Engdaw et al.

Antimicrobial Resistance and Infection Control (2019) 8:190

https://doi.org/10.1186/s13756-019-0634-z

RESEARCH Open Access

Hand hygiene compliance and associated

factors among health care providers in
Central Gondar zone public primary
hospitals, Northwest Ethiopia
Garedew Tadege Engdaw, Mulat Gebrehiwot and Zewudu Andualem*

Abstract
Background: Poor hand hygiene compliance is one in all the leading contributory factors to healthcare-associated
infections. This is an important source of complications across the continuum of care and poses a serious threat to
people admitted to hospitals. However, the magnitude and associated factors of hand hygiene compliance in
public primary hospitals were not well investigated in Ethiopia. Therefore, this study was conducted to assess hand
hygiene compliance and associated factors among health care providers in Central Gondar Zone public primary
hospitals, Northwest Ethiopia.
Methods: An Institutional based cross-sectional study was conducted from March to April 2019 among health care
providers. The data were collected using self-administered questionnaires and observational checklists. Using Epi
Info 3.1, data was entered and analyzed using SPSS version 23. The data were analyzed using descriptive statistics
and logistic regression models. A p-value less than 0.05 with 95% confidence interval was used to declare statistical
significance.
Results: Of 335 study participants, 50 (14.9%), had good hand hygiene compliance. Training on hand hygiene
(AOR = 8.07, 95%CI: 2.91, 22.39), availability of adequate soap and water for hand hygiene (AOR = 5.10, 95%CI: 1.93,
13.52), availability of alcohol-based hand rub (AOR = 3.23, 95%CI: 1.32, 7.92), knowledge about hand hygiene (AOR =
6.74, 95%CI: 2.96, 15.34) and attitude towards hand hygiene (AOR = 2.15, 95%CI: 1.04, 4.46) were factors associated
with hand hygiene compliance.
Conclusion: The overall level of hand hygiene compliance among health care providers was poor. Training,
availability of adequate soap and water, availability of alcohol-based hand rub, knowledge on hand hygiene, and
attitude of health care providers were significantly associated with hand hygiene compliance.
Keywords: Hand hygiene compliance, Health care provider, Public primary hospitals

Background related infections and thereby reveal antimicrobial resist-

Hand hygiene is the compliance of cleansing hands with ance in all settings, from advanced health care systems
soap and water or with antiseptic hand rub to remove to primary health care [2].
transient microorganisms from hands and maintain the Performing hand hygiene activities within the health
condition of the skin [1]. It is one of the most important institutions by health care providers with Alcohol-Based
health issues in the world and could be a single efficient Hand Rub (ABHR) at multiple times causes them to feel
and sensible life to reduce the incidence of health- uncomfortable. The right technique and duration of
handwashing using soap and water and ABHR are very
* Correspondence: [email protected]
important to confirm the removal of microorganisms.
Department of Environmental and Occupational Health and Safety, Institute This will be done before and once touching the patient,
of Public Health College of Medicine and Health Sciences, University of before handling an invasive device for patient care, once
Gondar, Gondar, Ethiopia

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Engdaw et al. Antimicrobial Resistance and Infection Control (2019) 8:190 Page 2 of 7

