Religious influence on hand hygiene should be considered when developing hand hygiene promotion strategies.
The interaction of religion and cultural norms should be specifically examined for better understanding of healthcare workers’
The practice of handwashing with soap and water or handrubbing using an alcohol‐based handrub (ABHR) is influenced by many social, cultural, and religious beliefs.
There are several reasons why religious and cultural issues should be considered when dealing with the topic of hand hygiene and planning a strategy to promote it in health-care settings.
The most important is that these Guidelines, issued as a WHO document, are intended to be disseminated all over the world and in settings where very different cultural and religious beliefs may strongly influence their implementation. Furthermore, the guidelines consider new aspects of hand hygiene promotion, including behavioural and transcultural issues.
Within this framework, a WHO Task Force on Religious and Cultural Aspects of Hand Hygiene was created to explore the potential influence of transcultural and religious factors on attitudes towards hand hygiene practices among HCWs and to identify some possible solutions for integrating these factors into the hand hygiene improvement strategy. This section reflects the findings of the Task Force.
In view of the vast number of religious faiths worldwide, only the most widely represented have been taken into consideration this reason, this section is by no means exhaustive. Some ethno-religious aspects such as the followers of local, tribal, animistic or shamanistic religions were also considered.
Philanthropy, generally inherent in any faith, has often been the motivation for establishing a relationship between the mystery of life and death, medicine, and health care.
This predisposition has often led to the establishment of health-care institutions under religious affiliations. Faith and medicine have always been integrated into the healing process as many priests, monks, theologians and others inspired by religious motivations studied, researched, and practised medicine.
In general, religious faith has often represented an outstanding contribution to highlighting the ethical implications of health care and to focusing the attention of health-care providers on both the physical and spiritual natures of human beings.
Well-known examples already exist, however, of health interventions where the religious point of view had a critical impact on implementation or even interfered with it.
Research has already been conducted into religious and cultural factors influencing health-care delivery, but mostly in the field of mental health or in countries with a high influx of immigrants where unicultural care is no longer appropriate.
In a recent world conference on tobacco use, the role of religion in determining health beliefs and behaviours was raised; it was considered to be a potentially strong motivating factor to promote tobacco control interventions.
A recent review enumerates various potential positive effects of religion on health, as demonstrated by studies showing its impact on disease morbidity and mortality, behaviour, and lifestyles as well as on the capacity to cope with medical problems.
Beyond these particular examples, the complex association between religion, culture, and health, in particular hand hygiene practices among HCWs, still remains an essentially unexplored, speculative area.
In the increasingly multicultural, globalized community that is health-care provision today, cultural awareness has never been more crucial for implementing good clinical practice in keeping with scientific developments.
Immigration and travel are more common and extensive than ever before as a result of the geopolitically active forces of migration, asylum-seeking and, in Europe, the existence of a broad, borderless multi-state Union.
With the increasingly diverse populations accompanying these changes, very diverse cultural beliefs are also more prevalent than ever. This evolving cultural topography demands new, rapidly acquired knowledge and highly sensitive, informed insights of these differences, not only among patients but also among HCWs who are subject to the same global forces.
It is clear that cultural – and to some extent, religious – factors strongly influence attitudes to inherent community handwashing which, according to behavioural theories (see Part I, Section 18), are likely to have an impact on compliance with hand cleansing during health care.
In general, the degree of HCWs’ compliance with hand hygiene as a fundamental infection control measure in a public health perspective may depend on their belonging to a community-oriented, rather than an individual-oriented society.
The existence of a wide awareness of everyone’s contribution to the common good, such as health of the community, may certainly foster HCWs’ propensity to adopt good hand hygiene habits.
For instance, hand cleansing as a measure of preventing the spread of disease is clearly in harmony with the fundamental Hindu value of non-injury to others (ahimsa) and care for their well-being (daya).
Another interesting aspect may be to evaluate optional methods of hand cleansing which exist in some cultures according to deep-seated beliefs or available resources.
As an example, in the Hindu culture, hands are rubbed vigorously with ash or mud and then rinsed with water. The belief behind this practice is that soap should not be used as it contains animal fat.
If water is not available, other substances such as sand are used to rub the hands. In a scientific study performed in Bangladesh to assess faecal coliform counts from post-cleansing hand samples, hand cleansing with mud and ash was demonstrated to be as efficient as with soap.766
In addition to these general considerations, some specific issues to be investigated in a transcultural and transreligious context are discussed.
