Hand Hygiene Practices Among Healthcare Workers Worldwide: A Systematic Review and Meta-Summary of Qualitative Research Xiaoxing He, MD, MPH 1, Sheryl Chatfield, PhD, CTRS 2, Jeffrey Hallam, PhD, CHES 1 1 Social and Behavioral Sciences, College of Public Health, Kent State University, Kent, OH 2 University of South Alabama, Mobile, AL Introduction Methods Results Table 1. Interpersonal FactorDeveloping CountryDeveloped Country Barriers:Limited knowledge, lack of skills, impractical, skin damage belief Limited knowledge, poor attitude, impractical, skin damage belief Facilitators:Self-protection, positive attitude, & training Self-protection, personalized feedback from surveillance data & evidence of efficacy Environment Factor Barriers:Water scarcity, lack of AHR or resources, emergency situations; understaff Emergent situation, understaff Facilitators:Improvement in resources, hand hygiene posters in strategic places Better resources, use of AHR, automated sinks Social Behavioral Factor Barriers:Tolerance of dirtiness, cultural belief of HH disrespectful to patients Negative role models,, adjusting own behavior to match social norm Facilitators:Positive role model, supervisors’ requirements Stronger social norm, positive role models System Factor Barriers:Inadequate support, absence of efficiency Lack of initiatives or sanction Facilitators:Supervision, hand hygiene policy, & training Audits, reinforcement Meta-Summary  Systematic search of five computer- based literature indexes to identify relevant peer-reviewed publications 1.Medline 2.PSYCINFO 3.CINAHL 4.EMBASE 5.Web of Science Core Collection  Used a combination of subject terms, methodological terms, and outcome terms  Appraised the identified studies, using the Critical Appraisal Skills Programme (CASP) qualitative research checklist Inclusion Criteria  Study setting: Hospitals, nursing homes and healthcare facilities worldwide  Study population: Health Care Workers  Study subject: Hand Hygiene Compliance  Study design: Qualitative or mixed methods with an emphasis on qualitative study design  Study outcome: Health Care Workers’ perception of factors associated with Hand Hygiene compliance American Public Health Association Annual Research Meeting ● Chicago, IL ● 2015  Use of individual criteria was more likely than HH guidelines  Lack of resources was a greater barrier in developing countries  Self-protection motivated higher compliance than reducing cross infection  Among new healthcare workers, work- site norm had more influence on compliance than previous training or education  Positive peers, supervisors, role models, and regular audits or performance feedback facilitated long- term compliance Epidemiological evidence shows that although hand hygiene is a simple and effective practice on preventing cross infections, compliance remains suboptimal. Published reviews have only synthesized quantitative study results. Specific Aims Systematically review qualitative research exploring healthcare workers’ perspectives regarding interpersonal, socio-environment, and health system factors associated with hand hygiene compliance. Discussion Total findings 17 grouped topics 5 major topics: Individual criteria (13%) Training & education (12%) Site norms & role models (12%) Resources (8%) Procedures & management (8%) Conclusion Intervention Priorities  Strengthen organizational infrastructure  Develop practice norm or patient safety climate  Set-up positive role models  On-going reminders or evidence-based education and training  Regular audits, feedback, or supervisions  Achieving optimal hand hygiene compliance is a complex challenge that benefits from developing a positive practice norm at both individual and system levels  Adequate infection control policy and resource planning could improve population health at healthcare facilities worldwide