Journal of Hospital Infection 76 (2010) 256e260

Available online at www.sciencedirect.com

Journal of Hospital Infection

journal homepage: www.elsevierhealth.com/journals/jhin

Hand hygiene in rural Indonesian healthcare workers: barriers beyond sinks,

hand rubs and in-service training
B. Marjadi a, *, M.-L. McLaws b
a
Public Health Department, Faculty of Medicine, Universitas Wijaya Kusuma Surabaya, Surabaya, Indonesia
b
School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia

a r t i c l e i n f o s u m m a r y

Article history: Few attempts to increase healthcare workers hand hygiene compliance have included an
Received 18 December 2009
in-depth analysis of the social and behavioural context in which hand hygiene is not under-
Accepted 23 June 2010
Available online 17 September 2010 taken. We used a mixed method approach to explore hand hygiene barriers in rural Indonesian
healthcare facilities to develop a resource-appropriate adoption of international guidelines.
Keywords: Two hospitals and eight clinics (private and public) in a rural Indonesian district were studied
Hand hygiene for three months each. Hand hygiene compliance was covertly observed for two shifts each in
Indonesia three adult wards at two hospitals. Qualitative data were collected from direct observation,
Low resource setting
focus group discussions and semistructured in-depth and informal interviews within health-
care facilities and the community. Major barriers to compliance included longstanding water
scarcity, tolerance of dirtiness by the community and the healthcare organisational culture.
Hand hygiene compliance was poor (20%; 57/281; 95% CI: 16e25%) and was more likely to be
undertaken after patient contact (34% after-patient contact vs 5% before-patient contact,
P < 0.001) and inherent opportunities associated with contacts perceived to be dirty (49%
inherent vs 11% elective opportunities associated with clean contacts, P < 0.001). Clinicians
frequently touched patients without hand hygiene, and some clinicians avoided touching
patients altogether. The provision of clean soap and water and in-service training will not
overcome strong social and behavioural barriers unless interventions focus on long term
community education and managerial commitment to the provision of supportive working
conditions.
2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.

Introduction
The literature abounds with reports of increased healthcare
workers (HCWs) hand hygiene compliance following improve-
ment of physical resources, the introduction of alcohol-based hand
rub (AHR), in-service education and attention to organisational
infrastructure.1e7 Bundled hand hygiene interventions have been
advocated because hand hygiene is a complex behaviour.6e13 Hand
hygiene compliance rates after such intervention rarely reach
>60%, the average being 40e50%.8,10,11,14e16 Interventions based in
medium to high resource settings, however, may not be easily
* Corresponding author. Address: Faculty of Medicine, Universitas Wijaya
Kusuma Surabaya, Jalan Dukuh Kupang XXV no. 54, Surabaya 60225, Indonesia.
Tel.: 62 8123 1010 94; fax: 62 31 5686 531.
E-mail address: b.marjadi@gmail.com (B. Marjadi).
applied in remote and low resource settings. This paper reports
results from a mixed methods study into the compliance and
barriers of hand hygiene in a rural Indonesian district.
Methods
This study was conducted in 10 healthcare facilities (one public
hospital, one private hospital, ve public clinics and three private
clinics) in one low-resourced rural Indonesian district. The district
has a population of about 300 000 who in the main are farm
labourers with junior high school education. The majority of
nursing and medical staff were local to the area with a small
proportion from more developed islands. A mixed method
approach was used that allows for a deeper exploration of barriers
and facilitators of hand hygiene compliance using qualitative
observations and interviews followed by quantitative measures of

0195-6701/$ e see front matter 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jhin.2010.06.021
 B. Marjadi, M.-L. McLaws / Journal of Hospital Infection 76 (2010) 256e260 257