Based on a review of the literature and the consultation of religious authorities, the most important topics identified were the importance of hand hygiene in different religions, hand gestures in different religions and cultures, the interpretation of the concept of “visibly dirty hands”, and the use of alcohol-based handrubs and alcohol prohibition by some religions.
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Importance of hand hygiene in different religions
Personal hygiene is a key component of human well-being regardless of religion, culture or place of origin. Human health-related behaviour, however, results from the influence of multiple factors affected by the environment, education, and culture.
According to behavioural theories hand cleansing patterns are most likely to be established in the first 10 years of life.
This imprinting subsequently affects the attitude to hand cleansing throughout life, in particular, regarding the practice called “inherent hand hygiene, which reflects the instinctive need to remove dirt from the skin.
The attitude to handwashing in more specific opportunities is called “elective handwashing practice” and may much more frequently correspond to some of the indications for hand hygiene during health-care delivery.
In some populations, both inherent and elective hand hygiene practices are deeply influenced by cultural and religious factors. Even though it is very difficult to establish whether a strong inherent attitude towards hand hygiene directly determines an increased elective behaviour, the potential impact of some religious habits is worth considering.
Hand hygiene can be practiced for hygienic reasons, ritual reasons during religious ceremonies, and symbolic reasons in specific everyday life situations (see ). Judaism, Islam and Sikhism, for example, have precise rules for handwashing included in the holy texts and this practice punctuates several crucial moments of the day.
Therefore, a serious, practicing believer is a careful observer of these indications, though it is well known that in some cases, such as with Judaism, religion underlies the very culture of the population in such a way that the two concepts become almost indistinguishable.
As a consequence of this, even those who do not consider themselves strong believers behave according to religious principles in everyday life. However, it is very difficult to establish if inherent and elective behaviour in hand hygiene, deep-seated in some communities, may influence HCWs’ attitude towards hand cleansing during health-care delivery.
It is likely that those who are used to caring about hand hygiene in their personal lives are more likely to be careful in their professional lives as well, and to consider hand hygiene as a duty to guarantee patient safety. For instance, in the Sikh culture, hand hygiene is not only a holy act, but an essential element of daily life.
Sikhs will always wash their hands properly with soap and water before dressing a cut or a wound. This behaviour is obviously expected to be adopted by HCWs during patient care.
A natural expectation, such as this one, could also facilitate patients’ ability to remind the HCW to clean their hands without creating the risk of compromising their mutual relationship.
Hand hygiene indications and alcohol prohibition in different religions.
Of the five basic tenets of Islam, observing regular prayer five times daily is one of the most important. Personal cleanliness is paramount to worship in Islam.
Muslims must perform methodical ablutions before praying, and clear instructions are given in the Qur’an as to precisely how these should be carried out.
The Prophet Mohammed always urged Muslims to wash hands frequently and especially after some clearly defined tasks. Ablutions must be made in freely running (not stagnant) water and involve washing the hands, face, forearms, ears, nose, mouth and feet, three times each. Additionally, hair must be dampened with water.
Thus, every observant Muslim is required to maintain scrupulous personal hygiene at five intervals throughout the day, aside from his/her usual routine of bathing as specified in the Qur’an. These habits transcend Muslims of all races, cultures and ages, emphasizing the importance ascribed to correct ablutions.770
With the exception of the ritual sprinkling of holy water on hands before the consecration of bread and wine, and of the washing of hands after touching the holy oil (the latter only in the Catholic Church), the Christian faith seems to belong to the third category of the above classification () regarding hand hygiene behaviour.
In general, the indications given by Christ’s example refer more to spiritual behaviour, but the emphasis on this specific point of view does not imply that personal hygiene and body care are not important in the Christian way of life.
Similarly, there are no specific indications regarding hand hygiene in daily life in the Buddhist faith, nor during ritual occasions, apart from the hygienic act of washing hands after each meal.
Similarly, specific indications regarding hand hygiene are nonexistent in the Buddhist faith. No mention is made of hand cleansing in everyday life, nor during ritual occasions.
According to Buddhist habits, only two examples of pouring water over hands can be given, both with symbolic meaning. The first is the act of pouring water on the hands of the dead before cremation in order to demonstrate forgiveness to each other, between the dead and the living.
The second, on the occasion of the New Year, is the young person’s gesture of pouring some water over the hands of elders to wish them good health and a long life.
Culture might also be an influential factor whatever the religious background. In certain African countries (e.g. Ghana and some other West African countries) hand hygiene is commonly practiced in specific situations of daily life according to some ancient traditions.
