Major article Predicting hand hygiene among Iranian health care workers using the theory of planned behavior Mary-Louise McLaws DipTropPubHlth, MPH, PhD a , Najmeh Maharlouei MD b , Farideh Yousefi MD c , Mehrdad Askarian MD d, * a School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia b Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran c College of Education and Psychology, Shiraz University, Shiraz, Iran d Department of Community Medicine, Shiraz University of Medical Sciences, Shiraz, Iran Key Words: Handwashing Predictive behavioral model Compliance Background: This study was conducted to identify significant predictors of handwashing associated with hospital elective (clean) and hospital inherent (dirty) contacts. Methods: This cross-sectional survey of 1,700 health care workers was based on the theory of planned behavior. Data were aggregated into components according to the theory and tested for predictors of hospital elective and hospital inherent handwashing using multiple logistic regression analysis. The a value was set at 0.05, and odds ratios (ORs) for significant predictors were adjusted by interquartile range. All wards studied were in private and government hospitals associated with the University of Medical Sciences, Shiraz, Iran between April and September 2008. Results: Of the 1,200 healthcare workers surveyed 1,077 (90%), of whom 83% were nurses, returned a completed survey. Hospital elective handwashing practice was positively influenced by community elective practice (adjusted OR [aOR], 2.1; P < .000), hospital inherent practice (aOR, 1.6; P < .000), perception that handwashing required little effort (aOR, 1.1; P ¼ .039), and subjective norms (nursing peers) (aOR, 1.1; P ¼ .025) and negatively influenced by poor attitudes regarding handwashing (aOR, 0.91; P ¼ .01). Hospital inherent handwashing practice was positively influenced by hospital elective practice (aOR 2.5; P < .000), community inherent practice (aOR, 1.5; P ¼ .001), subjective norms (infection control practitioners) (aOR, 1.4; P ¼ .001, and attitudes (aOR, 1.1; P ¼ .001) and negatively influenced by poor subjective norms (nurses) (aOR, 0.74; P < .000). Conclusion: Community-based handwashing practices exerted a strong influence on handwashing compliance in the hospital. Given this interdependence between community and hospital handwashing, a campaign to improve awareness of the benefit of community handwashing may improve clinicians’ compliance. Crown Copyright Ó 2012 Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc. All rights reserved. Health careeassociated infections (HAIs) are associated with increased morbidity, mortality, hospitalization, 1-4 and patient distress and with longer patient recovery times. 4 More than 1.4 million patients worldwide are estimated to suffer an HAI at any given time. 5 Between 5% and 10% of patients admitted to high-resourced health care systems acquire one or more infections during hospitalization. 5,6 HAIs are the 11th-leading cause of death in the United States. 2 The risk of HAI in low-resourced health care settings is between 2 and 20 times higher than the US rate. 5 Between 1999 and 2000, the incidence of HAI in the surgical department of a teaching hospital in Shiraz was 18%, and the estimated annual cost of this level of infection was approximately 120 billion Rials (wUS $150,000). 7 Regardless of the level of health service resources, hand hygiene compliance has an inverse influence on the rate of HAI 8 and is a cost- effective method of preventing infection transmission. 9-11 Contacts between nurses with contaminated hands and their patients are generally considered the main route of infectious spread between wards. Although nurses recognize hand hygiene as an important HAI prevention measure, their practice varies * Address correspondence to Mehrdad Askarian, MD, Professor of Community Medicine, Shiraz University of Medical Sciences, PO Box 71345-1737, Shiraz, Iran. E-mail address: askariam@sums.ac.ir (M. Askarian). This study was funded by the Vice-Chancellor for Research, Shiraz University of Medical Sciences. Conflict of interest: None to report. Contents lists available at ScienceDirect American Journal of Infection Control journal homepage: www.ajicjournal.org American Journal of Infection Control 0196-6553/$36.00 - Crown Copyright Ó 2012 Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc. All rights reserved. doi:10.1016/j.ajic.2011.04.004 American Journal of Infection Control 40 (2012) 336-9