The current status of hand washing and glove use among care staff in Japan: its association with the education, knowledge, and attitudes of staff, and infection control by facilities
Environ Health Prev Med
The current status of hand washing and glove use among care staff in Japan: its association with the education, knowledge, and attitudes of staff, and infection control by facilities
Ikuko Takahashi 0 1
Yoneatsu Osaki 0 1
Mikizo Okamoto 0 1
Aya Tahara 0 1
Takuji Kishimoto 0 1
0 Y. Osaki M. Okamoto A. Tahara T. Kishimoto Division of Environmental and Preventive Medicine, Department of Social Medicine, Faculty of Medicine, Tottori University , Nishi-machi 86, Yonago, Tottori 683-8503 , Japan
1 I. Takahashi (&) Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine , 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505 , Japan
Objective Hand hygiene is a basic measure to prevent infections. The purpose of this study was to obtain suggestions for the improvement of hand hygiene by evaluating the education, knowledge, and attitudes of care staff at facilities for the elderly in regard to hand washing and glove use, as well as infection control policies by those facilities. Methods Among a total of 147 special nursing homes and health service facilities for the elderly in Yamaguchi Prefecture, Japan, questionnaires were sent from October to November 2007 to 56 facilities which had agreed to participate in this survey. Two types of questionnaire, one for the facility manager and the other for care staff, were sent to each facility. Results The questionnaire was responded to by 42 managers (response rate 28.6%) and 1,323 staff members (response rate 26.3%). The rate of compliance with hand hygiene among them was 34.0%. Personal factors promoting hand hygiene were education and attitudes, while facility-related factor was the implementation of handwashing evaluation. Conclusion Since the hand hygiene compliance rate is low among care staff at facilities for the elderly, it is necessary to take measures to improve hand hygiene.
Hand washing; Facilities for the elderly; Glove; Care staff
Educational programs for hand hygiene should be
developed in view of the conditions of individual facilities.
Hand hygiene is emphasized as a basic measure to prevent
infections. However, the rate of compliance with hand
hygiene in medical practitioners is low, and the US Centers
for Disease Control and Prevention (CDC) published a
guideline for hand hygiene in healthcare settings in an
effort to promote it [
]. Hand hygiene means either
washing the hands with soap and water or hand antisepsis
with an alcohol-based hand-rub [
Research on hand hygiene at facilities has mainly
targeted physicians and nurses working for hospitals. In
Japan, Osuka [
] investigated the rate of practicing hand
washing and factors affecting hand hygiene behavior
among 93 nurses at two hospitals, and reported that the rate
was 50.9% on average, and factors such as workload,
education, and experience affected hand hygiene behavior.
Infection control is important at special nursing homes
and health service facilities for the elderly as well as at
hospitals. These facilities for the elderly, however, less
frequently involve invasive procedures [
], and therefore
they are expected to depend more on hand hygiene for the
prevention of infections. Challenges to infection control at
facilities for the elderly have been reported, including: (1)
there are many elderly people who cannot voluntarily take
preventive actions such as hand washing due to paralysis or
dementia, and this impairs the effectiveness of infection
control; (2) elderly residents are often less resistant due to
their chronic diseases [
]; (3) there are few medical
practitioners at facilities for the elderly, as special nursing
homes do not have a system of resident physicians/nurses
]. Thus, care workers and nurses (care staff) who take
care of residents were expected to play an important role in
preventing infections at facilities for the elderly.
When an outbreak of norovirus infection occurred at
facilities for the elderly over the period from December
2004 to January 2005, with 7 deaths of residents at a
special nursing home, the Ministry of Health, Labor, and
Welfare issued a notification requiring those facilities to
strengthen their infection control measures [
]. The number
of cases infected by norovirus at facilities for the elderly is
rising annually; it increased by more than 2.5 times during
the period from September 2006 to August 2007 [
Infection with norovirus is the most common at facilities
for the elderly, and the route of infection is
human-tohuman infection [
]. Since the possibility of norovirus
being transmitted to multiple patients by a single care
worker who missed a single occasion of hand hygiene has
been demonstrated [
], it is important for, and a challenge
to, facilities for the elderly to encourage care staff to
comply with hand hygiene measures.