compliance associated with practices identied from the qualita- hands visibly dirty or feeling sticky) and elective (i.e. associated
tive research. The study was approved by the University of New with clean contact with patients).11 No sample size calculations
South Wales Human Research Ethics Committee, the District Health were made a priori to undertaking the eldwork, yet all readily
Ofce and the hospital directors. observable hand hygiene opportunities were observed across six
observation periods. Epi Info version 6.04d was used to calculate
Step 1. Qualitative data the proportion of hand hygiene compliance, 95% condence
interval (95% CI) around proportions and P-values. Alpha was set at
Qualitative data for practice, barriers and facilitators of hand the 5% level.
hygiene were collected using direct observation, focus group The Results section will present hand hygiene compliance rates
discussion and in-depth semistructured and informal individual rst to establish for the readers the usual compliance level followed
interviews. A two-stage grounded theory sampling technique by the qualitative ndings. In accordance with qualitative reporting
(referred to as initial and theoretical sampling) was used to select style, themes identied from observational and interview data that
study participants.17 Stage 1, the initial sampling, involved inviting were interpreted within the Results section will be further inter-
stakeholders from each facility to participate in the study, and all preted within the Discussion section to focus on the complexity,
staff members who consented were enrolled. In accordance with origins and implications of hand hygiene barriers.
grounded theory the purpose of the initial sample was to identify
the range of barriers to and facilitators of hand hygiene. Theoretical Results
sampling was used to enrol additional participants and test the
emerging themes about barriers, beliefs and practices identied Hand hygiene compliance rates
from the data collected during the initial group sampled. In all, 318
participants enrolled: 19 doctors, 169 nursing staff, nine allied Seventeen nurses and no doctors were observed during a total
health staff, seven non-clinical staff, 13 managers, 96 community of 48 h of observation. At the public hospital, each observed shift
members who were visiting family and friends in the participating had only one nurse on clinical duty and this was the usual situation
hospitals and clinics, and ve teachers from the local nursing due to limited human resources. Hand hygiene was performed
(vocational senior) high school. between 5% and 30% across the six observed shifts at the public and
All qualitative data were collected by one Indonesian medical private wards (Table I).
microbiologist (B.M.). Member checking, analogous to validity In the public hospitals hand hygiene was performed in one-fth
checking of quantitative data, was undertaken at the end of the data (20%, 57/261; 95% CI: 16%e25%) of all opportunities and did not differ
collection period to establish the trustworthiness of the data.18 The signicantly across two observed shifts. Compliance in the private
qualitative data were analysed using the grounded theory approach hospital was similar across the observed shifts at the female ward
where the data were continuously examined for emerging themes (22% and 25%; not signicant) and the male ward (16% and 30%; were
and their interrelationship to nally develop a thematic framework not signicant). The difference between hand hygiene opportunities
of these themes to explain the complexity of barriers to hand per shift at the two hospitals was mainly due to the difference in
hygiene.19 nursing practice, such as the frequency of nurses visiting patients and
making direct contacts. Hand hygiene was performed on average <4
Step 2. Quantitative data times per 8 h shift in the private hospital and once per 8 h shift in the
public hospital (difference not statistically signicant).
In a separate study a week after the qualitative study, quanti- HCWs hand-washed signicantly more often across all six
tative data were collected for hand hygiene compliance to illustrate observed shifts for after-patient contact compared with before-
usual compliance practice. Data were collected only from hospitals patient contact opportunities (34% and 5% respectively; P < 0.001;
because the layout of the clinics did not allow for hand hygiene data not shown). All inherent hand hygiene actions were under-
opportunities and any subsequent attempted compliance to be taken four times more often (49%; 95% CI: 37%e60%) than elective
adequately observed. Three wards in the two hospitals (one mixed- hand hygiene (11%; 95% CI: 7%e16%; P < 0.001) (Table II).
sex medical ward in the public hospital and two sex-specic wards
of mixed diagnosis in the private hospital) were selected Qualitative results: barriers to hand hygiene
purposefully because a pilot study (not shown) identied the
clinical loads and patient characteristics to be similar in these Major barriers to hand hygiene identied from the natural
