World Applied Sciences Journal 31 (5): 811-818, 2014 ISSN 1818-4952 © IDOSI Publications, 2014 DOI: 10.5829/idosi.wasj.2014.31.05.1630
Measurement of the Health Belief Model (HBM) in Nurses Hand Hygiene among the Hospitals
1Mahbube Khatun Ghanbari, 23 Ali Asghar Farazi, Mohsen Shamsi, 45Mahboobeh Khorsandi and Babak Esharti
1Post-graduate student of Health Education and Promotion; Health Faculty; Arak Medical Sciences University; Arak-Iran; 2Infective and Tropical Diseases, Medical Faculty, Arak Medical Sciences University, Arak, Iran 3Health Education and Promotion, Medical Faculty, Arak Medical Sciences University, Arak, Iran 4Epidemiology; Health Faculty; Arak Medical Science's University; Arak-Iran
Abstract: Background: Hand hygiene is the most important factor in prevention and control of hospital infections. Since, the HBM attempts to explain the reasons for the health behaviors practice or not, this research is going to measure the HBM constructs in Nurse's hand hygiene behavior. Methods: This is a cross- sectional and analytical study conducted on 130 nurses in the hospitals affiliated to the Arak Medical Sciences University. Data collection instrument is a questionnaire designed by the researcher which measures the HBM constructs and the nurses' practice concerning the health behavior. Data were analyzed using descriptive analytical tests, Chi Square test, Pearson Correlation Coefficient and Fisher precise test. Results: In this study, the samples' mean age was 35.13±7.12; the findings revealed that nurses had poor practice, concerning their hand hygiene (38.76±9.81). The HBM constructs were at medium level including the perceived susceptibility (58.46±9.09), the perceived severity (57.66±11.011), the perceived threat (58.06±7.37) and the perceived benefits (69.29±8.09), respectively. The action to cues score (48.91±11.51) and self-efficacy score (45.04±8.14) were poor and the perceived barriers score was good (71.60±10.08). There appeared a reverse statistical relation between the perceived benefits and susceptibility (P<0.05). Also, there was a meaningful relation between the service location and self-efficacy (P<0.05). Conclusion: Based on this study's results, most of nurses have no good practice concerning the health behavior, despite of having medium attitude score, good perceived benefits score and high score of the perceived barriers. With regard to the crucial role of the nurses in prevention of hospital infections, the authorities must consider the necessary educations based on the successful educational models and adopt multiple approaches in conducting the hand hygiene behavior.
Key words: Hand hygiene Nurse Hospital infection Health belief model Practice
INTRODUCTION hands as the first step toward prevention [4, 5]. The main purpose of the prevention and control of hospital disease Nosocomial infection or Health care-associated is reduction of the infection risk among the patients, Infection affects seriously the amount of being infected, their accompanying individuals and hospital employees hospitalization duration and the related costs. It is among [6]. Nurses' role is of great importance in controlling and the crucial problems of world public health [1-3]. prevention of hospital infections; because they have the Researchers assume the role of hands as crucial in highest shares in health and care [7]. transferring the hospital infections and suggested it to all A psychological model attempts to explain and healthcare service providers as one of the most basic predict the health behaviors through concentration on sources of infection transferring and suggested washing individuals' attitude and beliefs [8]. but the mere
Corresponding Author: Ali Asghar Farazi, Physician of the Infection Section, Vaie Asr Hospital, Arak Medical Sciences University, Iran. Tel/Fax: +08632241411.