Regardless of the importance of promoting hand
hygiene among care staff at facilities for the elderly,
studies targeting individual facilities or surveying the
compliance of care staff with hand hygiene on the occasion
of their attending a training session have only been
conducted in Japan; no study has investigated the current status
of hand hygiene, and factors associated with it, among care
staff. Given the association of various factors with the
practice of hand hygiene [
], it is necessary to clarify both
personal and facility-related factors to improve the
compliance of care staff.
Focusing on the practice of hand washing and glove use
as preventive measures against infection, and targeting care
staff at facilities for the elderly, this study evaluated their
education, knowledge, and attitudes in regard to hand
washing and glove use, as well as infection control by those
facilities, to clarify the relationships between these
conditions and compliance with hand hygiene.
Materials and methods
The subjects were the managers and care staff of special
nursing homes and health service facilities for the elderly
in Yamaguchi Prefecture, Japan.
The target institutions were 147 facilities for the elderly
(87 special nursing homes and 60 health service facility) in
Yamaguchi Prefecture, Japan, listed as of December 14,
2006, on the Welfare and Medical Service Network System
(WAMNET). Each of the 147 facilities was requested in
writing to participate in this study, and a questionnaire was
sent to 56 facilities (31 special nursing homes and 25 health
service facilities) which had agreed to cooperate with us.
The questionnaire survey was conducted from October 22,
2007 to November 10, 2007.
The questionnaire for managers was collected from 42
facilities. The response rate was 28.6%, and 41 facilities
(27.9%) were used for analysis. On the other hand, the
questionnaire for care staff was answered by 1,323 (26.3%)
of a total of 5,026 staff members; 1,282 (25.5%) who
answered all of the 9 questions about hand washing and
glove use were subjected to analysis.
To evaluate any bias in the characteristics of these
facilities, 41 responding and 91 nonresponding facilities,
excluding 15 whose attitudes to the survey were unclear,
were tested for location, type, capacity, and number of care
staff, but no significant differences were found.
A questionnaire was developed in consultation with
previous studies [
3, 12, 13
], the CDC guideline for hand
hygiene in healthcare settings [
], and an infection control
manual by the Ministry of Health, Labor, and Welfare [
for the elderly in a facility.
A copy of the questionnaire for the facility manager and
a necessary number of copies for care staff were sent in an
envelope to each facility.
The completed questionnaire for care staff was put in an
envelope by each staff member, collected together with
that for the facility manager, and returned by the person
responsible at each facility.
Questionnaire for the facility manager
Items of the questionnaire for the facility manager included
basic characteristics (facility type, capacity, number of
staff, numbers of new/retired employees), resident
information (number of residents by care level), establishment
of an infection control committee, presence of an infection
control manual, provision of infection and hand-washing
training, implementation of hand-washing evaluation,
guidance for hand washing and glove use, vaccination
(influenza, Streptococcus pneumoniae, hepatitis B), stocks
of disposable gloves, gowns, masks, and N95 masks,
availability of private rooms upon the onset of infection,
availability of a sink in the residents’ rooms, installation of
alcohol-based hand-rubs, and carrying of alcohol-based
hand-rub in the pocket.
Questionnaire for care staff
Items on the questionnaire for care staff included basic
characteristics (age, gender, job type, years of experience,
years of continuous employment, employment status),
education (receipt of pre- and post-employment education
on infection and hand washing), practice of hand washing
and glove use, knowledge of infection routes (itch,
methicillin-resistant Staphylococcus aureus [MRSA], influenza
virus, tubercle bacillus [TB], hepatitis B and C viruses,
human immunodeficiency virus [HIV], norovirus),
knowledge of hand washing (hand-washing methods for visibly
unsoiled and soiled hands), and attitudes (thinking that you
will take standard precautions, that hand washing is
effective, that infection can be prevented by knowledge, that
infection can be prevented by proper behavior, that you
have knowledge of infection, that you can take appropriate
actions in poor health, and that you are busy at work).
