Review Article

Hand hygiene adherence among Iranian nurses: A systematic review and meta-analysis


Background & Aim: Adherence of nurses to hand hygiene is important for the prevention of healthcare-associated infections. This study aims to systematically review the existing studies that assess Iranian nurses' adherence to hand hygiene and estimate their amount with meta-analysis.
Methods & Materials: We performed a systematic search for peer-reviewed journals published from 2005 to 2018. The systematic search was conducted using both international (Google Scholar, PubMed, SCOPUS, and Web of Sciences) and Iranian databases (Scientific Information Database, IranMedex, Magiran, and MedLib). The search was carried out using a combination of the following terms: “adherence”, “compliance”, “hand hygiene”, “nurse”, “Iran”, “nursing practice”, “nursing”, and “guidelines”. The combinations of these words with Boolean operators like ‘AND’, ‘OR’ and ‘NOT’ were used.
Results:  A total of 22 articles were used in the final analyses. The pooled proportion of hand hygiene adherence was 40.5 percent [95% confidence interval [CI]: 31.1–49.8]. Sensitivity analysis confirmed that the overall estimated pooled proportion of hand hygiene adherence did not vary significantly with the elimination of any of the 22 studies, observer or self-reported hand hygiene, instrument of measurement, unit of measurements, sample size, and time.
Conclusion: The level of adherence of Iranian nurses to hand hygiene can potentially increase the chance of healthcare-associated infections and put patients and nurses at risk. Hospital and nursing managers should take practical steps to investigate factors contributing to the failure of hand hygiene adherence among nursing staff. They should ensure the continuous implementation of hand hygiene improvement strategy.

1. Ziaee M, Vafaeenejad R, Bakhtiari G, Mostafavi I, Gheibi M, Fathabadi JM, et al. National Nosocomial Infection Surveillance System–based study in north eastern of Iran. Social Determinants of Health. 2017;3(2):64-9.
2. Magill SS, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Kainer MA, et al. Multistate point-prevalence survey of health care–associated infections. New England Journal of Medicine. 2014;370(13):1198-208.
3. Allegranzi B, Nejad SB, Combescure C, Graafmans W, Attar H, Donaldson L, et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. The Lancet. 2011;377(9761):228-41.
4. Fry DE. The economic costs of surgical site infection. Surgical infections. 2002;3(S1):s37-s43.
5. Bagheri P. The Review Systematic and Meta Analysis of Prevalence and Causes of Nosocomial Infection in Iran. Iranian Journal of Medical Microbiology. 2015;8(4):1-12.
6. Murni IK, Duke T, Kinney S, Daley AJ, Soenarto Y. Reducing hospital-acquired infections and improving the rational use of antibiotics in a developing country: an effectiveness study. Archives of disease in childhood. 2015;100(5):454-9.
7. Ciorlia LA, Zanetta DM. Hepatitis B in healthcare workers: prevalence, vaccination and relation to occupational factors. Brazilian Journal of Infectious Diseases. 2005;9(5):384-9.
8. Menzies D, Joshi R, Pai M. Risk of tuberculosis infection and disease associated with work in health care settings [state of the art series. Occupational lung disease in high-and low-income countries, edited by M. Chan-Yeung. Number 5 in the series]. The International Journal of Tuberculosis and Lung Disease. 2007;11(6):593-605.
9. AL-Rawajfah OM, Tubaishat A. Nursing students' knowledge and practices of standard precautions: a Jordanian web-based survey. Nurse education today. 2015;35(12):1175-80.
10. Salama MF, Jamal WY, Al Mousa H, Al-AbdulGhani KA, Rotimi VO. The effect of hand hygiene compliance on hospital-acquired infections in an ICU setting in a Kuwaiti teaching hospital. Journal of infection and public health. 2013;6(1):27-34.
11. Harbarth S, Sax H, Gastmeier P. The preventable proportion of nosocomial infections: an overview of published reports. Journal of Hospital infection. 2003;54(4):258-66.
12. Cole M. Exploring the hand hygiene competence of student nurses: a case of flawed self assessment. Nurse education today. 2009;29(4):380-8.
13. Loveday H, Wilson J, Pratt R, Golsorkhi M, Tingle A, Bak A, et al. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection. 2014;86:S1-S70.
14. Efstathiou G, Papastavrou E, Raftopoulos V, Merkouris A. Compliance of Cypriot nurses with standard precautions to avoid exposure to pathogens. Nursing & health sciences. 2011;13(1):53-9.
