Patients’ Beliefs and Perceptions of Their Participation to Increase Healthcare Worker Compliance with Hand Hygiene
Background. Research suggests that patients could improve healthcare workers’ compliance with hand hygiene recommendations by reminding them to cleanse their hands.
Objective. To assess patients’ perceptions of a patient‐participation program to improve healthcare workers’ compliance with hand hygiene.
Design. Cross‐sectional survey of patient knowledge and perceptions of healthcare‐associated infections, hand hygiene, and patient participation, defined as the active involvement of patients in various aspects of their health care.
Setting. Large Swiss teaching hospital.
Results. Of 194 patients who participated, most responded that they would not feel comfortable asking a nurse (148 respondents [76%]) or a physician (150 [77%]) to perform hand hygiene, and 57 (29%) believed that this would help prevent healthcare‐associated infections. In contrast, an explicit invitation from a healthcare worker to ask about hand hygiene doubled the intention to ask a nurse (from 34% to 83% of respondents; 
) and to ask a physician (from 30% to 78%; 
). In multivariate analysis, being nonreligious, having an expansive personality, being concerned about healthcare‐associated infections, and believing that patient participation would prevent healthcare‐associated infections were associated with the intention to ask a nurse or a physician to perform hand hygiene (
). Being of Jewish, Eastern Orthodox, or Buddhist faith was associated also with increased intention to ask a nurse (
), compared with being of Christian faith.
Conclusions. This study identifies several sociodemographic characteristics associated with the intention to ask nurses and physicians about hand hygiene and underscores the importance of a direct invitation from healthcare workers to increase patient participation and foster patient empowerment. These findings could guide the development of future hand hygiene–promotion strategies.
Received December 22, 2008; accepted March 17, 2009; electronically published July 30, 2009.
Patient participation is defined as the active involvement of patients in various aspects of their health care. Also known as “patient involvement” or “patient empowerment,” patient participation has been increasingly recognized as a key component in the redesign of healthcare processes.1‐3 Its first and most obvious application consists of inviting patients to participate in clinical decision making, but it has also been used to improve the care of patients with chronic conditions.4‐7
More recently, researchers have studied the ways in which patients could participate to improve patient safety and prevent medical errors.8,9 Among these ways, it has been suggested that patients could help increase healthcare workers’ (HCWs') compliance with hand hygiene recommendations by reminding them to cleanse their hands before patient contact.10‐12 Few studies have assessed patients’ views of patient‐participation programs to improve hand hygiene,13‐15 and available data suggest that up to 60% may refuse to participate.11 Participation rates differ also according to healthcare setting and HCW category, and a marked disparity has been noted in patient participation during interaction with nurses and physicians.11 If patient‐participation programs are to be widely promoted, it is critical to understand the degree to which patients wish to participate and to identify sociodemographic factors and personal beliefs influencing their views. We conducted a hospital‐based survey to investigate patients’ perceptions of each of these aspects.
Methods
Study Design
We performed a cross‐sectional study to assess patients’ perceptions of a patient participation program to improve HCWs’ compliance with hand hygiene at the University of Geneva Hospitals (HUG) in Geneva, Switzerland. HUG is a primary and tertiary healthcare facility admitting 47,000 patients annually with a long‐standing experience of intensive hand hygiene promotion since 1994.16,17 A multimodal hand hygiene strategy has been pioneered at HUG,16 but patient participation has not been included as a component. We used a convenience sampling strategy for respondents by recruiting patients during hospital stay in the following departments: internal medicine, surgery, obstetrics, gynecology, geriatrics, rehabilitation, intensive care, and emergency medicine. Selection of respondents and determination of ability to participate was left to the judgment of the interviewer. Patients were excluded if they were too ill, were cognitively or hearing impaired, or did not speak French. The study was approved by the institutional review board as a continuous quality improvement project.
Survey Questionnaire
Respondents were interviewed at the bedside by infection control nurses and medical students trained in interviewing techniques between November 30, 2006, and April 27, 2007. Guidelines from social cognitive theories applied to health‐related behavior18‐20 were used for the construction of the questionnaire, which consisted of 40 open‐ or closed‐ended questions. Responses consisted of short answers, 5‐ or 10‐point Likert scale rankings, or multiple choice. The questionnaire was pretested with 10 patients for comprehensibility and length and modified where appropriate. Interviews took approximately 20 minutes to complete. No incentives were given to increase the response rate.