The statistical software package SPSS version 15.0 for
Windows was used for statistical analysis.
Hand washing and glove use were designated as
dependent variables, and those who answered yes to all of the 9
questions about the practice of ‘‘hand washing required by
the CDC guideline for hand hygiene in healthcare settings
],’’ ‘‘hand washing during daily work,’’ and ‘‘glove use
required by standard precautions [
]’’ were regarded as
the hand-hygiene compliant group, and those who answered
no to any of the 9 questions were regarded as the hand
hygiene noncompliant group. The questions were about: (1)
hand washing before direct contact with residents, (2) hand
washing after direct contact with residents, (3) hand
washing when moving from a contaminated body site to a
clean one during resident care, (4) hand washing after
removing gloves, (5) hand washing before eating and after
using the restroom, (6) hand washing during busy work, (7)
use of a new pair of gloves for each care episode, (8) glove
use in the presence of possible infection, and (9) glove
replacement when moving from a contaminated body site to
a clean one during resident care.
Although glove use itself cannot guarantee hand hygiene
], this study considered it within the scope of hand
hygiene as the standard precautions require glove use as a
measure to prevent infection via the hands.
Analysis of personal factors and compliance with hand hygiene
Correlations between the levels of compliance with hand
hygiene and the variables of care staff were examined by
the chi-square test or t test.
To clarify personal factors contributing to compliance
with hand hygiene, multiple logistic regression analysis
was performed with hand hygiene compliance levels
used as dependent variables, and basic characteristics,
education, knowledge, and attitudes as explanatory
The variables entered were ‘‘years of experience,’’ ‘‘job
type (nurse or other),’’ ‘‘education,’’ ‘‘knowledge of
handwashing methods for visibly soiled or unsoiled hands,’’
‘‘knowledge of infection routes of infection with scabies,
MRSA, influenza, TB, hepatitis B/C, HIV, or norovirus,’’
‘‘I think I will take standard precautions,’’ ‘‘I think hand
washing is effective in preventing infection,’’ ‘‘I think
infection can be prevented by knowledge,’’ ‘‘I think
infection can be prevented by proper behavior,’’ ‘‘I think I
have knowledge of infection,’’ ‘‘I think I can take
appropriate actions in poor health,’’ and ‘‘I think I am busy at
For the variable ‘‘education,’’ those who answered
‘‘received adequate education’’ or ‘‘received education’’ on
both infection and hand washing before employment, and
‘‘received training’’ on both infection and hand washing
after employment were regarded as adequate, and others
were regarded as inadequate.
Analysis of facility-related factors and compliance rate with hand hygiene
To clarify the relationships between those facilities
conditions and compliance rate with hand hygiene, multiple
regression analysis was performed compliance rate with
hand hygiene used as dependent variables, and basic
characteristics and infection control by the facility and its
environment as explanatory variables.
The variables entered were ‘‘facility type,’’ ‘‘number of
residents per staff member,’’ ‘‘infection training,’’
‘‘implementation of hand-washing evaluation,’’
‘‘handwashing environment in the residents’ room,’’ ‘‘carrying an
alcohol-based hand-rub in the pocket,’’ and ‘‘guidance for
hand-washing and glove use.’’
The variable ‘‘hand-washing environment in the
residents’ room,’’ was categorized into three: both a sink and
alcohol-based hand-rub available was scored as 2 point,
either one available was scored as 1 point, or both
unavailable was scored as 0 point.
