Infections related to healthcare are among the most important causes of morbidity and mortality in hospitalized patients. A study of prevalence carried out by the World Health Organization (WHO) in 55 hospitals from 14 countries, showed that 8.7% of hospitalized patients contract Nosocomial Infections (NI). The importance of NI in terms of morbidity, mortality, impact on quality of life in patients and relatives and secondary economic costs, has been emphasized repeatedly in the last years [
1]. In the developed countries, around 5-10% of patients admitted to hospitals for acute conditions presented an infection that was not being incubated or present at the time of admission. Healthcare-related infections are the direct cause of 80,000 deaths in the United States and 5,000 deaths in England every year [
2,
3]. According to data from the Survey on Prevalence of Nosocomial Infection in Spain (EPINE study) for 2006 [
4], NI affected between 7% and 9% of patients admitted to Spanish hospitals. These data are very similar to those for developed countries in terms of frequency, economic cost and mortality [
5]. NI present many of the characteristics that define a significant problem in patient safety: affect millions of people all over the world, complicate patient care, contribute to the patient death or temporary/permanent disability, increase resistance to antimicrobials and generate substantial additional costs in the treatment of the patient disease.
There are many causes of NI, which are related to healthcare systems and processes, as with the behavior of the professionals involved. The results of the Study of the Efficacy of Nosocomial Infection Control (SENIC study) finding that vigilance is an effective method for the prevention of NI [
6,
7]. Indeed, in the hospitals included in the infection prevention program where prevention and control activities were carried out, infection rates was a reduction near to 32%. Other studies have shown the benefits of NI prevention in healthcare and economic terms [
8,
9].
Measures to reduce infections related to healthcare: hand hygiene
The areas of action against these infections are based on simple and well established precautions which have been seen to be effective and widely accepted - the "ordinary precautions" cover all the basic principles for controlling infections that required in all healthcare centers. They are applied to all patients regardless of their diagnosis, risk factors, and infection status, in order to reduce the risk to the patient and healthcare workers of contracting infections. Hand hygiene (HH) is an important element in ordinary precautions and is the most effective measure for preventing infections.
The hands of health workers (HCWs) are the most common carrier of transmission of microorganisms from one patient to another, from one area of the patient's body to another and from a polluted environment to patients. The HH is considered the most important measure, because of its proven efficiency (it is estimated that the impact on the reduction of NI is 50%), its effectiveness, and its low cost [
10]. However, there is poor compliance with HH regulations by healthcare workers all over the world, and all the studies carried out in hospitals suggest that the frequency of compliance is lower than 50% of the opportunities in which the practice is considered a priority [
11,
12].
There are different factors contributing to low levels of HH compliance, both among the professionals: lack of knowledge of the importance of preventing NI, a lack of understanding of the appropriate techniques involved, the occurrence of contact dermatitis; and by the healthcare organization: staff shortaged, work overload, difficult access to points used for conventional hand hygiene, and finally, the absence of an institutional commitment to overall improvement of HH.
Pittet et al [
13], carried out a study in a university hospital, based on direct observation of physicians, and identified behavioral factors associated with beliefs, attitudes and perceptions in non-compliance of HH. There was over 75% believed that not performing HH led to a higher risk of cross-transmission, 72% thought that HH was unnecessary after removing gloves and 72% thought that HH was necessary after each patient.
In an epidemiological study of HH carried out in 1994 in hospitals affiliated to the University of Geneva, was observed an average rate of compliance of 48% [
14]. This study identified as factors associated with a lack of compliance: professional category (nurses had higher rates of compliance than other professionals), high risk activities for NI in units caring for patients in a critical condition, undertaking procedures with a high level of bacterial contamination, and an overload of work among healthcare professionals.
In another study, in a Spanish hospital [
15], about HH compliance and its associated factors, the average for compliance was 31%. This is very low, regarding that the observation was made after a period of health education on the HH and with the prior knowledge of the professional that they were being evaluated.
The Atlanta Centers for Disease Control and Prevention (CDC) published an extensive review of recommendations for HH in healthcare institutions in 2002. It recommended using alcohol-based solutions, instead of washing hands with soap or antiseptic, in order to increase compliance with this action for the prevention of NI [
16].
Numerous studies have shown that educational programs can effectively increase knowledges, positive attitudes and appropriate practice to ensure compliance with international protocols and regulations for the prevention and control of NI [
17‐
19].
The Cochrane review in 2007 on "Interventions to improve hand hygiene compliance in patient care" concludes that there are few evidence to inform the choice of interventions to improve HH, and that studies with consistent designs are urgently required in order to examine the effectiveness of well designed interventions to increase HH compliance, and take into account the factors related to the behavior of HCWs, based on knowledge of the behavioral and social sciences [
20].
The WHO in 2004, approved the creation of an "Alliance for Patient Safety", which acknowledged the universal need to improve HH in healthcare institutions, developing a strategy with a very clear call to action: "Clear hands are safer hands". These globally approved recommendations reinforce the need for multidisciplinary interventions, including important elements such as education and motivation on healthcare workers, the inclusion of alcohol-based solutions, the use of compliance indicators and a strong commitment by all healthcare managers [
21,
22].
The Quality Plan for the Spanish National Health System of 2007, in patient safety, proposed the development of strategies, measures and programs to promote safe practices in healthcare centers. These included the promotion of clean hands practices in all healthcare centers, and recommended the use of alcohol-based solutions as an effective measure to reduce the incidence of healthcare-associated infection [
23].
In view of all the above, it seems necesary to carry out studys like the one proposed here, in order to evalued the effect of a hand hygiene training program (TP) on the reduction of healthcare-associated infections among health workers in primary healthcare centers, and to know what factors (intrinsic and extrinsic) are related with the failure (or inadequate compliance with) in the HH.