contact with body fluids or excretions, mucous mem- marginal error 5%, and a standard Z score of 1.96 corre-
branes, non-intact skin, or wound dressings, moving sponding to 95% confidence interval, by adding 5% non-
from a contaminated body web (site) to a different body response rate the final sample size was 403. But in the
site throughout care of the identical patient [3, 4]. study setting, the total number of healthcare providers
Healthcare-associated infections (HCAIs) have an ex- was 341. Due to a small number and affordable to do
cellent impact on morbidity, length of hospital stays, and research on all health care providers, we have included
treatment prices [5]. Health care providers’ hands are all HCP from five public primary hospitals.
the main usual mode of the vehicle for the transmission
of HCAIs. About 50% of HCAIs happens due to the
hand of health care providers [6]. Data collection tools
During patient care, unless there are recommended Data were collected by a self-administered questionnaire
hand hygiene compliance of health care suppliers un- and observation checklist adapted from different literature
interrupted, hands are contaminated with a microorgan- [6, 10, 11]. The questionnaire had questions related to
ism [7]. Annually regarding many numerous patients socio-demographic, knowledge, attitude, and practice.
have suffered from HCAIs worldwide [8]. Improper This questionnaire had both open and close-ended ques-
hand hygiene by HCPs is answerable for regarding 40% tions. The English version of the questionnaire was trans-
of health facility infections [9]. This infection is answer- lated into the local language (Amharic) and it was
able for nearly 50% of the deaths that occur on the far translated back into English by the third person to check
side a pair of weeks of age [3]. its consistency. Two days training was given on the data
Therefore, the aim of this study was to assess hand hy- collection tools, questioning techniques, and ethical issues,
giene compliance and associated factors among health interview techniques, ways of obtaining the verbal consent
care providers in Central Gondar Zone public primary and how to interact with respondents as precautions for
hospitals, Northwest Ethiopia, 2019. data collectors and supervisors. The data collectors were
Nurses and Environmental health professionals under the
Methods and materials supervision of two field supervisors.
Study design, period, and study area
The institutional-based cross-sectional study was con-
Operational definitions
ducted to assess hand hygiene compliance and associated
Good hand hygiene compliance
factors among health care providers in central Gondar
Health care providers who practiced all of the hand hy-
zone public primary Hospitals, northwest Ethiopia, from
giene moments from the observational checklist [12].
March to April, 2019.
The study was conducted in the region of northwest
Amhara in five primary hospitals named, Kolladiba, Poor hand hygiene compliance
Aykel, Wogera, Delgi, and Guhala. These hospitals have Health care providers who do not practice at least one
clinical and administrative staff. The number of health of the hand hygiene moments from the observational
care providers differ from hospital to hospital. Kolladiba checklist [12].
(70), Aykel (80), Wogera (66), Delgi (54) and Guhala
(71) public primary hospitals.
Data processing and analysis
Eligibility criteria For completeness and consistency, the collected data
Inclusion criteria were rechecked. Data were entered in Epi-Info version
All health care providers who had worked at least 6 3.1 software and exported to SPSS version 23 for further
months in the central Gondar zone public primary hos- analysis. Descriptive statistics was employed for the
pitals who were included in this study. socio-demographic characteristics of the respondents.
Bivariable and multivariable logistic regressions were
Exclusion criteria carried out to identify significantly associated variables
Health care providers who were not present during the with hand hygiene compliance by backward logistic re-
data collection time due to different reasons were gression variable selection method. Crude Odds Ratio,
excluded. and Adjusted Odds Ratio (AOR) with 95%CI were com-
puted to determine the associated factor of hand hygiene
Sample size determination compliance and P- value less 0.05 was considered as de-
The required sample was calculated using single popula- clared statistically significant. Hosmer and Lemeshow
tion proportion formula with the assumption of the pro- goodness of fit (P > 0.05) were used to test the fitness of
portion P-value is 50% (there is no previous study), and the model during analysis.
Engdaw et al. Antimicrobial Resistance and Infection Control (2019) 8:190 Page 3 of 7

Results Hand hygiene compliance of health care providers

Socio-demographic characteristics of respondents In this study, the prevalence of hand hygiene compliance
A total of 341 respondents were aimed for this study. Of from observation was 14.9%, (95% CI: 11.3, 18.5). Above
these, 335 respondents were recorded with a response half 181 (54%) of the respondents were knowledgeable
rate of 98.2%. The mean age of the respondents was about hand hygiene compliance. Of the respondents, 140
28 ± 5.6 (± SD) years. Most of the 299 (89.3%) study re- (41.8%) health care providers are trained about hand hy-
spondents were Orthodox Christians in religion. Profes- giene compliance and 177 (52.8%) assured the presence of
sional respondents were 120 (35.8%) Nurses (Table 1). alcohol-based hand rub in their working area (Table 2).