Respondents were asked about their knowledge and perception of healthcare‐associated infections (HAIs), knowledge of hand hygiene and infection control strategies, perception of HCWs’ compliance with hand hygiene, and their beliefs on patient participation in the care process. Respondents’ intention to remind HCWs to perform hand hygiene was assessed without an explicit invitation (“Do you intend to remind your physician/nurse to wash his/her hands the next time you observed that he/she had forgotten to do so?”) and with an explicit invitation (“If your physician/nurse asked you to remind him/her to wash his/her hands the next time you observed that he/she had forgotten, would you intend to do so?”). Sex, age, ethnic origin, country of birth, religion, education, occupation, history of past hospitalization, personal experience of HAI, and personality traits (expansive vs reserved and dominating vs accommodating) were also recorded.
Statistical Analysis
We investigated factors associated with patients’ intention to ask a nurse or a physician whether they performed hand hygiene before caring for them by building 2 different models. All group comparisons were performed using logistic regression. The scale variables “intention to ask a nurse,” “intention to ask a physician,” “seriousness of HAI,” and “worried by HAI” were transformed into dichotomous variables by considering the last 2 points of the scale closest to the positive perceptive evaluation as positive answers and all other points as negative answers.21 Similarly, the 10‐point scale variables assessing personality traits were grouped into 1 of 3 categories (ie, 1–3, 4–7, and 8–10) to facilitate interpretation. The continuous variable “perception of the proportion of patients who develop a HAI” was divided into quartiles. Open answers were categorized into major themes. We used the McNemar test to investigate differences in patients’ intention to ask a nurse versus a physician and in patients’ intention to ask with versus without an explicit invitation from a HCW.
To adjust for potential confounders, all covariates found to be associated with the intention to ask a nurse or a physician by bivariate analysis (defined as a P value of <.05) were considered for inclusion in a multivariate model.22 We built 2 forced‐entry models to determine factors associated with intention to ask a nurse and a physician. The variables “perception of comfort to ask a nurse/physician about hand hygiene” were omitted from the final models because they are on the causal pathway to the outcomes.22 Age was stratified in bivariate analyses to facilitate interpretation, but it was included as a continuous variable in multivariate analyses.22 For both multivariate models, all data related to a single respondent were excluded when any of the variables included in the model had missing values. The magnitude of the association between outcomes and explanatory variables was measured by odds ratios and corresponding 95% confidence intervals. All tests were 2 tailed, and a P value of less than .05 was defined as statistically significant. All analyses were conducted using SPSS software, version 14.0 (SPSS).
Results
Respondent Characteristics
A total of 194 patients participated in the survey. Respondent characteristics are presented in Table 1. Approximately half were female, and the median age was 63 years (range, 16–93 years). More than 90% were white, approximately half were born in Switzerland, and one‐third had completed upper secondary schooling or higher. One hundred seventy respondents (87.6%) had been hospitalized previously, and 11.9% reported having acquired a HAI in the past. Eighty‐two respondents (42.2%) were interviewed in the department of internal medicine, 80 (41.2%) in the department of surgery, and 29 (16.6%) in other departments.
Perception and Knowledge of HAIs and Infection Control Strategies
Seventy‐nine percent of respondents reported having heard about HAI. However, only 18.6% could name correctly these infections as “nosocomial” or “healthcare associated” (Table 2). Sixty‐eight percent of respondents considered HAIs a serious problem, and more than 70% were worried about these infections; 13.9% estimated that HAIs affected at least 1 of every 5 patients. Hand hygiene was correctly identified by 39.2% as the most important preventive measure, and two‐thirds believed that HCWs should perform hand hygiene before shaking hands with a patient. Furthermore, 84.5% reported that nurses cleanse their hands “always” or “most of the time,” whereas 66.5% thought the same of physicians.
Beliefs Regarding Patient Participation to Improve Staff Compliance and Influence of Explicit Staff Invitation
Table 3 describes the beliefs related to patient participation to improve staff hand hygiene practices. Approximately 40% of respondents believed that patients should remind caregivers to cleanse their hands, and 29.4% thought that this would help prevent HAIs. Most respondents reported that they would not feel comfortable asking a nurse (76.3%) or a physician (77.3%) to cleanse their hands if they noticed they had not done so. Consequently, only approximately one‐third of respondents declared their intention to ask a physician or a nurse whether they had cleansed their hands before touching them (Figure). In addition, respondents were less likely to intend to ask a physician than to ask a nurse to perform hand hygiene (29.9% vs 34.0%; 
). However, an explicit invitation from a HCW significantly increased the intention to ask a physician (from 29.9% to 77.8% of respondents; 
) and the intention to ask a nurse (from 34.0% to 82.5%; 
) to perform hand hygiene. Nevertheless, despite an explicit authorization, the intention to ask a physician remained lower than the intention to ask a nurse (77.8% vs 82.5%; 
).