For instance, hands must always be washed before raising anything to one’s lips. In this regard, there is a local proverb: “when a young person washes well his hands, he eats with the elders”.
Furthermore, it is customary to provide facilities for hand aspersion (a bowl of water with special leaves) outside the house door to welcome visitors and to allow them to wash their face and hands before even enquiring the purpose of their visit.
Unfortunately, the above-mentioned hypothesis that community behaviour influences HCWs’ professional behaviour has been corroborated by scanty scientific evidence until now (see also Part I, Section 18).
In particular, no data are available on the impact of religious norms on hand hygiene compliance in health-care settings where religion is very deep-seated. This is a very interesting area for research in a global perspective, because this kind of information could be very useful to identify the best components of a programme for hand hygiene promotion.
It could be established that, in some contexts, emphasizing the link between religious and health issues may be very advantageous.
Moreover, an assessment survey may also show that in populations with a high religious observance of hand hygiene, compliance with hand hygiene in health care will be higher than in other settings and, therefore, does not need to be further strengthened or, at least, education strategies should be oriented towards different aspects of hand hygiene and patient care.
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Hand gestures in different religions and cultures
Hand use and specific gestures take on considerable significance in certain cultures.
The most common popular belief about hands, for instance in Hindu, Islam, and some African cultures, is to consider the left hand as “unclean” and reserved solely for “hygienic” reasons, while it is thought culturally imperative to use the right hand for offering, receiving, eating, for pointing at something or when gesticulating.
In the Sikh and Hindu cultures, a specific cultural meaning is given to the habit of folding hands together either as a form of greeting, as well as in prayer.
There are many hand gestures in Mahayana and Tibetan Buddhism. In Theravada Buddhist countries, putting two hands together shaped like a lotus flower is representative of the flower offered to pay respect to the Buddha, Dhamma (teaching) and Sangha (monk).
Walking clockwise around the relic of the Buddha or stupa is also considered to be a proper and positive form of respect towards the Buddha. Washing hands in a clockwise movement is suggested and goes well with the positive manner of cheerful and auspicious occasions.
Studies have shown the importance of the role of gesture in teaching and learning and there is certainly a potential advantage to considering this for the teaching of hand hygiene, in particular, its representation in pictorial images for different cultures.
In multimodal strategies to promote hand hygiene, posters placed in key points in health-care settings have been shown to be very effective tools to remind HCWs to cleanse their hands.
Efforts to consider specific hand uses and gestures according to local customs in visual posters, including educational and promotional material, may help to convey the intended message more effectively and merits further research.
The concept of “visibly dirty” hands
Both the CDC guidelines58 and the present WHO guidelines recommend that HCWs wash their hands with soap and water when visibly soiled.
Otherwise, handrubbing with an alcohol-based rub is recommended for all other opportunities for hand hygiene during patient care as it is faster, more effective, and better tolerated by the skin.
Infection control practitioners find it difficult to define precisely the meaning of “visibly dirty” and to give practical examples while schooling HCWs in hand hygiene practices. In a transcultural perspective, it could be increasingly difficult to find a common understanding of this term.
In fact, actually seeing dirt on hands can be impeded by the colour of the skin: it is, for example, more difficult to see a spot of blood or other proteinaceous material on very dark skin.
Furthermore, in some very hot and humid climates, the need to wash hands with fresh water may also be driven by the feeling of having sticky or humid skin.
According to some religions, the concept of dirt is not strictly visual, but reflects a wider meaning which refers to interior and exterior purity. In some cultures, it may be difficult to train HCWs to limit handwashing with soap and water to some rare situations only.
For instance, external and internal cleanliness is a scripturally enjoined value in Hinduism, consistently listed among the cardinal virtues in authoritative Hindu texts (Bhagavadgita, Yoga Shastra of Patanjali).
Furthermore, in the Jewish religion, the norm of washing hands immediately after waking in the morning refers to the fact that during the night, which is considered one sixtieth of death, hands may have touched an impure site and therefore implies that dirt can be invisible to the naked eye. Therefore, the concept of dirt does not refer only to situations in which it is visible.
This understanding among some HCWs may lead to a further need to wash hands when they feel themselves to be impure and this may be an obstacle to the use of alcohol-based handrubs.
The cultural issue of feeling cleaner after handwashing rather than after handrubbing was recently raised within the context of a widespread hand hygiene campaign in Hong Kong and might be at the basis of the lack of long-term sustainability of the excellent results of optimal hand hygiene compliance achieved during the Severe Acute Respiratory Syndrome pandemic (W H Seto, personal communication).