Reasons for not practicing hand hygiene Factors associated with hand hygiene compliance
Half of the study participants argue that the inaccessibil- In bivariable logistic regression; knowledge of six steps
ity of sink and ABHR is a reason for not practicing good of hand hygiene, knowledge on five moments of hand
hand hygiene (Fig. 1). hygiene, having training for hand hygiene, presence of
promotion for hand hygiene in the hospital, having ad-
Table 1 Socio-demographic characteristics of the health care
equate soap and water for hand hygiene, presence of ad-
providers Central Gondar Zone public primary hospitals,
Northwest Ethiopia, 2019 (n = 335)
equate individual/wall matted alcohol-based hand rub
for hand hygiene, presence of posters for hand hygiene,
Variable Frequency Percent (%)
presence of protocol for hand hygiene, knowledge on
Age 18–24 55 16.4
hand hygiene compliance and attitude were found to be
25–34 243 72.5 significantly associated variables with the hand hygiene
> 35 37 11.1 compliance of health care providers.
Sex Male 238 71 After fitting these variables in multivariable logistic re-
Female 97 gressions; having trained for hand hygiene, have adequate
Religion Orthodox 299 89.3
soap & water for hand hygiene, presence of an adequate
individual or wall matted alcohol-based hand rub, know-
Muslima 36 10.7
ledge on hand hygiene compliance, and the attitude were
Profession Physician 41 12.2 significantly associated with the hand hygiene compliance.
Nurse 120 35.8 Study participants who have taken training about hand
Laboratory 34 10.1 hygiene were 8.07 times more likely to have good hand
Midwives 74 22.1 hygiene compliance than those who have not taken train-
Others b
66 19.7
ing (AOR = 8.07, 95% CI: 2.91, 22.39). Study participants
who have adequate soap and water for handwashing were
Level of education Diploma 87 26
5.10 times more likely to have good hand hygiene compli-
Bachelor 200 59.7 ance as compared to study participants who have not ad-
2nd degree and abovec 48 14.3 equate soap and water for handwashing (AOR = 5.10,
Marital status Married 159 47.5 95%CI: 1.93, 13.52). The odds of having good hand hy-
Singled 176 52.5 giene compliance were 3.23 times more likely who have
Working experience 0–5 201 60
alcohol-based hand rub individually/wall matted than
those who did not have alcohol-based hand rub individu-
6–10 63 18.8
ally/wall matted. (AOR = 3.23, 95%CI: 1.32, 7.92). Those
11–15 36 10.7 who were knowledgeable of hand hygiene were 6.74 times
>16 35 10.5 more likely to have good handwashing compliance than
Unit of work OPD 74 22.1 those who were not knowledgeable for hand hygiene
Emergency 36 10.7 (AOR = 6.74, 95%CI: 2.96, 15.34). Furthermore, Study
Inpatient 53 15.8
participants who had a positive attitude towards hand
hygiene were 2.15 times more likely to have good
Laboratory 34 10.1
hand hygiene compliance as compared to who have a
OR 41 12.2 negative attitude for hand hygiene (AOR = 2.15, 95%
GYN Obs 63 18.8 CI: 1.04, 4.46) (Table 3).
Otherse 34 10.1
a
Protestant, Others Discussion
b
c
HO, Radiography, Anaesthesia, Optometry, pharmacy Poor hand hygiene compliance of health care providers
Masters and GP
d
Divorced, Widowed,
and its healthcare-associated infections have a greater
e
Triage impact on the patients in health care settings [13].
Engdaw et al. Antimicrobial Resistance and Infection Control (2019) 8:190 Page 4 of 7

Fig. 1 Study participants’ reasons for not practicing hand hygiene in Central Gondar Zone public primary hospitals, Northwest Ethiopia, 2019

The present study demonstrated that overall good Kuwait 33.4% [15], India 43.4% [16] and black lion hos-
hand hygiene compliance was 14.9%. The finding the pital, Ethiopia 79% [10]. But, this finding was higher as
study was in line with other study conducted in Univer- compared with a study carried out in Wachemo Univer-
sity of Gondar teaching hospital, Ethiopia 16.5% [11] sity teaching Hospital, Ethiopia 9.2% [17]. The variation
and lower than a studies conducted in Mali 21.8% [14], might be due to study setting, sample size, a lack of

