In this study, an exclusion clerk refers to a nurse who was on leave or engaged in academic studies at the time of data collection. Data was analyzed descriptively and inferentially using path analysis with the Structural Equation Model (SEM) and the Partial Least Squares (PLS) technique in SmartPLS software.
Results: Hospital facilities become an important predictor of hand hygiene compliance (p < 0.05). The respondents agreed that the facilities available at the hospital were adequate, as demonstrated by high-grade response statements (61 %). Nurses’ awareness has a significant influence on hand hygiene compliance (p < 0.05), good knowledge leading to a positive perception of maintaining hand hygiene behaviours. The respondents’ level of knowledge of hand hygiene ranged from high (40 %) to low (34 %). Perceived behavioral control significantly affects hand hygiene behaviour (p < 0.05). Nurses with strong perceptions and beliefs about hand hygiene are more likely to have better hand hygiene performance. Respondent compliance with hand hygiene was high (60 %). The hospital facilities and nurse knowledge have a significant effect on perceived behavioral control with an explanatory factor of 36.4 %. All factors, namely hospital facilities, nurse knowledge, and perceived behavioral control were able to explain hand hygiene compliance by 45.2 %.
Conclusions: Factors of knowledge and facilities play a crucial role in shaping perceived behavioral control in hand hygiene. These three influencing criteria have positively influenced hand hygiene compliance among nurses in Indonesian hospitals. The structural model provides insights that can be used to design more effective infection prevention strategies, especially in health care.

1. Abalkhail, A., Mahmud, I., Alhumaydhi, F. A., Alslamah, T., Alwashmi, A. S. S., Vinnakota, D., & Kabir, R. (2021). Hand Hygiene Knowledge and Perception among the Healthcare Workers during the COVID-19 Pandemic in Qassim, Saudi Arabia: A Cross-Sectional Survey. Healthcare, 9(12), 1627. Retrieved from https://doi.org/10.3390/healthcare9121627

2. Abd Rahim, M. H., Ibrahim, M. I., Md Noor, S. S., & Fadzil, N. M. (2021). Predictors of self-reported hand hygiene performance among nurses at tertiary care hospitals in east coast Malaysia. International Journal of Environmental Research and Public Health, 18(2), 1–10. Retrieved from https://doi.org/10.3390/ijerph18020409

3. Abdella, N. M., Tefera, M. A., Eredie, A. E., Landers, T. F., Malefia, Y. D., & Alene, K. A. (2014). Hand hygiene compliance and associated factors among health care providers in Gondar University Hospital, Gondar, North West Ethiopia. BMC Public Health, 14(1), 96–103. Retrieved from https://doi.org/10.1186/1471-2458-14-96

4. Abuosi, A. A., Akoriyea, S. K., Ntow-Kummi, G., Akanuwe, J., Abor, P. A., Daniels, A. A., & Alhassan, R. K. (2020). Hand hygiene compliance among healthcare workers in Ghana’s health care institutions: An observational study. Journal of Patient Safety and Risk Management, 25(5). Retrieved from https://doi.org/10.1177/2516043520958579

5. Alhumaid, S., Al Mutair, A., Al Alawi, Z., Alsuliman, M., Ahmed, G. Y., Rabaan, A. A., … Al-Omari, A. (2021). Knowledge of infection prevention and control among healthcare workers and factors influencing compliance: a systematic review. Antimicrobial Resistance and Infection Control, 10(1). Retrieved from https://doi.org/10.1186/s13756-021-00957-0

6. Asadollahi, M., Arshadi Bostanabad, M., Jebraili, M., Mahallei, M., Seyyed Rasooli, A., & Abdolalipour, M. (2015). Nurses’ knowledge regarding hand hygiene and its individual and organizational predictors. Journal of Caring Sciences, 4(1). Retrieved from https://doi.org/10.5681/jcs.2015.005

7. Atif, S., Lorcy, A., & Dubé, E. (2019). Healthcare workers’ attitudes toward hand hygiene practices: Results of a multicentre qualitative study in Quebec. Canadian Journal of Infection Control, (6), 41–48. Retrieved from https://doi.org/10.36584/CJIC.2019.004

8. Caesarino, R. I., Wahjono, H., & Lestari, E. S. (2019). Tingkat Kepatuhan Perawat Rumah Sakit X Di Semarang Terhadap Pelaksanaan Cuci Tangan. Diponegoro Medical Journal (Jurnal Kedokteran Diponegoro), 8(2), 852–859.

9. de Kraker, M. E. A., Tartari, E., Tomczyk, S., Twyman, A., Francioli, L. C., Cassini, A., … Pittet, D. (2022). Implementation of hand hygiene in health-care facilities: results from the WHO Hand Hygiene Self-Assessment Framework global survey 2019. The Lancet Infectious Diseases, 22(6), 835–844. Retrieved from https://doi.org/10.1016/S1473-3099(21)00618-6

10. Dwipayanti, N. M. U., Lubis, D. S., & Harjana, N. P. A. (2021). Public Perception and Hand Hygiene Behavior During COVID-19 Pandemic in Indonesia. Frontiers in Public Health, 9. Retrieved from https://doi.org/10.3389/fpubh.2021.621800

11. Fhirawati, & Kurniawan, Y. (2023). Hubungan Sikap dan Keterampilan Dengan Kepatuhan Perawat Dalam Hand Hygiene Five Moment Di Rumah Sakit Bhayangkara Balikpapan, 2(1).

