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.
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.
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 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 Table I.
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.
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 Table I. 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 , 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.
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. Similarly, cocaine is permitted as a local anaesthetic halal , allowed but is inadmissible as a recreational drug haram , forbidden.
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 , 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 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.
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. 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.
Whereas insignificant levels of ethanol were measured in the breath and serum of a minority of participants, isopropanol was not detected see Part I, Section 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 Table I. 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. When preparing guidelines, international and local religious authorities should be consulted and their advice clearly reported. 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 Table I.
Results of these discussions could be summarized in an information leaflet to be produced and distributed locally. 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 see Part V. 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.
All rights reserved. Turn recording back on. National Center for Biotechnology Information , U. Show details Geneva: World Health Organization ; Search term. Figure I. 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.
Table I. Hand gestures in different religions and cultures Hand use and specific gestures take on considerable significance in certain cultures. 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. Possible solutions In addition to targeting areas for further research, possible solutions may be identified Table I.
In this Page. Other titles in this collection. As recommended by the World Health Organisation, strategies for hand hygiene need to take into consideration religious and cultural issues.
Alcohol-based rubs are the norm in the Western world, but alcohol is a potential problem for some faiths. This includes the use of alcohol for disinfection. Judaism and handwashing. In Temple times the washing of hands was adopted as a ritual before going to the altar to offer a sacrifice.
It was symbolic of washing away impurity. When the Temple was destroyed, the table in the home became symbolic of the altar and bread became symbolic of the sacrifice offered at the altar. The practice of washing hands became a ritual. This ritual washing is not actually an act of physical cleanliness and is only required before a meal at which bread is eaten. Islam, the Qur'an and handwashing. Islam places great emphasis on spiritual and physical cleanliness and purification. The Qur'an offers specific advice on how and when hand cleansing should occur, including prior to prayer five times a day , before and after eating, after using the toilet, after touching a dog, a cadaver or shoes, and after touching anything that is soiled.
The ritual washing before prayer is called Wudhu. It involves washing of the hands, mouth, nasal passage, face forearms and feet, and wiping the head and beard. Ghusi is ritual bathing. Clean, soap-free water must run all over the body.
Culture and ancient tradition in some African countries. In some West African countries, hand hygiene is practised in accordance with ancient traditions. It is also customary to leave a bowl of water with special leaves outside the house, allowing visitors to wash their hands and face before any enquiry is made about the reason they are visiting. Handwashing is a fascinating and complex tradition, not just attributable to personal hygiene and as a means of preventing the spread of disease.
There are many traditions all over the world that incorporate handwashing as ritual, respectful custom and as a result of ancient practices. Go Back. Health and Safety News Occupational health and safety news and guidance. The curious culture of handwashing around the world The religious and cultural aspects of hand hygiene If we are to adopt a universal approach to healthcare hygiene, handwashing customs need to transcend religion, culture and place.
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