811 World Appl. Sci. J., 31 (5): 811-818, 2014 behavioral factors do not lead to behavior by themselves. prevention of the hospital infections may be efficient Of course, it is probable that appropriate health behavior in this regard and considering that compliance with the to be adopted under the influence of the following hand hygiene may reduce the hospital infections in factors: demography, age, gender, education, personal developing countries [12], the present study has been information about the health behavior etc [9]. This model conducted in order to measure the HBM constructs consists of the main constructs including susceptibility, roles in nurses' hand hygiene. It can be used as a severity and their combination which is called the reference for the future studies and for adopting the perceived threat, the perceived benefits and barriers, preventive policies and educational programs aiming at action to cues and self-efficacy. Based on this model, an promotion of the health behaviors against the hospital individual adopts the preventive health behavior when infections. the following factors affect him or her: MATERIALS AND METHOD Perceived susceptibility: perceiving and believing that an individual faces the disease risk. This study has been cross-sectional and analytical, Perceived severity: perceiving and believing that the conducted on 130 nurses who worked in hospitals problem is serious and the health problem may lead affiliated to Arak Medical Sciences University in 2013. to a serious problem for the individual. The two The samples have been selected using a simple random constructs may totally be introduced under the title method and invited to participate in the study after they of perceived threat were informed about the procedures. Inclusion criterion Perceived barriers: physical, mental or financial was having nursing academic license and at least health barriers etc. encountered by individual for adopting care course diploma. The exclusion criterion was lack of health behavior. tendency to participate in the research. The research Perceived benefits: individual's belief in behavior or environment consisted of urgency sections, women and observing the suggestions with benefits or effects on children sections, operation sections, surgery, CCU, prevention of a disease or reduction of its severity nursing post, dialysis and delivery rooms of three and side effects. hospitals. Data collection instrument was a questionnaire Action to cues: includes health messages, mass designed by the researcher based on the HBM consisted media, dignified people such as physicians, political of questions about demographic information such as age, and religious leaders and mass media which are gender, employment situation, educations, as part one; assumed reliable by individuals. All of them are and some questions about the perceived susceptibility, efficient in conducting the behavior among the target severity, threats, benefits and barriers, self-efficacy, group. action to cues and practice as part two. The part one Self-efficacy: refers to the amount of self-reliance and included 5 questions for each item and practices estimation that a behavior would result in the embarrassing the external action to cues; and the part two predetermined goals; consisted of five questions for the above mentioned items and six questions concerning the external action to And Practice: observing the health behavior which is cues and one open ended question to be answered by the under the influence of the above six constructs [8, 10]. nurses, freely. The questionnaire had a third part consisted of a check list with 10 items about the According to Gelenz's educational planning, the individuals' practices concerning the health behavior most crucial activities are selection of a condition-based adoption. Scoring system was as follows: theory or model, recognizing the problem efficacy and Questions of the HBM (five questions for each item) the aim of model and theory, which is in conformity with were scored based of Likert's five-scale system, from 5 for the aims of the plan [8]. The studies conducted using the completely agree to 1 for completely disagree. The total HBM for promotion of the nurses' attitude, compliance score range was 1-20 and individual's final score was and practice of hand hygiene are very restricted; but calculated based on 100 for each part. The check list score application of the model is highly effective on the was also based on the Likert's scale and based on the planning the health education interventions [10, 11]. number of behaviors conducted on hand health divided Since the HBM is very efficient in preventive by the total number of the mentioned behaviors behaviors and since feeling threat and acting toward multiplied by 100.