For the variable ‘‘guidance for hand-washing and glove
use,’’ the correct answer to 8 questions for care staff with
hand-washing and glove use, except the question about
hand washing during busy work, guidance by explain was
scored as 2 point, only paper was scored as 1 point, no
guidance was scored as 0 point, and then these values were
Explanation to the subjects was made by the responsible
person at each facility using briefing material that
described the purpose of the survey, how to complete the
questionnaire, protection of privacy, the completely voluntary
nature of participating in the study, and consideration for
the subjects not to be disadvantaged.
This study was conducted with the approval of the
Medical Research Ethics Committee of the Faculty of
Health Sciences, Yamaguchi University Graduate School
The overall condition of the facilities
By facility type, 52.4% were special nursing homes and
47.6% were health service facilities. Capacity was
78.4 ± 20.9 (mean ± standard deviation, SD) and number
of staff was 39.8 ± 14.8 (mean ± SD).
Regarding the facility environment, ‘‘availability of a
sink in the residents’ room’’ (56.1%), ‘‘installation of
alcohol-based hand-rubs’’ (43.9%), and ‘‘carrying an
alcohol-based hand-rub in the pocket’’ (24.4%) were
confirmed (Table 1).
Personal factors and compliance with hand hygiene
The subjects included more women (79.1%) than men
(20.9%); mean age was 37.5 years. Regarding job type,
‘‘certified care worker’’ was the most common (51.1%),
followed by ‘‘care worker (helper)’’ (20.7%) and ‘‘nurse’’
(17.5%). Compliance with hand hygiene was confirmed in
436 (34.0%) of the 1,282 staff members, being 30.5% in
certified care workers, 33.7% in care workers (helpers), and
Table 1 Facility conditions
(n = 41)
41.5% in nurses. No item of the basic characteristics
showed significant difference between the
hand-hygienecompliant and noncompliant groups (Table 2).
Regarding pre- and post-employment education, about
50% of care staff stated they had ‘‘received adequate
education’’ or ‘‘received education’’ on both infection
and hand washing before employment, and some 60–70%
of them had received such education after employment.
For all items, the compliant group had more educated
staff members than the noncompliant group, showing a
significant difference except for the item ‘‘previous
receipt’’ of ‘‘post-employment education on infection’’
Those who chose alcohol-based hand-rubs as a
handwashing method for visibly unsoiled hands accounted for
31.2%. Concerning their knowledge of infection routes,
more than 90% answered correctly for scabies, influenza
virus, and norovirus, whereas the correct answer for
tuberculosis (TB) was given by some 80%; the lowest rate
was 49.5%, for methicillin resistant Staphylococcus aureus
(MRSA). For each of influenza virus, TB, hepatitis B/C
viruses, and HIV, a significant difference was observed,
with more correct answers in the noncompliant group
Regarding attitudes toward hand hygiene, those who
answered yes to each of the questions regarding thinking
‘‘that infection can be prevented by knowledge’’ and ‘‘that
infection can be prevented by proper behavior’’ were
significantly more common in the compliant group. Those
who thought they ‘‘had knowledge of infection,’’ and/or
‘‘could take appropriate actions such as having a rest and
seeing a doctor in poor health’’ accounted for about 50% of
all; more precisely, those with the positive attitude
comprised 58.2% and 41.5% of the compliant and
noncompliant groups, respectively, and those with the negative
attitude comprised 65.3% and 46.5%, respectively
and personal factors such as basic characteristics,
education, knowledge, and attitudes as explanatory variables.
The results showed that the item ‘‘I think infection can
be prevented by knowledge’’ was the strongest factor
promoting compliance with hand hygiene (odds ratio, OR
1.95). Other hand-hygiene-promoting factors identified by
the analysis included ‘‘education’’ (OR 1.38), ‘‘I think I
have knowledge of infection’’ (OR 1.86), and ‘‘I think I can
take appropriate actions such as having a rest and seeing a
doctor in poor health’’ (OR 1.66). Education and attitude
showed significant correlations as hand-hygiene-promoting
factors, while basic characteristics and knowledge were not
significant contributing factors (Table 6).
