以健康信念模式探討臺灣醫護人員執行手部衛生意圖之相關因素

Abstract

背景：醫療照護相關感染是公共衛生領域中重要的病人安全議題，依據世界衛生組織之估計，全球每年約有10% 之住院病人遭受感染，造成諸多不良的健康後果，而醫療照護相關感染的病原體最常透過醫護人員的手傳播，但手部衛生遵從率不到四成，為感染控制需加強之處。先前研究證實，提升醫護人員手部衛生行為，是預防醫療照護相關感染之經濟且有效的方法，然而，臺灣目前對於醫護人員執行手部衛生之意圖及相關因素，仍缺乏依據理論之系統性調查與討論。 目的：本研究係以健康信念模式 (Health Belief Model, HBM) 為架構，透過問卷調查，檢視臺灣醫護人員手部衛生意圖之相關因素，並將醫師與護理師分層進行分析，以供未來發展適性衛教或介入策略之實證參考依據。 方法：本研究係於2018年12月至2019年3月期間，透過網路匿名自填式問卷，針對臺灣執業於醫學中心、區域醫院或地區醫院之醫師及護理師進行招募，共計705位醫護人員參與並納入最終統計分析。問卷題項主要依據HBM之五大構念（自覺罹患性、自覺嚴重度、自覺利益、自覺障礙、行動線索）設計而成，並使用探索性因素分析，針對前四項構念之相關題項萃取潛在因素，再運用多變項羅吉斯迴歸，進行醫護分層分析，探討影響醫護人員未來執行手部衛生意圖之相關因素。 結果：本研究之探索性因素分析共萃取出十個潛在因素，針對醫護人員整體而言，其中四因素與高洗手意圖具統計顯著關聯，分別為：較高之與預防感染相關之「自覺利益」(AOR=2.84)、較高之與工作相關之「自覺利益」(AOR=1.70)、較高之與時間相關之「自覺障礙」(AOR=0.36)，及較高之「行動線索」(AOR=1.89)。將醫護分層分析後發現，與醫師未來洗手意圖最相關之因素為，與預防感染相關之「自覺利益」(AOR=14.27)，反觀護理師，較認同執行手部衛生可以讓自己覺得是位稱職的醫護人員時 (AOR=2.99)，其未來具高洗手意圖之勝算比顯著較高。此外，本研究亦發現，當醫護人員工作之醫療場所有推行洗手政策時 (AOR=4.43)，對醫護人員整體之洗手意圖亦有正向影響。 結論：此研究運用HBM為架構，探討臺灣醫護人員未來執行手部衛生之意圖，發現影響醫師與護理師洗手意圖之因素不同。未來若欲提升醫師洗手意圖，建議可於常態之感染控制課程中，提供實證科學之證據，強化其洗手可有效預防感染之信念；對護理師而言，則建議可於醫院內衛教宣導及單位會議中，以正向態度表揚與讚美其表現，增強其洗手可展現其專業性之信念。最後，醫療院所可用多元管道加強宣導並落實全院性洗手政策，建立完整獎懲制度，以提升醫護人員手部衛生行為。

Background: Healthcare-associated infection (HAI) is an important patient safety issue in public health. The World Health Organization (WHO) estimated that 10% of inpatients worldwide suffered from HAI each year, causing many adverse health consequences, and HAI was mostly transmitted through the hands of healthcare workers (HCWs), but their prevalence of hand hygiene (HH) practice was below 40%, which could be improved for infection control. Prior studies have confirmed that increasing the HH practice of HCWs was a cost-effective way to prevent HAI; however, little is known about HH intention and its associated factors among HCWs in Taiwan. Objectives: This study aimed to systematically examine the HH intention and associated factors among physicians and nurses in Taiwan, using the Health Belief Model (HBM) as a theoretical framework. Analysis would also be performed separately for physicians and nurses for comparison. Methods: An anonymous online survey was conducted between December 2018 and March 2019. Responses from 103 physicians and 602 nurses were received. Survey items were developed on the basis of the five constructs of HBM (perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action). Multivariate logistic regression was used to explore factors associated with HH intention, separately for physicians and nurses. Results: Exploratory factor analysis extracted ten potential factors, four of which were significantly associated with high HH intention among HCWs, as follows: high “perceived benefits” about infection prevention (AOR=2.84), high “perceived benefits” about praise/respect at work (AOR=1.70), high “perceived barriers” about time (AOR=0.36), and high “cues to action” (AOR=1.89). The stratified analysis found that physicians’ HH intention was strongly related to “perceived benefits” about infection prevention (AOR=14.27). By contrast, nurses who believed HH can make them feel like a competent HCW (AOR=2.99) were more likely to have high HH intention. Notably, in hospitals with HH policy (AOR=4.43), HCWs also had greater HH intention. Conclusions: This HBM-based study explored HH intention among HCWs in Taiwan and found different HBM factors associated with physicians’ and nurses’ HH intention. To increase physicians’ HH intention, empirical evidence could be provided to them via on-the-job training to strengthen their beliefs in the effectiveness of HH practice for HAI prevention. For nurses, praising their HH practice during departmental meetings might help enhance their beliefs in their professionalism if they practice HH as recommended. Finally, efforts should be made to further promote hospital-wide HH policy with proper incentives to improve the HH practice among HCWs.