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In this research, the questionnaire's validity was Table 1: Demographic characteristics of the nurses participating in the measured using content validity method based on the study WHO Guidelines on Hand Hygiene in health care [13, 14] Personal information Demographic Percent Numbers and using opinions of the experienced professors and Educations Diploma 20.8 27 the experts' panel. The reliability was also measured in a Graduated 77.7 101 50-sample system through calculation of Cronbach's Post-graduate and higher 1.5 2 alpha In data analysis the two parts of HBM constructs Employment status Project 23 30 and nurses practice concerning the hand hygiene Contract 38.5 50 behavior were scored as weak, moderate and good with Official 38.5 50 scores of 50 and lower, 50-70 and over 70, respectively. Marital status Single 30.8 40 The researchers received permission of the Moral Married 69.2 90 Committee of Arak Medical sciences University and Service location Internal-surgery 13.1 17 observed all required regulations and arrangements. CCU 16.2 21 Data analysis was conducted using SPSSv.20, descriptive Urgency 22.3 29 statistics such as relative and absolute frequency tables, mean values and inferential statistics such as chi square Women-delivery 11.5 15 test, Pearson correlation coefficient and fisher precise Dialysis 4.6 6 test. Operation room 10.0 13 Delivery room 14.6 19 RESULTS Nursing 7.7 10 Total 100 130 In this study the samples average age was 35.13±7.12 years and the average of job experience was 11.23±6.73 Table 2: Frequency distribution of hand rub preference with alcoholic via years. Also, 23 participants (17.7%) were male and 107 soap and water among nurses participants (82.3%) were female. Other samples' The choice for hand Rub Numbers Frequency (Percent) demographic characteristics have been shown in Table 1. Solution with alcohol-base 77 59.23 The research findings have been classified in two target Water and soap 16 12.30 groups: the nurses' practice and measurement of the HBM none 37 28.46 constructs in hand hygiene behavior. Concerning the Total 130 100% practice we found that the minimum value (0.56±0.76) was related to hand hygiene during urgency services and Table 3: Criterion deviation mean for external cues to action for nurses' maximum value (2.17±0.79) was related to replacing glove health behavior adoption wearing with hand washing. There was a meaningful External action to cues Mean Criterion deviation relation between the service location and practice P<0.05). Table 2 shows the comparison of the answer to one Section's official 3.35 0.95 question about preference or not preference alcoholic Holding educational workshop 2.70 1.00 solution against water and soap for hand rub. Some facts Control unit for hospital infections 2.15 1.12 about the HBM constructs: 1- The highest score of the Education Supervisor 1.59 1.25 perceived susceptibility with this content: "a nurse may Visual medial (poster, book be infected to hospital infections because of not and magazine) 1.22 0.95 observing hand hygiene principles". However, the score Internet 0.71 0.78 of a question about the patient infection was 2.40 ± 1.01; and the minimum score (2.01± 9.09) was related to The two constructs are combined and form the perceived wearing gloves during clinical practices which suffices to threat with the score of 58.6±7.37 which was at medium reduce hospital infections. 2- In the perceived severity, level. 3- concerning the perceived benefits, the high score the highest score (3.72±0.97) was related to the question (4.03±0.51) was related to practice the hand hygiene of "I feel that the consequences of not observing hand principles which is assumed as useful for the nurses hygiene is a serious for the patient" with the score of 2.69 and the law score (3.50±1.04) was related to the problem ±1.08; and the minimum score (2.49±11.01) was related to for the patients; however the minimum score (3.50±1.03) the question of "I believe that hospital infections may be was related to bad consequences of hospital cured using drugs and they are not so dangerous". infections which are preventable through hand hygiene.
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Table 4: Mean (SD) of the practice and HBM constructs of nurses regarding hand hygiene behavior Variables Mean Criterion deviation Minimum Maximum Perceived susceptibility 58.46 9.09 40.00 80.00 Perceived severity 57.66 11.01 28.00 92.00 Perceived threat 58.06 7.37 40.00 78.00 Perceived benefits 69.29 8.09 48.00 88.00 Perceived barriers 71.60 10.08 40.00 96.00 Self-efficacy 45.04 8.14 28.00 72.00 Action to cues 48.91 11.51 20.83 79.17 practice 38.76 9.81 13.33 63.33
Table 5: Pearson correlation coefficient between practice and HBM constructs Perceived Perceived Perceived Perceived Cues to susceptibility severity benefits barriers Self-efficacy action practice Perceived susceptibility r p1 Perceived severity r 0.067 p 0.452 1 Perceived benefits r 0.075 -0.005 p 0.400 0.957 1 Perceived barriers r -0.173* -0.103 -0.085 p 0.049 0.242 0.338 1 Self-efficacy r -0.043 0.026 -0.080 0.117 p 0.624 0.768 0.366 0.186 1 Action to cues r -0.058 -0.038 0.014 0.091 0.143 p 0.512 0.671 0.876 0.304 0.104 1 practice r 0.20 0.125 -0.080 -0.143 0.266** -0.034 p 0.820 0.156 0.366 0.105 0.002 0.702 1 *correlation is significant at the 0.05 level (2-tailed). **correlation is significant at the 0.01 level (2-tailed).
