title: Intervening with healthcare workers' hand hygiene compliance, knowledge, and perception in a limited-resource hospital in Indonesia: a randomized controlled trial study.
abstract: BACKGROUND
  Hand hygiene is recognized as an important measure to prevent healthcare-associated infections. Hand hygiene adherence among healthcare workers is associated with their knowledge and perception. This study aimed to evaluate the effect of three different educational programs on improving hand hygiene compliance, knowledge, and perception among healthcare workers in a tertiary care hospital in Indonesia.
  
  
  METHODS
  The study was performed from May to October 2014 and divided into a pre-intervention, intervention, and post-intervention phase. This cluster randomized controlled trial allocated the implementation of three interventions to the departments, including role model training-pediatrics, active presentation-surgery, a combination of role model training and active presentation-internal medicine, and a control group-obstetrics-gynecology. Both direct observation and knowledge-perception survey of hand hygiene were performed using WHO tools.
  
  
  RESULTS
  Hand hygiene compliance was observed during 2,766 hand hygiene opportunities, and knowledge-perception was assessed among 196 participants in the pre-intervention and 88 in the post-intervention period. After intervention, the hand hygiene compliance rate improved significantly in pediatrics (24.1% to 43.7%;P< 0.001), internal medicine (5.2% to 18.5%;P< 0.001), and obstetrics-gynecology (10.1% to 20.5%;P< 0.001). The nurses' incorrect use of hand rub while wearing gloves increased as well (P< 0.001). The average knowledge score improved from 5.6 (SD = 2.1) to 6.2 (SD = 1.9) (P< 0.05). In the perception survey, "strong smell of hand alcohol" as a reason for non-compliance increased significantly in the departments with intervention (10.1% to 22.9%;P= 0.021).
  
  
  CONCLUSIONS
  The educational programs improved the hand hygiene compliance and knowledge among healthcare workers in two out of three intervention departments in a limited-resource hospital in Indonesia. Role model training had the most impact in this setting. However, adjustments to the strategy are necessary to further improve hand hygiene.
authors.affiliation: Department of Microbiology, Faculty of Medicine, Brawijaya University/Dr. Saiful Anwar Hospital, Malang, Indonesia.|Infection Prevention and Control Committee, Dr. Saiful Anwar Hospital, Malang, Indonesia.|Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, 's-Gravendijkwal 230, Rotterdam, 3015 CE The Netherlands.
authors.forename: Dewi
authors.initials: D
authors.lastname: Santosaningsih
authors.affiliation: Department of Microbiology, Faculty of Medicine, Brawijaya University/Dr. Saiful Anwar Hospital, Malang, Indonesia.
authors.forename: Dewi
authors.initials: D
authors.lastname: Erikawati
authors.affiliation: Department of Microbiology, Faculty of Medicine, Brawijaya University/Dr. Saiful Anwar Hospital, Malang, Indonesia.
authors.forename: Sanarto
authors.initials: S
authors.lastname: Santoso
authors.affiliation: Department of Microbiology, Faculty of Medicine, Brawijaya University/Dr. Saiful Anwar Hospital, Malang, Indonesia.|Infection Prevention and Control Committee, Dr. Saiful Anwar Hospital, Malang, Indonesia.
authors.forename: Noorhamdani
authors.initials: N
authors.lastname: Noorhamdani
authors.affiliation: Infection Prevention and Control Committee, Dr. Saiful Anwar Hospital, Malang, Indonesia.
authors.forename: Irene
authors.initials: I
authors.lastname: Ratridewi
authors.affiliation: Infection Prevention and Control Committee, Dr. Saiful Anwar Hospital, Malang, Indonesia.
authors.forename: Didi
authors.initials: D
authors.lastname: Candradikusuma
authors.affiliation: Infection Prevention and Control Committee, Dr. Saiful Anwar Hospital, Malang, Indonesia.
authors.forename: Iin N
authors.initials: IN
authors.lastname: Chozin
authors.affiliation: Infection Prevention and Control Committee, Dr. Saiful Anwar Hospital, Malang, Indonesia.
authors.forename: Thomas E C J
authors.initials: TECJ
authors.lastname: Huwae
authors.affiliation: Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, 's-Gravendijkwal 230, Rotterdam, 3015 CE The Netherlands.
authors.forename: Gwen
authors.initials: G
authors.lastname: van der Donk
authors.affiliation: Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, 's-Gravendijkwal 230, Rotterdam, 3015 CE The Netherlands.
authors.forename: Eva
authors.initials: E
authors.lastname: van Boven
authors.affiliation: Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, 's-Gravendijkwal 230, Rotterdam, 3015 CE The Netherlands.
authors.forename: Anne F
authors.initials: AF
authors.lastname: Voor In 't Holt
authors.affiliation: Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, 's-Gravendijkwal 230, Rotterdam, 3015 CE The Netherlands.
authors.forename: Henri A
authors.initials: HA
authors.lastname: Verbrugh
authors.affiliation: Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, 's-Gravendijkwal 230, Rotterdam, 3015 CE The Netherlands.
authors.forename: Juliëtte A
authors.initials: JA
authors.lastname: Severin
keywords: Hand hygiene; Healthcare-associated infections; Indonesia