15. Gammon J, Morgan‐Samuel H, Gould D. A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions. Journal of clinical nursing. 2008;17(2):157-67.
16. Ahn E, Kang H. Introduction to systematic review and meta-analysis. Korean journal of anesthesiology. 2018;71(2):103-12.
17. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. 2000;283(15):2008-12.
18. Haghdoost AA, Moosazadeh MJJorimstojoIUoMS. The prevalence of cigarette smoking among students of Iran's universities: A systematic review and meta-analysis. 2013;18(8):717.
19. Moosazadeh M, Nekoei‐moghadam M, Emrani Z, Amiresmaili MJTIjohp, management. Prevalence of unwanted pregnancy in Iran: a systematic review and meta‐analysis. 2014;29(3):e277-e90.
20. Rezaei S, Hajizadeh M, Zandian H, Fathi A, Nouri BJRin, health. Period prevalence and reporting rate of needlestick injuries to nurses in Iran: a systematic review and meta‐analysis. 2017;40(4):311-22.
21. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. Bmj. 2003;327(7414):557-60.
22. Ades A, Lu G, Higgins JJMDM. The interpretation of random-effects meta-analysis in decision models. 2005;25(6):646-54.
23. Higgins JP, Thompson SGJSim. Controlling the risk of spurious findings from meta‐regression. 2004;23(11):1663-82.
24. Tobias AJSTB. Assessing the influence of a single study in the meta-analysis estimate. 1999;47:15-7.
25. Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infection Control & Hospital Epidemiology. 2010;31(3):283-94.
26. Pires D, Pittet D. Hand hygiene mantra: teach, monitor, improve, and celebrate. Elsevier; 2017.
27. Shafer E. Infection prevention in hospitals: The importance of hand hygiene. Infectious Diseases in Children. 2014;27(6):1.
28. Chan MF, Ho A, Day MC. Investigating the knowledge, attitudes and practice patterns of operating room staff towards standard and transmission‐based precautions: results of a cluster analysis. Journal of clinical nursing. 2008;17(8):1051-62.
29. Osborne S. Influences on compliance with standard precautions among operating room nurses. American journal of infection control. 2003;31(7):415-23.
30. Kermode M, Jolley D, Langkham B, Thomas MS, Holmes W, Gifford SM. Compliance with Universal/Standard Precautions among health care workers in rural north India. American journal of infection control. 2005;33(1):27-33.
31. Barrett R, Randle J. Hand hygiene practices: nursing students’ perceptions. Journal of Clinical Nursing. 2008;17(14):1851-7.
32. Kingston LM, O'Connell NH, Dunne CP. Survey of attitudes and practices of Irish nursing students towards hand hygiene, including handrubbing with alcohol-based hand rub. Nurse education today. 2017;52:57-62.
33. Pittet D, Allegranzi B, Boyce J, Experts WHOWAfPSFGPSCCGo. The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations. Infection Control & Hospital Epidemiology. 2009;30(7):611-22.
34. Safety WP, Organization WH. A guide to the implementation of the WHO multimodal hand hygiene improvement strategy. 2009.
35. Smiddy MP, O'Connell R, Creedon SA. Systematic qualitative literature review of health care workers' compliance with hand hygiene guidelines. American journal of infection control. 2015;43(3):269-74.
36. Huang L, Lin G, Tang L, Yu L, Zhou Z. Special attention to nurses’ protection during the COVID-19 epidemic. BioMed Central; 2020.
37. Tabrizi JS. Clinical attitude process: "hand hygiene" in nurses. Nursing Management 2015;4(1):39-48.
38. Tabrizi JS, Partovi Y. Clinical Audit of Hand Hygiene Process of Nurses in a General Hospital in Tabriz city. Journal of Hospital. 2015;14(2):23-34.
39. Nematian SSS, Palenik CJ, Mirmasoudi SK, Hatam N, Askarian M. Comparing knowledge and self-reported hand hygiene practices with direct observation among Iranian hospital nurses. American journal of infection control. 2017;45(6):65-7.
40. Mostafazadeh-Bora M, Bahrami M, Hosseini A. A survey of nurses' compliance with hand hygiene guidelines in caring for patients with cancer in a selected center of Isfahan, Iran, in 2016. Iranian journal of nursing and midwifery research. 2018;23(2):119.
41. Albughbis M, Neisi A, Borvayeh H. Hand Hygiene Compliance among ICU Health Workers in Golestan Hospital in 2013. Jundishapur Scientific Medical Journal. 2016;15(3):355-62.