wards. Direct observation was conducted by one observer (B.M.) environment, the resultant community norms and the HCWs
over six separate observation periods for each of the three study working conditions were intertwined, as detailed below.
wards: each for an entire 8 h morning shift on a weekday and an
entire 8 h afternoon shift on a weekend (totalling 48 h of obser- Table I
Observed hand hygiene compliance by healthcare facility
vation). As the entire shift was observed, all clinicians on duty
during the shift were observed for all compliance opportunities. To Location No. of HCWs Hand hygiene
minimise the Hawthorne effect, hand hygiene compliance data (type of hospital, observed
Opportunities Practised Compliance 95% CI
ward) on duty
were collected covertly one week after qualitative interviews about
a
hand hygiene had ceased. By this stage the HCWs had become Public, medical 1 20 1 5% 0.3%e22%
1 20 1 5% 0.2%e22%
accustomed to seeing the observer make notes of unrelated
observations and interviews on the wards over the previous 10 Private, maleb 4 69 11 16% 9%e26%
4 63 19 30% 20%e42%
weeks. The hand hygiene audit tool was based on Association for
Professionals in Infection Control and Epidemiology (APIC) guide- Private, femalec 3 44 11 25% 14%e40%
lines and had been developed and tested in a previous study.2 Hand 4 65 14 22% 13%e33%
hygiene was dened as any attempted practice of hand cleansing Total 17 281 57 20% 16%e25%
with soap and water or alcohol-based hand rub.10 Hand hygiene HCW, healthcare worker; CI, condence interval.
opportunities were classied as before- and after-patient contact a,b,c
No signicant difference in hand hygiene compliance between the two observed
and as inherent (i.e. associated with contacts that would leave shifts in each ward.
258 B. Marjadi, M.-L. McLaws / Journal of Hospital Infection 76 (2010) 256e260
Table II
Inherenta and electiveb hand hygiene compliance rates
Hospital type Compliance rate (n practised/N opportunities) [95% CI]
Inherent hand hygienea Elective hand hygieneb
Public 40% (2/5) 0% (0/35)
[7%e82%] [0%e8%]
Private 49% (32/65) 13% (23/176)
[37%e61%] [9%e19%]
Total 49% (34/70) 11% (23/211)
[37%e60%] [7%e16%]
CI, condence interval.
a
Hand hygiene opportunities associated with opportunities that leave hands
looking dirty or feeling sticky.11
b
Hand hygiene opportunities associated with patient contacts that leave hands
looking or feeling clean.11
Natural environment and community norms as barriers
The district has a longstanding water scarcity and water projects
had failed because the pipelines had been frequently destroyed
during neighbourhood feuds. A tolerance for lack of water in the
community was observed, some villagers being able to bathe only
twice-weekly. Community members, including a village chief and
a midwife, accepted the consequences such as dirty hands and
ngernails. The lack of hand washing was placed into perspective
by the locals who used water for life-sustaining priorities: We
dont even have water to drink or cook; how could you expect us to
bathe regularly, let alone wash our hands?
Both local and non-local HCWs of various ranks were observed
to have a tolerance for lack of hand washing that mirrored the
community norm. Lack of hand hygiene was observed in two local
community health workers during oral polio vaccine and vitamin A
provision in a health post, a local nurse caring for diarrhoea
patients, two non-local doctors with readily accessible soap and
running water, and a non-local surgeon who consistently touched
postoperative drains, urinary catheters and intravenous lines
during ward rounds. When interviewed, these HCWs did not
perceive themselves as being at risk of transferring infections. Their
focus was self-protective rather than preventing cross-infections
between patients. A doctor said: I do not wash my hands after each
patient contact because I rarely eat after examining patients . so I
just wash when I get home. A nurse expressed her perception of
risk associated with not hand washing with a laugh saying: Its like
I am immune already. I am used to it; Ive been working like this
from the beginning.
The impact of formal healthcare education on community
normative behaviour had not been sufcient to change practice, the
majority of nursing staff being nurse aides (56%) or nursing high
school graduates (31%). Nursing teachers interviewed reported
a minimum theoretical knowledge on hand hygiene during classes
and clinical placements at hospitals and clinics. Although 13% of
nurses attended a three-year Nursing Academy course in more
developed islands, they reported not having studied the impor-
tance of hand hygiene in any depth.
Observed barriers in the working condition
The working condition in healthcare facilities provided addi-
tional barriers for HCWs who may have overridden their com-
munitys normative behaviour had the resources and physical
conditions been different. Hand hygiene resources were limited
and many clinical areas were without working hand hygiene