Table 2 Variables related to hand hygiene compliance of health care providers in Central Gondar Zone public primary hospitals,
Northwest Ethiopia, 2019 (n = 335)
Variables Frequency Percent (%)
Knowledge Good 181 54
Poor 154 46
Frequently keep hand hygiene Yes 301 89.9
No 34 10.1
Taking training Yes 140 41.8
No 195 58.2
Hospital promotes the importance of HH to the staffs Yes 161 48.1
No 174 51.9
The presence of soap and water Yes 290 86.6
No 45 13.4
The presence of hand washing sink Yes 162 48.4
No 173 51.6
The presence of wall mount/ individual ABHR Yes 177 52.8
No 158 47.2
The presence of gloves Yes 266 79.4
No 69 20.6
The presence of posters Yes 137 40.9
No 198 59.1
The presence of a protocol level Yes 106 31.6
No 229 68.4
Attitude Positive 183 54,6
Negative 152 45.4
Engdaw et al. Antimicrobial Resistance and Infection Control (2019) 8:190 Page 5 of 7

Table 3 Bivariable and multivariable logistic regression analysis of factors associated with hand hygiene compliance among health
care providers in Central Gondar Zone public primary hospitals, Northwest Ethiopia, 2019 (n = 335)
Variables Hand hygiene compliance COR (95% CI) AOR (95% CI)
Good Poor
Knowing six steps of hand hygiene Yes 43 202 2.52 (1.09, 5.84) 1.36 (.47, 3.91)
No 7 83 1 1
Knowing five movements of hand hygiene Yes 45 229 5.87 (1.38, 24.88) 3.5 (.16, 5.65)
No 5 56 1 1
Trained for hand hygiene Yes 45 165 6.55 (2.52, 16.98) 8.07 (2.91, 22.39)a
No 5 120 1 1
Promotion for HH in Hospital Yes 32 129 2.15 (1.15, 4.01) 1.57 (.74, 3.33)
No 18 156 1 1
Have adequate soap & water for hand hygiene Yes 44 190 3.67 (1.51, 8.91) 5.10(1.93, 13.52)a
No 6 95 1 1
Presence of alcohol hand rub for individual Yes 43 156 5.07 (2.21, 11.68) 3.23 (1.32, 7.92)a
No 7 129 1 1
Presence of posters for hand hygiene Yes 28 109 2.06 (1.12, 3.77) .99 (.36, 2.67)
No 22 176 1 1
Presence of protocol level for hand hygiene Yes 26 80 2.78 (1.51, 5.12) 1.31 (.60, 2.85)
No 24 205 1 1
Knowledge about hand hygiene Good 41 140 4.71 (2.21, 10.07) 6.74(2.96, 15.34)a
Poor 9 145 1 1
Attitude towards hand hygiene Positive 34 149 1.94 (1.03, 3.67) 2.15 (1.04, 4.46)a
Negative 16 136 1 1
Statistically significant at α = 0.05, 1 = Reference group
a

awareness on healthcare-associated infections among Kingdom [20] and China [21] also showed that training
health care providers, passive Infection Prevention and had a positive relationship with HH compliance in all
Control Committees (IPCCs) holding nonsystematic medical staff. This may be due to the fact that training
hand hygiene training and audits, inaccessibility of hand built the knowledge of health care providers which had a
hygiene resources and it might be due availability of significant association in HH compliance and those
hand hygiene products and facilities. Alcoholic disinfec- HCPs who had got training is expected to be a role
tants were only used for disinfection of patients’ skin model for others in terms of practicing good HH, Know-
prior to aseptic procedures [18]. ledge of HCPs will help to identify risk and benefits
Knowledge of hand hygiene was associated with hand practice on the way of HCAIs transmission and how to
hygiene compliance. As a result, those who have good prevent. A single lecture on basic hand hygiene proto-
knowledge of HH had 6.74 times more compliance than cols had a significant and sustained effect in enhancing
those who have poor knowledge. This was in line with hand hygiene compliance in a Swedish hospital [22]. A
other similar study done in Kuwait which showed that study conducted in University hospital in central
knowledge of HCPs was significantly associated with good Ethiopia showed compliance with hand hygiene at base-
HH compliance [15]. The possible explanation might be line and at follow up after training have a significant re-
due to knowledge on hand hygiene compliance will help lationship with compliance [18].
to comply with hand hygiene with recommended way, The attitude was found to be significantly associated
knowledge will help to identify the advantage and disad- with HH compliance. As a result, those who had a posi-
vantages of hand hygiene compliance and identify the way tive attitude on hand hygiene had 2 times more compli-
of HCAIs transmission and how it is prevented. ance than a negative attitude. This was in line with other
Trained health care providers for hand hygiene were similar study done in Jordan which showed that the atti-
8.07 times more likely to have good hand hygiene com- tude of health care providers was significantly associated
pliance than those who were not trained health care pro- with good hand hygiene compliance [23]. Different
viders. Other studies were done in India [19], United reasons can be suggested for this, including the light
Engdaw et al. Antimicrobial Resistance and Infection Control (2019) 8:190 Page 6 of 7