Facility-related factors contributing to compliance rate
with hand hygiene
Multiple regression analysis (stepwise method) was
performed using compliance rate with hand hygiene as
dependent variable, and facility-related factors such as
basic characteristics, infection control by the facility, and
its environment as explanatory variables (n = 37).
‘‘Implementation of hand-washing evaluation’’
(regression coefficient b = 0.42) was strongly related with hand
hygiene compliance rate. However, there was no
significant related factor. The adjusted coefficient of
determination was R2 = 0.15.
In this study, not many facilities responded, but the
response rate of employees in the responding facilities was
high. Therefore bias is small.
There were special nursing homes (59.1%) and health
service facilities (40.8%) in Yamaguchi Prefecture, Japan,
whose capacity was 71.6 ± 20.2 (mean ± SD) and
number of staff was 36.0 ± 12.2 (mean ± SD). We were able
to collect data to represent the facilities in Yamaguchi
Prefecture, Japan, because their type, capacity, and number
of staff were not different from the subjects of this study.
The rate of compliance with hand washing and glove use
was 34.0%. Specifically, it was 30.5% in certified care
workers, 33.7% in care workers (helpers), and 41.5% in
nurses, with no significant differences between job types.
Especially, the compliance rate in nurses was some 40%,
regardless of their learning about infections, infection
control, standard precautions, and hand hygiene over the
course of basic education. According to literature that
summarized hand hygiene compliance rates in previous
foreign studies, the compliance rates differed greatly,
ranging from 5% to 81%, and the mean rate was 40% [
The overall compliance rate in this study was 34.0%,
showing a trend similar to those in previous studies. The
relatively low rate of compliance with hand hygiene has
raised a problem at these facilities, and it is a major
challenge to them to improve the compliance rate.
The study showed that hand hygiene was complied with
by those who thought ‘‘infection can be prevented by
knowledge,’’ and/or ‘‘I have knowledge of infection.’’ It is
said that intentional behavior is associated with attitudes
toward behavior and the subjective norm of behavior, and
can be modified by approaching these factors [
the importance of attitudes was suggested in this study as
well, the promotion of hand hygiene requires that care staff
recognize the importance of hand hygiene and its
effectiveness in preventing infection.
Education is essential in promoting compliance with
hand hygiene. A previous study revealed that, as a result
of intervention including education, the compliance rate
improved from 56% before intervention to 83% after
intervention, and then reduced to 76% during follow-up
]. The hand hygiene compliance rate can improve
through education, but this effect does not persist. As a
correlation between those who had received education
during the past year and their compliance with hand
hygiene was observed in this study as well, it is necessary
to continually encourage them to be aware of the
importance of hand hygiene. While the importance of monitoring
the compliance of care staff with hand hygiene is
emphasized as a means to maintain and improve the compliance
], evaluation of their hand-washing activities was
found to be a factor increasing hand hygiene rate in this
study as well. Hand washing can be evaluated by such
methods as self-evaluation by a check sheet, observation,
measurement of the amount of alcohol-based hand-rubs
used, and evaluation using fluorescent lotion, which is
applied to the hands and irradiated with ultraviolet rays
from a black-light lamp after washing the hands to check
for any remaining contamination. Black light provides a
convenient, easy-to-use approach that allows self-check
and facilitates self-awareness. Although only 26.2% of the
facilities that responded to this survey applied the
blacklight method, one idea to improve the hand hygiene
compliance rate is to combine lectures with opportunities to
self-evaluate hand washing by such means as a black-light
in education for care staff.
Preparing an environment readily conducive to hand
washing brings about an improvement of hand hygiene,
and, in fact there is a study demonstrating an improvement
in the hand hygiene compliance rate by carrying a hand-rub
in the pocket [
]. This study, however, did not show a
correlation between carrying a hand-rub in the pocket and
compliance with hand hygiene. As a hand-washing method
for visibly unsoiled hands, the ‘‘use of an alcohol-based
hand-rub,’’ rather than ‘‘washing the hands with soap and
water,’’ is recommended [
]. However, the rate of correctly
answering the question about this issue was only 31.2%.