facilities. Broken water tanks and pumps remained in disrepair.
HCWs extensively used stationary hand-washing basins or poured
water from a bucket with a ladle to ones own hands, a practice that
was observed to recontaminate washed hands due to contact with
the ladle. In one public clinic, a scarce working piped water system
was diverted by the staff to their nearby housing complex for
domestic use. The local social norm of not washing hands also
P-value
inuenced HCWs to rarely change water and antiseptics in
stationary basins resulting in unusable contaminated water. This
0.013
lack of washing facilities encouraged the adoption of local hand-
washing norms by non-local HCWs.
<0.001
Another observed hand hygiene barrier was a high patient load.
In the outpatient setting, up to 200 patients were seen by two
<0.001
HCWs (doctors and/or nurses) between 09:00 and 14:00, averaging
3 min per patient. Similarly, a typical workload in the inpatient
settings for one doctor averaged at 20 patients in one 60 min ward
round. One public clinic doctor reported that proper clinical
examinations, including hand washing between patients, increased
the service time three-fold and her staff protested because they
were made to work late without overtime provision. The doctor
insisted on washing hands but soon after the wash basins went
missing. An attending doctor at the private hospital admitted to
performing hand hygiene between rooms, not between patients, as
the only solution to her patient load. None of the chief executives
was willing to discuss human resources or nancial factors asso-
ciated with this high workload because these issues were culturally
off limits.
During the study AHR was not provided by healthcare facilities.
Commercial AHR at US$0.50 per 60 mL was prohibitively expensive
especially for junior nurse aides whose average monthly income
was US$10. Several HCWs who could afford AHR (mainly doctors)
were pessimistic about the prospect of having the product widely
available in healthcare facilities. HCWs in the public hospital sug-
gested that their management may not be interested in providing
AHR because the low cost of its provision would bring insufcient
commission to the purchaser. Managers of the private institutions
would not discuss the purchase of AHR.
Consequences of the barriers
Many HCWs were observed to respond to hand hygiene barriers
by providing clinical care without hand hygiene. Some HCWs per-
formed limited hand hygiene according to a hierarchy of perceived
risk to oneself. The hierarchy reected practices inuenced by
disgust and self-protection rather than based on sound microbio-
logical knowledge or patient safety. Perceived higher risks included
contacts with blood, abscesses, and patients with diarrhoea. A
doctor reported that he washed his hands after examining patients
with pulmonary tuberculosis because when I auscultate them, they
breathe on my hand. Perceived lower risks led to an absence of
hand hygiene for regular touching (pegang biasa) such as touching
a patients forehead with the back of hand to check temperature.
A unique minimum-touch technique to avoid the need for hand
hygiene was observed. One nurse requested her patient change his
own wound dressing under her supervision to eliminate the need
for her to hand wash. In response to a non-local doctors complaints
about her hands becoming dirty after examining patients with poor
hygiene, local nurses commented Thats why you shouldnt touch
the patients [Makanya jangan pegang-pegang pasien]. With a lack of
hand hygiene facilities, two doctors described their minimising
direct patient contact during physical examination by using a single
nger for palpation.
Discussion
Limitations of our study include reduced generalisability due to
the small number of locations and clinical staff interviewed.
However, all potential compliance opportunities were recorded for
all clinicians on duty for the shifts included in the 48 h of obser-
vations, and we had observed more than 200 hand hygiene
 B. Marjadi, M.-L. McLaws / Journal of Hospital Infection 76 (2010) 256e260
opportunities as recommended by the WHO Guidelines.10 Other
limitations include the inuence of an outside observer on the
reliability of the quantitative data and the trustworthiness of
observational and interview data. The interviewers identity (B.M.)
as a doctor may have produced measurement bias due to a cultural
custom of providing good answers to a respected outsider. Despite
our precautions we cannot guarantee the absence of Hawthorne
effect resulting in a higher level of observed compliance than the
unobserved reality.
Our observed hand hygiene rates of compliance (5%e30%) were
in line with similarly resourced healthcare systems in Morocco
(17%) and Algeria (18%), but lower than the global average of
40e50%.10,14,20 Our HCWs washed their hands six times more
frequently after patient care than before, reecting a similar bias
toward post-contact hand hygiene observed in high resource