12. Haenen, A., de Greeff, S., Voss, A., Liefers, J., Hulscher, M., & Huis, A. (2022). Hand hygiene compliance and its drivers in long-term care facilities; observations and a survey. Antimicrobial Resistance and Infection Control, 11(1). Retrieved from https://doi.org/10.1186/s13756-022-01088-w

13. Harun, M. G. D., Anwar, M. M. U., Sumon, S. A., Mohona, T. M., Hassan, M. Z., Rahman, A., … Styczynski, A. R. (2023). Hand hygiene compliance and associated factors among healthcare workers in selected tertiary-care hospitals in Bangladesh. Journal of Hospital Infection, 139, 220–227. Retrieved from https://doi.org/10.1016/j.jhin.2023.07.012

14. Kiprotich, K., Wang, H., Kaminga, A. C., & Kessi, M. (2021). Observed and self-reported hand hygiene compliance and associated factors among healthcare workers at a county referral hospital in Kenya. Scientific African, 14. Retrieved from https://doi.org/10.1016/j.sciaf.2021.e00984

15. Knudsen, A. R., Hansen, M. B., & Møller, J. K. (2023). Individual hand hygiene improvements and effects on healthcare-associated infections: a long-term follow-up study using an electronic hand hygiene monitoring system. Journal of Hospital Infection, 135, 179–185. Retrieved from https://doi.org/10.1016/j.jhin.2023.02.017

16. Korniewicz, D. M., & El-Masri, M. (2010). Exploring the factors associated with hand hygiene compliance of nurses during routine clinical practice. Applied Nursing Research, 23(2), 86–90. Retrieved from https://doi.org/10.1016/j.apnr.2008.06.002

17. Lescure, D., Haenen, A., de Greeff, S., Voss, A., Huis, A., & Hulscher, M. (2021). Exploring determinants of hand hygiene compliance in LTCFs: a qualitative study using Flottorps’ integrated checklist of determinants of practice. Antimicrobial Resistance and Infection Control, 10(1). Retrieved from https://doi.org/10.1186/s13756-021-00882-2

18. Marquer, C., Guindo, O., Mahamadou, I., Job, E., Rattigan, S. M., Langendorf, C., … Isanaka, S. (2021a). An exploratory qualitative study of caregivers’ knowledge, perceptions and practices related to hospital hygiene in rural Niger. Infection Prevention in Practice, 3(3), 100160. Retrieved from https://doi.org/10.1016/j.infpip.2021.100160

19. Marquer, C., Guindo, O., Mahamadou, I., Job, E., Rattigan, S. M., Langendorf, C., … Isanaka, S. (2021b). An exploratory qualitative study of caregivers’ knowledge, perceptions and practices related to hospital hygiene in rural Niger. Infection Prevention in Practice, 3(3), 100–160. Retrieved from https://doi.org/10.1016/j.infpip.2021.100160

20. Maryana, M., & Anggraini, R. B. (2021). Nurses’ Individual Characteristics Associated with Five Moments Handwashing Compliance. Jurnal Ners, 16(2), 135–141. Retrieved from https://doi.org/10.20473/jn.v16i2.22399

21. Maskerine, C., & Loeb, M. (2006a). Improving adherence to hand hygiene among health care workers. Journal of Continuing Education in the Health Professions, 26(3), 244–251. Retrieved from https://doi.org/10.1002/chp.77

22. Maskerine, C., & Loeb, M. (2006b). Improving adherence to hand hygiene among health care workers. Journal of Continuing Education in the Health Professions, 26(3), 244–251. Retrieved from https://doi.org/10.1002/chp.77

23. Nur Anna. (2019). Pengaruh Persepsi Siswa Atas Fasilitas Belajar Terhadap Efektivitas Pembelajaran Pada Mata Pembelajaran Akuntansi Kelas XI Akuntansi SMK Negeri 1 Pangkep. Pendidikan Akuntansi Fakultas Ekonomi Universitas Negeri Makassar.

24. Potter, P. A., Perry, A. G., Patricia A Stockert, R. B. M. P., & Hall, A. (2019). Fundamentals of Nursing Vol 1- 9th Indonesian Edition: Praktik Keperawatan; Unit II Caring Sepanjang Rentang Kehidupan; Unit III Berpikir Kritis dalam Praktik Keperawatan; Unit IV Standar Profesional dalam Praktik Keperawatan; Unit V Dasar untuk Praktik K. (D. Deswani, E. Novieastari, K. Ibrahim, & S. Ramdaniati,Eds.). Singapore: Elsevier Health Sciences.