workload they might have, the presence of Water Sanita- is minimal. This is primarily due to lack of infrastructure,
tion and Hygiene (WASH) committee, the presence of trained manpower, surveillance systems, poor sanitation,
positive peer pressure, good professional attitude to- overcrowding and understaffing of hospitals, the unfavor-
wards hand hygiene compliance, social factors, direct in- able social background of population, lack of legislation
struction from the respected body, personal experience, mandating accreditation of hospitals and a general attitude
media and educational and religious institutions. of non-compliance amongst health care providers towards
The odds of having good hand hygiene compliance even basic procedures of infection control [8].
were 3.23 times more likely who have alcohol-based Improvement strategies of poor hand hygiene compli-
hand rub individually/wall matted than those who did ance among health care providers by ensuring that the
not get alcohol-based hand rub individually/wall matted. necessary infrastructure and products are in place to
This is in line with other studies done in Taiwan [24] allow hand hygiene performance at the point of care.
and Brazil [25]. The availability of alcohol-based hand This includes access to a safe, continuous water supply
rub resulted in significant improvement in hand hygiene and the availability of soap and disposable towels, avail-
compliance of health care providers. This might be due ability of effective and well-tolerated alcohol-based hand
to the presence of alcohol-based hand rub the best way rub products at the point of care [2, 3, 27, 28].
of improving hand hygiene compliance, the presence of Provision of regular training to all healthcare workers is
alcohol-based hand rub at point of care was a reminder essential to heighten awareness of microbial transmission
to health care providers to do hand hygiene and it might by hands, emphasize the importance of hand hygiene and
be easy for implementing hand hygiene. Inaccessibility its indications, and to demonstrate the correct procedures
of resources in their nearby ward might be one of the for hand rubbing and hand washing. It may be achieved
reasons for not practicing hand hygiene. using regular presentations, e-learning modules, posters,
The other possible reasons are product selection on the focus groups, reflective discussion, videos, self-learning
antimicrobial profile, user acceptance, and cost. Additional modules, practical demonstrations, feedback from assess-
activity against fungi (including molds), mycobacteria, and ment, or combinations of these and other methods and
bacterial spores may be relevant in high-risk wards or dur- hand hygiene compliance health care providers may im-
ing outbreaks [2] and they are often available as a gel, or prove through placing reminders and prompts (posters,
on wipes. a study supports the fact that interactive educa- stickers, voice prompts, leaflets, gadgets, etc.) related to
tional programs combined with free availability of hand the importance of hand hygiene and the appropriate indi-
disinfectants significantly increased hand hygiene compli- cations and procedures for its performance [29–36].
ance [22]. Therefore, it is an excellent alternative to hand As far as a self-reported self-administered question-
hygiene when antimicrobial efficacy, time for the proced- naire the study may prone to social desirability bias.
ure, and limited access to sinks are of concern [26]. Since the study was done in public primary hospitals it
The use of WHO advocated alcohol-based hand rubs may lack generalizability for private primary hospital.
is a practical solution to overcome these constraints be-
cause these can be distributed individually to staff for Conclusions
pocket carriage and placed at the point of care. The Hand hygiene compliance among health care providers in
major advantage is that its use is well applicable to situa- Central Gondar Zone public primary hospital was poor as
tions typical of developing countries, such as two pa- compared to the WHO threshold. Training, attitude, the
tients sharing the same bed, or patient’s relatives being presence of alcohol-based hand rub in the working area, the
requested to help in care provision [14]. presence of adequate soap and water in the working area
Health care providers who got adequate soap and were significantly associated with hand hygiene compliance.
water for handwashing were 5.10 times more likely to Implementing five movements of hand hygiene are the best
had good hand hygiene compliance as compared to method for preventing healthcare-associated infections.
health professionals who had not got adequate soap Therefore, the health care provider should be followed this
and water for handwashing. This is in line with the principle to fight healthcare-associated infections.
study done in Black Lion hospital, Ethiopia [10] but,
Abbreviations
there was no significant relation with adequate soap AOR: Adjusted odds ratio; COR: Crude odds ratio; HCAI: Healthcare-associated
and water and hand hygiene compliance from a study Infections; HCP: Health care providers; HH: Hand hygiene; WHO: World
conducted in Gondar university teaching hospital, Health Organization
Ethiopia [11]. This may be due to the difference in hos- Acknowledgments
pitals setting, availability, and accessibility of resources, We are highly indebted to the College of Medicine and Health Sciences,
user acceptance, and cost. University of Gondar, for supporting this research project. We would like to
extend our thanks to Amhara regional state, all hospital administration for
Like in other developing countries, the priority given to permission to conduct the study. We would also like to extend our
prevention and control of healthcare-associated infection appreciation to the study participants, supervisors and data collectors.
Engdaw et al. Antimicrobial Resistance and Infection Control (2019) 8:190 Page 7 of 7