settings.2,14,15,21e23 These observations are suggestive of a behav-
iour motivated by self-protection rather than by patient safe-
ty.11,21e24 With w11% of elective and 50% of all inherent hand
hygiene opportunities undertaken and as few as one hand hygiene
per 8 h shift, the challenge for our deprived setting is very different
than for high resource settings.25
Our qualitative data revealed practices that posed an even
greater risk to patient safety than could have been identied from
quantitative data alone. The omission of hand-washing facilities
and the dirty water or antiseptics in hand-washing basins may
contribute to the transmission of healthcare-associated infections
(HCAIs).10 Indonesian hospital tap water often has high levels of
Gram-negative bacteria that may lead to HCAI outbreaks.26e28
Unless the quality of hand hygiene facilities is improved, simply
increasing hand hygiene compliance may reduce the risk for cross-
infection between patients but increase patients risk of colonisa-
tion with Gram-negative bacteria.
Environmental and
community norm barriers
Poor HCW
education
High patient
load
Low priority placed by
management
Poor hand
Working condition hygiene facilities
barriers
Legend: = Main outcome findings
= Causes / risk factors
= Logical consequence but no evidence due to
lack of surveillance and laboratory facilities
Figure 1. Thematic framework of factors related to healthcare workers hand hygiene practice in the district.
259
The synthesis of our quantitative and qualitative data resulted in
a thematic framework that reects the complex interrelationship
between environmental barriers and adaption in the community
and working environment (Figure 1). The natural water scarcity,
compounded by feudal conicts, had perpetuated the absence of
hand hygiene in the community. HCWs education for appropriate
levels of hygiene was overridden by a high community tolerance to
dirtiness. Peer pressure to accept low hand hygiene compliance,
which can be more powerful than positive role models, was
reected by passiveeaggressive resistance against provision of
hand-washing basins and diversion of water pipes away from the
clinics.24
A bundled hand hygiene improvement intervention was
implemented in an Indonesian tertiary hospital and resulted in
an increase in hand hygiene compliance after six months.29
However, the generalisability of this intervention may be
reduced in remote facilities like ours where the baseline rate was
as low as 5% and supporting facilities and human resources were
lacking.30
Alcohol-based hand rub is the method of choice to improve
hand hygiene compliance because it is low cost and saves
time.6,10,26,31 However, in the tropics where air conditioning is
uncommon, HCWs hands are often sweaty and sticky after contact
with patients whose major activity is manual labour. Research must
be undertaken to ensure that AHR in these conditions is still
effective.10,32,33 The district healthcare managers may also be
reluctant to provide locally produced AHR under the present local
nancial arrangements and other competing priorities in this low
resource setting.10 Therefore, notwithstanding the role of AHR, we
believe that improvement of water supply and hand washing must
not be neglected in remote low resource settings. The most
pressing needs in our setting are simple and inexpensive facilities
Chronic
water scarcity
Poor inherent
hand hygiene
HCWs' poor Minimum-touch Poor diagnosis
hand hygiene technique establishment
Cross-
infection?
Consequences
= Cultural factors (community or organisational)
= Factors external to healthcare facilities
260 B. Marjadi, M.-L. McLaws / Journal of Hospital Infection 76 (2010) 256e260
provision and rearrangement of clinical workload, supported by an
engaged organisational culture.7,8,10,34
The impact that the general community has on HCWs in the
healthcare setting should not be underestimated.11,35 We believe
that the acceptance of low frequency hand washing by the general
community in our district has been the single most inuential
barrier for hand hygiene in the healthcare setting. Disgust, the
usual hand hygiene motivator, has been modied in the district by
longstanding deprivation of water.36 Even visibly dirty hands
would not elicit the frequent inherent hand hygiene usually
associated with contacts that make hands look or feel visibly or
emotionally dirty if the community has become tolerant to dirti-
ness and disgust as innate emotional responses to avoid infectious
diseases.10,11,36 Therefore, improving community hand hygiene
behaviour should be the initial step to achieve longlasting
improvement of HCWs hand hygiene. Every hand hygiene
campaign in a healthcare setting needs to be supported by
a community-based campaign as a long term strategy to achieve
a sustained awareness and improvement among HCWs.37
Conict of interest statement
None declared.
Funding source
AusAid funded this project as an Australian Development
Scholarship for Dr B. Marjadis PhD candidature.
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