From a global perspective, the above considerations highlight the importance of making every possible effort to consider the concept of “visibly dirty” in accordance with racial, cultural and environmental factors, and to adapt it to local situations with an appropriate strategy when promoting hand hygiene.
Use of alcohol-based handrubs and alcohol prohibition by some religions
According to scientific evidence arising from efficacy and cost–effectiveness, alcohol-based handrubs are currently considered the gold standard approach.
For this purpose, WHO recommends specific alcohol-based formulations taking into account antimicrobial efficacy, local production, distribution, and cost issues at country level worldwide (see also Part I, Section 12).
In some religions, alcohol use is prohibited or considered an offence requiring a penance (Sikhism) because it is considered to cause mental impairment (Hinduism, Islam) .
As a result, the adoption of alcohol-based formulations as the gold standard for hand hygiene may be unsuitable or inappropriate for some HCWs, either because of their reluctance to have contact with alcohol, or because of their concern about alcohol ingestion or absorption via the skin.
Even the simple denomination of the product as an “alcohol-based formulation” could become a real obstacle in the implementation of WHO recommendations.
In some religions, and even within the same religious affiliation, various degrees of interpretation exist concerning alcohol prohibition. According to some other faiths, on the contrary, the problem does not exist .
In general, in theory, those religions with an alcohol prohibition in everyday life demonstrate a pragmatic vision which is followed by the acceptance of the most valuable approach in the perspective of optimal patient-care delivery.
Consequently, no objection is raised against the use of alcohol-based products for environmental cleaning, disinfection, or hand hygiene. This is the most common approach in the case of faiths such as Sikhism and Hinduism.
For example, in a fundamental Hindu textbook, the Shantiparvan, it is explicitly stated that it is not sinful to drink alcohol for medicinal purposes.
In Buddhism, obstacles to the use of alcohol in health care are certainly present, but from a completely different perspective. According to the law of kamma, the act or the intention to kill living creatures is considered a sinful act.
As microorganisms are living beings, killing them with an alcohol-based handrub may lead to demerit. According to Expositor (1:128), the five conditions for the act of killing are: a living being; knowledge that it is a being; intention of killing; effort; and consequent death.
Nevertheless, considering that HCWs for the most part have good intentions in their work, namely, to protect patients from pathogen transmission, the result of this sinful action does not bear heavy consequences.
Therefore, when comparing a human patient’s life with a bacterium’s life, most people adhering to the Buddhist kamma agree that a patient’s life is more valuable.
Furthermore, according to Phra Depvethee, a Thai Buddhist monk and scholar, the consequences of killing depends on the size and good contribution of that being.
The Islamic tradition poses the toughest challenge to alcohol use. Fortunately, this is also the only context where reflection on alcohol use in health care has begun.
Alcohol is clearly designated as haram (forbidden) in Islam because it is a substance leading to sukur, or intoxication leading to an altered state of mind. For Muslims, any substance or process leading to a disconnection from a state of awareness or consciousness (to a state in which she or he may forget her or his Creator) is called sukur, and this is haram.
For this reason, an enormous taboo has become associated with alcohol for all Muslims. Some Muslim HCWs may feel ambivalent about using alcohol-based handrub formulations.
However, any substance that man can manufacture or develop in order to alleviate illness or contribute to better health is permitted by the Qur’an and this includes alcohol used as a medical agent.
Similarly, cocaine is permitted as a local anaesthetic (halal, allowed) but is inadmissible as a recreational drug (haram, forbidden).
To understand Muslim HCWs’ attitudes to alcohol-based hand cleansers in an Islamic country, the experience reported by Ahmed and colleagues at the King Abdul Aziz Medical City (KAAMC) in Riyadh, Kingdom of Saudi Arabia, is very instructive.
the policy of using alcohol handrub is not only permitted, but has been actively encouraged in the interest of infection control since 2003. No difficulties or reluctance were encountered in the adoption of alcohol-containing hand hygiene substances.
Though Saudi Arabia is considered to be the historic epicentre of Islam, no state policy or permission or fatwa (Islamic religious edict) were sought for approval of the use of alcohol-containing handrubs, given that alcohol has long been a component present in household cleaning agents and other materials for public use, including perfume, without legislated restriction within the Kingdom.
In all these instances, the alcohol content is permitted because it is not for ingestion. In 2005, the Saudi Ministry of Health pledged its commitment to the WHO Global Patient Safety Challenge, and most hospitals across the country have joined in a national campaign implementing the WHO multimodal Hand Hygiene Improvement Strategy centred on the use of alcohol-based handrub at the point of care.