Authors’ contributions 14. Allegranzi B, Sax H, Bengaly L, Riebet H, Minta DK, Chraiti M-N, et al.
All stated authors GTE, MG, ZA are involved in the study from the inception Successful implementation of the World Health Organization hand hygiene
to design, acquisition of data, analysis and interpretation and drafting of the improvement strategy in a referral hospital in Mali, Africa. Infect Control
manuscript. All authors read and approved the final manuscript. Hosp Epidemiol. 2010;31(2):133–41.
15. Al-Wazzan B, Salmeen Y, Al-Amiri E. Abul aa, Bouhaimed M, Al-Taiar a. hand
Funding hygiene practices among nursing staff in public secondary care hospitals in
No funding source. Kuwait: self-report and direct observation. Med Princ Pract. 2011;20(4):326–31.
16. Sharma S, Sharma S, Puri S, Whig J. Hand hygiene compliance in the
Availability of data and materials intensive care units of a tertiary care hospital. Indian J Community Med.
Data will be made available upon the reasonable request to the primary 2011;36(3):217.
author. 17. Ayele Y, Addise A. Hand hygiene compliance and associated factors among
health professionals in Wachemo University hospital, Hossaena, south West
Ethics approval and consent to participate Ethiopia. IJIRD. 2017;6:28–35.
Ethical clearance was approved and obtained from the Institutional Review 18. Pfäfflin F, Tufa T, Mesfun MG, Nigussie T, Schönfeld A, Häussinger D, et al.
Board of the University of Gondar College of Medicine and Health Sciences, Implementation of the WHO multimodal hand hygiene improvement
Institute of Public Health. Then the official permission letter was collected strategy in a University Hospital in Central Ethiopia. Antimicrob Resist Infect
from the Central Gondar Zone health department and from each Public Control. 2017;6:3.
Primary Hospital admin offices. Written informed consent was obtained from 19. Suchitra J, Devi NL. Impact of education on knowledge, attitudes and
each study participant after they were included in this study. The purpose of practices among various categories of health care workers on nosocomial
the study was explained to study participants before giving consent. We infections. Indian J Med Microbiol. 2007;25(3):181.
deliver information on the right to interrupt the observation and refuse to fill 20. Randle J, Clarke M, Storr J. Hand hygiene compliance in healthcare workers.
the self-administered questionnaires. J Hosp Infect. 2006;64(3):205–9.
21. Lam BC, Lee J, Lau Y. Hand hygiene practices in a neonatal intensive care
unit: a multimodal intervention and impact on nosocomial infection.
Consent for publication
Pediatrics. 2004;114(5):e565–e71.
Not applicable.
22. Sjöberg M, Eriksson M. Hand disinfectant practice: the impact of an
education intervention. Open Nurs J. 2010;4:20.
Competing interests
23. Al-Hussami M, Darawad M, Almhairat II. Predictors of compliance handwashing
The authors declare that they have no competing interests.
practice among healthcare professionals. Healthc Inf. 2011;16(2):79–84.
24. Chen Y-C, Sheng W-H, Wang J-T, Chang S-C, Lin H-C, Tien K-L, et al.
Received: 28 August 2019 Accepted: 24 October 2019
Effectiveness and limitations of hand hygiene promotion on decreasing
healthcare–associated infections. PLoS One. 2011;6(11):e27163.
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