25. Prasad, A., Ng Chok, H., & Wilkes, L. (2017). Hand hygiene practices amongst patients. International Journal of Infection Control, 13(2), 1–8. Retrieved from https://doi.org/10.3396/IJIC.v13i2.009.17

26. Safir, N., Mursal, Akbar, Y., & Abrar. (2021). Tingkat Pengetahuan Perawat tentang Lima Momen Kebersihan Tangan. Jurnal Lentera, 4(2), 1–7.

27. Sands, M., & Aunger, R. (2020). Determinants of hand hygiene compliance among nurses in US hospitals: A formative research study. PLoS ONE, 15(4). Retrieved from https://doi.org/10.1371/journal.pone.0230573

28. Sin, C. S., & Rochelle, T. L. (2022). Using the theory of planned behaviour to explain hand hygiene among nurses in Hong Kong during COVID-19. Journal of Hospital Infection, 123, 119–125. Retrieved from https://doi.org/10.1016/j.jhin.2022.01.018

29. Soleh. (2020). Monograf: Kesadaran Nasabah, Pengetahuan Produk dan Religiositas dengan Persepsi Bank Syari’ah. (J. Noor,Ed.) (1st ed.). Banten: La Tansa Mashiro Publisher.

30. Stackelroth, J., Sinnott, M., & Shaban, R. Z. (2015). Hesitation and error: Does product placement in an emergency department influence hand hygiene performance? American Journal of Infection Control, 43(9), 913–916. Retrieved from https://doi.org/10.1016/j.ajic.2015.04.199

31. Sundal, J. S., Aune, A. G., Storvig, E., Aasland, J. K., Fjeldsæter, K. L., & Torjuul, K. (2017). The hand hygiene compliance of student nurses during clinical placements. Journal of Clinical Nursing, 26(23–24). Retrieved from https://doi.org/10.1111/jocn.13811

32. Syukur, S. B., Syamsuddin, F., & Djumuli, D. (2023). Faktor-Faktor yang Mempengaruhi Perilaku Hand Hygiene Perawat di Puskesmas Telaga. Jurnal Rumpun Ilmu Kesehatan, 3(2), 95–108. Retrieved from https://doi.org/10.55606/jrik.v3i2.1842

33. Thakker, S. V., & Jadhav, R. P. (2015). Knowledge of hand hygiene in undergraduate medical, dental, and nursing students: A cross-sectional survey. Journal of Family Medicine and Primary Care, 4(4), 582–586. Retrieved from https://doi.org/10.4103/2249-4863.174298

34. Umar, H., Geremew, A., Worku Kassie, T., Dirirsa, G., Bayu, K., Mengistu, D. A., … Mulat, S. (2022). Hand hygiene compliance and associated factor among nurses working in public hospitals of Hararghe zones, Oromia region, eastern Ethiopia. Frontiers in Public Health, 10. Retrieved from https://doi.org/10.3389/fpubh.2022.1032167

35. Utami, N. N. A. (2020). Pengaruh Tingkat Pengetahuan terhadap Persepsi Masyarakat Mengenai Relokasi SMP Negeri 3 Surakarta.

36. Vaughan-Malloy, A. M., Chan Yuen, J., & Sandora, T. J. (2023). Using a human factors framework to assess clinician perceptions of and barriers to high reliability in hand hygiene. American Journal of Infection Control, 51(5), 514–519. Retrieved from https://doi.org/10.1016/j.ajic.2023.01.013

37. Wahab, M. T. (2023). Nudges as a suitable and effective intervention to improve hand hygiene compliance among healthcare workers in patient care settings: a narrative review. International Journal of Infection Control. Retrieved from https://doi.org/10.3396/ijic.v19.22762

38. Wardhani, V. (2017). Manajemen Keselamatan Pasien di Rumah Sakit (1st ed.). Malang: Universitas Brawijaya Press.

39. World Health Organisation. (2022). Global report on infection prevention and control.

40. World Health Organization. (2002). SEA-HLM-343 Distribution: General Guidelines on Prevention and Control of Hospital Associated Infections, (January).

41. World Health Organization (WHO). (2022). Hand hygiene. Retrieved 28 October 2022, from https://www.who.int/teams/integrated-health-services/infection-prevention-control/hand-hygiene#:~:text=The WHO Guidelines on hand,-to-use practical tools.

42. Yadav, S. K., & Giri, A. (2019). Assessment of Hand Hygiene Knowledge among Residents and Nursing staffs at Nobel Medical College Teaching Hospital, Biratnagar. Journal of Nepal Paediatric Society, 38(2), 69–73. Retrieved from https://doi.org/10.3126/jnps.v38i2.20547

43. Zhang, C. Q., Fang, R., Zhang, R., Hagger, M. S., & Hamilton, K. (2020). Predicting hand washing and sleep hygiene behaviors among college students: Test of an integrated social-cognition model. International Journal of Environmental Research and Public Health, 17(4). Retrieved from https://doi.org/10.3390/ijerph17041209