Given this high level commitment, WHO selected hospitals in Saudi Arabia in 2007 for the testing of the present Guidelines. Preliminary results indicate a very strong adoption of the strategy, including a preference for handrubbing instead of handwashing, which has led to a significant increase of hand hygiene compliance among HCWs and a reduction of HCAI rates in ICUs.
This example shows that positive attitudes to the medicinal benefits of alcohol, coupled with a compassionate interpretation of Qur’anic teachings, have resulted in a readiness to adopt new hand hygiene policies, even within an Islamic Kingdom which is legislated by Sharia (Islamic law).
The risk of accidental or intentional ingestion of alcohol-based preparations is one of the arguments presented by sceptics concerning the introduction of these products because of cultural or religious reasons. Even if this is a potential problem, it is important to highlight that only a few cases have been reported in the literature.
In specific situations, however, this unusual complication of hand hygiene should be considered and security measures planned to be implemented.
Another concern regarding the use of handrub formulations by HCWs is the potential systemic diffusion of alcohol or its metabolites following skin absorption or airborne inhalation. Only a few anecdotal and unproven cases of alcohol skin absorption leading to clinical symptoms are reported in the literature.
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In contrast, reliable studies on human volunteers clearly demonstrate that the quantity of alcohol absorbed following application is minimal and well below toxic levels for humans.
In a study mimicking use in large quantities and at a high frequency,783 the cutaneous absorption of two alcohol-based handrubs with different alcohol components (ethanol and isopropanol) was carefully monitored.
Whereas insignificant levels of ethanol were measured in the breath and serum of a minority of participants, isopropanol was not detected
Finally, alcohol smell on skin may be an additional barrier to handrubbing, and further research should be conducted to eliminate this smell from handrub preparations.
In addition to targeting areas for further research, possible solutions may be identified. For example, from childhood, the inherent nature of hand hygiene which is strongly influenced by religious habits and norms in some populations could be shaped in favour of an optimal elective behaviour towards hand hygiene.
Indeed, some studies have demonstrated that it is possible to successfully educate children of school age to practise optimal hand hygiene for the prevention of common paediatric community-acquired infections
Religious and cultural aspects of hand hygiene in health care and potential impact and/or solutions.
When preparing guidelines, international and local religious authorities should be consulted and their advice clearly reported.
An example is the statement issued by the Muslim Scholars’ Board of the Muslim World League during the Islamic Fiqh Council’s 16th meeting held in Mecca, Saudi Arabia, in January 2002:
“It is allowed to use medicines that contain alcohol in any percentage that may be necessary for manufacturing if it cannot be substituted. Alcohol may be used as an external wound cleanser, to kill germs and in external creams and ointments.
In hand hygiene promotion campaigns in health-care settings where religious affiliations prohibiting the use of alcohol are represented, educational strategies should include focus groups on this topic to allow HCWs to raise their concerns openly regarding the use of alcohol-based handrubs, help them to understand the scientific evidence underlying this recommendation, and identify possible solutions to overcome obstacles .
Results of these discussions could be summarized in an information leaflet to be produced and distributed locally. It has been suggested to avoid the use of the term “alcohol” in settings where the observance of related religious norms is very strict and rather use the term “antiseptic” handrubs.
However, concealing the true nature of the product behind the use of a non-specific term could be construed as deceptive and considered unethical; further research is thus needed before any final recommendation can be made.
Medical practices different from Western medicine, such as traditional medicines, should be explored for further opportunities to promote hand hygiene in different cultural contexts. For instance, traditional Chinese medicine practitioners are very open to the concept of hand hygiene.
During a usual traditional Chinese medicine consultation, both inpatient and outpatient, there can be a vast array of direct contacts with the patient.
These include various kinds of physical examination such as the routine taking of the pulse and blood pressure for almost all patients, but may also involve various kinds of massages and examination of the oral cavities or other orifices, and contact can be often more intense than in Western medicine.
In this context, the potential for using an alcohol-based handrub is tremendous for the practitioner, given the high frequency of hand hygiene actions, and there is a definite avenue for further research in this setting.
Finally, the opportunity to involve patients in a multimodal strategy to promote hand hygiene in health care should be carefully evaluated
Despite its potential value, this intervention through the use of alcohol-based handrubs may be premature in settings where religious norms are taken literally; rather, it could be a subsequent step, following the achievement of awareness and compliance among HCWs.