42. Askarian M, Khalooee A, Emroodi N. Personal hygiene and safety of governmental hospital staff in Shiraz, Islamic Republic of Iran. Eastern Mediterranean Health Journal. 2006;12(6):768.
43. Kavakebi N, Aliabadi P, Pazani K, Aslnejad-Moghaddami N, Tahmasbi Z, Abbasian P, et al. Hand Hygiene Compliance among Personnel of Taleghani Hospital in Tabriz. Taṣvīr-i salāmat. 2016;7(3):46-53.
44. Najafi Ghezeljeh T, Abbasnejad Z, Rafii F, Haghani H. Nurses’ Knowledge, Beliefs and Practices towards Hand Hygiene. Journal of hayat. 2015;21(1):79-93.
45. Toulabi T, Amini F, Payamani S. The rate of following infection control principles in educational hospitals of Khorramabad Yafteh. 2006;8(3):37-46.
46. Fesharaki MG, Rahmati-Najarkolaei F, Aghamiri Z, Mohamadian M. Hand-Washing Compliance Rate and the Influencing Factors. Archives of Clinical Infectious Diseases. 2014;9(4):1-4.
47. Zandiyeh M, Borzo SR. The level of hand hygiene compliance by operating room personnel of‎ Educational Hospitals in Hamadan University of Medical Science. Journal of Holistic Nursing And Midwifery. 2012;22(1):23-9.
48. Hazavehei MM, Noryan F, Rezapour Sahkolaee F, Moghimbayge A. Assessing the effective factors on hand hygiene using Planned Behavior Model among nursing and midwifery staff in Atea hospital of Hamadan in 2015. Journal of Hospital. 2016;15(1):51-8.
49. Nazari R, Hasani SA, Khazaeinejad S. Effect of involuntary motivational factors on hand hygiene by health care providers. Journal of Nursing and Midwifery Sciences. 2015;2(4):24-9.
50. Samadipour E, Daneshmandi M, Salari MM. Hand hygiene practice in Sabzevar hospitals Iran Journal of Sabzevar University of Medical Sciences. 2008;15(1):59-64.
51. Hosseinialhashemi M, Kermani FS, Palenik CJ, Pourasghari H, Askarian M. Knowledge, attitudes, and practices of health care personnel concerning hand hygiene in Shiraz University of Medical Sciences hospitals, 2013-2014. American journal of infection control. 2015;43(9):1009-11.
52. Sharif A, Arbabisarjou A, Balouchi A, Ahmadidarrehsima S, Kashani HH. Knowledge, Attitude, and Performance of Nurses toward Hand Hygiene in Hospitals. Global journal of health science. 2016;8(8):57.
53. Ataei B, Zahraei S, Pezeshki Z, Babak A, Nokhodian Z, Mobasherizadeh S, et al. Baseline evaluation of hand hygiene compliance in three major hospitals, Isfahan, Iran. Journal of Hospital Infection. 2013;85(1):69-72.
54. Nazari R, Haji Ahmadi M, Dadashzade M, Asgari P. Study of hand hygiene behavior among nurses in Critical Care Units. Iranian Journal of Critical Care Nursing. 2011;4(2):93-6.
55. Naderi HR, Sheybani F, Mostafavi I, Khosravi N. Compliance with hand hygiene and glove change in a general hospital, Mashhad, Iran: an observational study. American Journal of Infection Control. 2012;40(6):221-3.
56. Farbakhsh F, Shafieezadeh T, Zahraiee M, Pezeshki Z, Hodaiee P, Farnoosh F, et al. Acceptance Rate of Hand Hygiene in Health Worker. Iranian Journal of Infectious Diseases and Tropical Medicine. 2013;18(61):9-13.
57. Sadeghi Moghaddam P, Arjmandnia M, Shokrollahi M, Aghaali M. Does training improve compliance with hand hygiene and decrease infections in the neonatal intensive care unit? A prospective study. Journal of Neonatal-Perinatal Medicine. 2015;8(3):221-5.
58. Shiva F, Kamali M, Shirvani F, Armin S, Ghanaiei R, Tabatabaie SR, et al. Hand hygiene compliance by the health care staff in a pediatric hospital. Archives of Pediatric Infectious Diseases. 2014;2(4):1-5.
IssueVol 8 No 1 (2021): Winter QRcode
SectionReview Article(s)
nurses; hand hygiene; adherence; clinical guidelines; systematic review; Iran

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
Nouri B, Hajizadeh M, Bahmanpour K, Sadafi M, Rezaei S, Valiee S. Hand hygiene adherence among Iranian nurses: A systematic review and meta-analysis. NPT. 8(1):11-24.