There appeared a reverse statistical relation between the the score was 2.37±0.86 concerning the patient protection. perceived benefits and service location (P <0.05). 4-In the On the other hand, the least score (1.71±0.70) was related perceived barriers, the question about "wearing gloves to the question of "I can observe the correct hand instead of washing hands" received the highest score hygiene principles even in emergency". Other findings are (4.28±0.97) as the most basic barrier and the lowest score shown in table4. There was a significant statistical relation (2.64±0.94) as the least important barrier was related to between self-efficacy and service location (P<0.05). "lack of access to hygiene facilities and equipment|". 5- Table 4 shows the relation between the model constructs concerning 130 individuals' opinions about the internal and the practice. action clue, the factors ranking was as follows: occupational commitment and conscience with 52 DISCUSSION individuals (40%), fear of being infected with 38 individuals (29.32%), being rewarded with 23 individuals Practice and Compliance with Hand Hygiene: The (17.69%) and finally fear of patients infecting with 77 findings of this study concerning the first goal revealed individuals (13.07%). The findings related to the external that the nurses' practice and compliance with hand action to cues are summarized in table 3. 6- In the hygiene are weak. Bischoff et al. concluded that under the perceived self-efficacy construct the high score usual conditions, compliance with hand washing among (2.98±1.01) was related to the question of "I can apply the the physicians and nurses is unacceptable [15]. Another correct principles of hand hygiene to protect myself" and study in Tyvan revealed that hand hygiene compliance
814 World Appl. Sci. J., 31 (5): 811-818, 2014 among the employees of a nursing institution was conformity with those of Alahe Bakhshian et al. [24]. relatively low [16]. Kang explained that 9.48% of the Angelillo et al studied the subject and evaluated their nurses announced the lack of knowledge and 30% lack attitude as good and positive. They pointed to necessity of time as the main reason of not washing hands. He of creating susceptibility and stimulation among the suggested protective equipment and washing hand in nurses to reduce hospital infections [26]. Moreover, in a addition to nurses' knowledge about the infection cycle study conducted in Greece, the nursing students' and their understanding of the subjects and methods of approach has been reported as positive [27]. The results infection transfer as well as environment quality, in order of the study revealed that nurses did not believe in hand to prevent the infection dispersion [17]. The theoretical hygiene as an important and useful factor in prevention study revealed that the situations in which nurses comply of hospital infections which is not in conformity with with hand hygiene are considerably less that what is Stein et al [25]. findings which considered it as the most expected and their practice was weak [18]. crucial factor, in this regard. Since the hand hygiene Akyol and bilski have announced the reasons for behavior's benefits were more sensible for nurses than nurses' low tendency to observe the hand hygiene as that for patients, it seems necessary to change nurses' crowdedness of sections, habit of doing customary beliefs and attitudes toward the importance of benefits activities, lack of knowledge, ignorance, lack of related to patients as well as enhancement of other equipments to observe hygiene principles and lastly preventive actions' benefits. On the other hand, false management weakness [19, 20]. attitudes barriers as well as other barriers against infection Moreover,Larson et al. has assessed the hand prevention must be so weakened that nurses become hygiene behavior as weak [21] which is in conformity with willing to conducted preventive actins in order to achieve the present study's findings. In another study, it was the two sided benefits (for themselves and patients). announced that just 49% of the nurses comply with the Concerning the perceived barriers, it was found out hygiene practices and just 43% of them observe the hand that nurses face lack of time and this problem as a barrier hygiene disinfection according to WHO orders [22]. makes them wear gloves instead of practicing hand However, Yang and Leo studied 1444 nurses and hygiene. concluded that they are relatively high concerning the According to the theoretical research, nurses often hygiene compliance and washing hand. They have wear gloves when conducting clinical cares [18]. Akule announced the reason as repetition of trainings and high and bilski introduced gloves wearing as a preventive or ranks of the under study hospitals [7]. In the present reducer factor [19, 20]. Nazary stated that nurses' access study, nurses prefer the alcoholic solution to water and to hygiene facilities improve the hand hygiene behavior soap to conduct hand rub which is in conformity with the [18]. However, Masud Hossein claims that: when the theoretical studies [18], because it is in access more healthcare givers were asked about commitment to the easily and consumes less time which is a predictable hand hygiene if they were provided with all hand phenomenon and justifiable with regard to time restriction washing facilities? Physicians (48.7%) and health faced by nurses. However, Forster concluded that 89.5% personnel (66.2%) announced that they would commit; of nurses prefer water and soap rather than alcoholic and others announced that having no enough time and solutions [23]. In our study, most of nurses prefer to wear lack of authorities' supervision as the main reasons for gloves instead of complying with hand hygiene which is their refraining from compliance [28]. A study conducted not confirmed by Stein et al and Alahe Bakhshian et al in