This suggests the presence of care staff not knowing this
CDC recommendation at facilities for the elderly, and the
necessity to disseminate the CDC-recommended
handwashing methods and alcohol-based hand-rubs among
Regarding the questions about infection routes, the
correct answer rate was low for the question on MRSA,
probably because the survey regarded droplet transmission
as an incorrect answer to this question. Although MRSA is
mainly transmitted via contact, there is still a possibility of
it being transmitted by droplets. However, the survey
requested the subjects to choose a more common infection
route at facilities for the elderly when there was more than
one possible route. For MRSA, these facilities primarily
take preventive measures against contact transmission [
The subjects’ knowledge of infection routes was scored
and subjected to multivariate analysis, and it was found not
to be a factor significantly correlated with compliance
toward hand hygiene. While knowledge of infection routes
was not a factor promoting hand hygiene, as described
above, a positive attitude toward prevention was found to
be a factor positively contributing to compliance with hand
hygiene. As reported by Gruber et al. [
] and Ronk et al.
], imparting knowledge does not always promote
behavior. Since this study demonstrated the importance of
training after employment, and confirmed greater value of
attitudes than of personal knowledge, it was considered
significant to provide care staff with education with content
that could improve their attitudes. To achieve this, it is
recommended to first explain to care staff the reasons why
hand hygiene is necessary using literature, then promote
their understanding of hand hygiene and behavior through
a group discussion, and finally evaluate their compliance
with hand hygiene and provide them with feedback.
Evaluation of compliance with hand hygiene and its
feedback are important as a ‘‘motivation’’ [
], and considered
to be an effective method to promote attitudes toward hand
This study explored personal and facility-related factors
expected to contribute to compliance with hand hygiene.
‘‘Receipt of adequate education,’’ ‘‘awareness of having
knowledge of infection,’’ ‘‘belief that infection can be
prevented by knowledge,’’ ‘‘ability to take appropriate
actions in poor health,’’ and ‘‘implementation of
handwashing evaluation’’ were found to be factors improving
compliance with hand hygiene. Therefore, it is effective to
include these factors in measures for improvement of hand
This study was based on a questionnaire survey, and in
general self-evaluation tends to be better than the actual
condition. Kakeya et al. [
] examined nurses’ compliance
with hand washing in 6 clinical scenes using both a
questionnaire and observation, and reported compliance rates of
83.5% based on the questionnaire conducted among 39
nurses, and 68.9% based on the observation of 20 nurses.
Since a questionnaire results in a higher compliance rate
than observation, an accurate estimation of the hand
hygiene compliance rate should be made based on
observation. However, observation was not feasible in this study,
which was based on a large-scale survey to collect as many
data as possible to identify factors contributing to
compliance with hand hygiene.
In addition, no causal relationship could be extracted
from this study, which was cross-sectional. On the
assumption that factors identified in this study are factors
promoting compliance with hand hygiene, it is necessary to
develop measures to improve the compliance rate, and
conduct an interventional study.
In this study, the response rate to the questionnaire was
relatively low, probably because it was conducted with
the prior approval of the facility director. However, we
could collect questionnaires from managers (75.0%, 42/
56) and care staff (77.1%, 1,282/1,663). A response bias
was considered, but we judged its influence to be small.
Previous Japanese studies on compliance with hand
hygiene mainly targeted one or several facilities, and no
such studies have been conducted on a scale covering all
facilities in a prefecture. Although its coverage was a
single prefecture, this study was considered to be
meaningful as it specifically targeted care staff at welfare
facilities for the elderly, and explored not only personal
factors but also facility-related factors contributing to
compliance with health hygiene.
Acknowledgments We would like to thank people at the facilities
for their cooperation in this study despite their busy schedules. This
work was supported by KAKENHI (18791726).
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