Korea has revealed that complexities of the hand [24, 25]. Since the nurses' ignorance is highly rooted in hygiene behavior and intervention of various external having no enough time, it is suggested that the number of factors in this regard made it is very difficult to promote nurses to be increased to standard level. the behavior and depends on the delicate balance of the existing benefits and barriers [29]. In the present study, Measurement of Hbm Constructs in Hand Hygiene: The among the attitude items, the perceived barriers and results of this study for the second goal have revealed susceptibility revealed a significant reverse relation. that the values of the perceived susceptibility and Masud Hosein reported the vulnerability sense creation severity and combination as the perceived threat have among nurses and reduction of costs for patients and been at medium level. However, despite that the nurses in hospitals as well as reduction of the perceived barriers both items felt engaged with the perceived susceptibility for all hospital employees, specifically nurses are and severity, their practice was weak. This finding is requirements for creating and enhancing the health beliefs
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[28]. Concerning the external action to cues, the most medical cares are of great importance in prevention and efficient person has been pointed as the section authority, controlling hospital infections [7]. Therefore, proper because of his or her supervisory role. According to educations and trainings based on the successful studies human resources require continuous training and educational models and evaluation of the health centers stimulation, but the health interventions needs for and nurses' strengths and weak points are proposed. MO appropriate observatory techniques [29]. Amerioun also J et al. reported that HBM-based education has improved believes that nurses are the most efficient factors in the hand hygiene among the nursing students [33]. controlling the hospital infections; because infection This study was faced two main restrictions as control, hygiene, disinfecting the sections and follows: equipments, isolation, bandage of wounds and sterilization are among their cove responsibilities [6]. The The selected sample volume was not representative second top factor is the external action to cues and the of all nurses in Markazi Province and 2- The effective items on adopting the hand hygiene behavior questionnaire-based findings were in self-report form through holding training workshops and educational and they may not be the true interpretation of the seminars. Masud Hosein also pointed the training HBM items and nurses' practice. workshops, visual and printed media as two crucial factors in promotion of the hand hygiene among nurses CONCLUSION [28]. Boyce has also suggested the education as one of the most important infrastructural factors for promotion of According to the results of this study, most of the hand hygiene among the health care employees and nurses have no good practice concerning the hand at all levels [14]. Chandra studied the internal action to hygiene, despite of their positive attitudes and their perceived benefits. cues and proposed that the most crucial factor of hospital Regarding the crucial role of the behavior in infection preventing is individual conscience and prevention of the hospital infections and complex commitment [30] which confirms our study. Since, the fear reasons for not conducting it among the health care ratio of patient being infected to nurse himself or herself employees as well as inevitable role education, the was the least efficient factor, our finding would be authorities must concern the problem more seriously justified; i.e. nurses concern more about their own health and adopt multiple approaches and attempt to promote rather than patients. O'Boyle emphasized on the role of the nurses' knowledge about the hospital infections. internal stimulating factors in creating commitment to According to the modern worlds' standards and hand hygiene principles [31]. Concerning the perceived proportionate to each countries environment and based self-efficacy or nurses' self-confidence levels in hand on the successful educational models. hygiene practice, most hospital sections were weak; this is contrary to the findings of Ghadmgahi [32]. As we Ethical Considerations: Ethical issues (Including mentioned earlier, self-efficacy is prerequisite for behavior plagiarism, Informed Consent, misconduct, data change and the findings of this research reveals a fabrication and/or falsification, double publication and/or significant relation between self-efficacy and practice. Luo submission, redundancy, etc) have been completely Y showed a statistical meaningful relation between self- observed by the authors. efficacy and compliance with standard precautions [17]. The maximum self-efficacy was achieved in nurses' self- ACKNOWLEDGEMENT care and the minimum was related to management of hand hygiene in urgency cases which can be interpreted with This study has been supported by Arak University regard to the results of this study. of Medical Sciences and Health Services. The findings of this research, concerning the HBM Grant number 91-138-3. The authors declare that there constructs measurement in hand hygiene behavior is no conflict of interest. revealed that nurses observe this level of hygiene; because they worry about being infected and concerning REFERENCES their own health, rather than the paints. Nazari has also claimed that nurses concentrate on their own health 1. Pittet, D., 2003. Hand hygiene: improved standards instead of attempting to protect patients against and practice for hospital care. Current Opinion in infections [18]. Considering the High quality and safe Infectious Diseases, 16(4): 327-35.
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