Figure. Intention of 194 patients to ask physicians (white bars) and nurses (black bars) whether they performed hand hygiene, without or with explicit invitation to ask from the healthcare workers.
Reasons for Not Intending to Ask About Hand Hygiene
Analysis of open‐ended questions identified 9 major reasons for not intending to ask HCWs about hand hygiene (Table 4). The main reasons were the perception that caregivers already know (or should know) when to perform hand hygiene, the belief that asking about hand hygiene is not part of the patient’s role, and a feeling of embarrassment or awkwardness associated with asking about hand hygiene. Interestingly, the fear of reprisals was more frequently mentioned as a reason not to intend to ask a nurse, compared with a physician (11.6% vs 3.2%, respectively).
Variables Predicting Intention to Participate
By bivariate analysis, younger age, non‐Christian faith, an expansive personality, the perception of being worried about HAI acquisition, having never heard about hand hygiene, the belief that patients should remind HCWs to perform hand hygiene, the perception of the efficacy of patient participation to diminish HAIs, and the perception of being comfortable to remind a nurse to perform hand hygiene were significantly associated with the intention to ask a nurse to perform hand hygiene. Younger age, North African ethnicity, Muslim faith or absence of religious beliefs, an expansive personality, the perception of being worried by HAI, the belief that patients should remind HCWs, the perception of the efficacy of patient participation to diminish HAIs, the perception of being comfortable to remind a physician to perform hand hygiene, and having previously asked a physician to perform hand hygiene were significantly associated with intention to ask a physician to perform hand hygiene.
In multivariate analysis, being nonreligious, having an expansive personality, being worried about HAI acquisition, believing that patients should remind HCWs to perform hand hygiene, and believing that patient participation would prevent HAIs were independently associated with intention to ask a nurse or a physician to perform hand hygiene (Table 5). Furthermore, being of Jewish, Eastern Orthodox, or Buddhist faiths was independently associated with the intention to ask a nurse to perform hand hygiene, in contrast to findings for Christian faith, whereas having asked a physician previously to perform hand hygiene was associated with the intention to ask a physician to perform hand hygiene.
Discussion
Patient participation has been successfully implemented in many healthcare settings to improve decision making and care of chronic diseases.4‐7 More recently, recourse to patient participation has been advocated by international guidelines to improve HCWs’ compliance with hand hygiene,23 but little is known about patients' perception of the topic. To our knowledge, our study is the first to assess patient perception on hand hygiene, after adjustment for potential confounders.
Most patients interviewed in our institution reported having already heard about HAI and were worried by such an adverse event. Although most considered correctly that HCWs should cleanse their hands before shaking hands and that more frequent performance of hand hygiene could prevent infection, approximately two‐thirds of respondents did not intend to ask a nurse or a physician to perform hand hygiene if they noticed that the HCW had not done so. A telephone survey of 2078 patients discharged from US hospitals showed that only 45% would be “very comfortable” asking HCWs whether they have washed their hands.13 Another survey of 80 patients in a surgical department in the United Kingdom reported that most would probably not ask a HCW if they had washed their hands.14 Some studies have suggested that more innovative, error‐preventing behaviors such as questioning caregiver judgment or actions might be unacceptable to the public,14,24 and patient‐participation programs might be perceived as part of this category by many respondents. Furthermore, an initiative to enlist patients to improve hand hygiene adherence could be perceived as putting inappropriate responsibility on an already weakened and vulnerable individual.25
Refusal to participate despite being worried by HAI arises, at least in part, from the perception that monitoring of hand hygiene is not the patient’s role. Few respondents (42%) believed that patients should remind caregivers about performing hand hygiene. These results contrast markedly with data from 2 other studies, which found that 70%–80% of patients hospitalized in the United Kingdom believed that they should be involved in helping HCWs to improve hand hygiene adherence.15,26 The reason for such a disparity is unclear and could be linked to the framing of the questions, which was more theoretical in the latter studies. The erroneous perception that hand hygiene is already performed always or most of the time by HCWs may also contribute to the lack of motivation. Contrary to patients’ beliefs, studies in numerous countries show that nurses and physicians clean their hands on less than half of the recommended occasions.23,27
An explicit invitation from the HCW to ask about hand hygiene has in previous research been suggested to have an impact on patients’ intention to participate.14,28 In a telephone survey of 1008 Americans, 80% of respondents indicated their readiness to ask HCWs to wash their hands if the HCW explained the importance of asking.28 Our study shows that an invitation from the HCW more than doubles the intention to ask about hand hygiene. Authorization diminishes the sense of being disrespectful and reassures the patient that this task is part of their role. This result underscores the importance of obtaining overt support from caregivers in future patient‐participation campaigns. In addition, our survey showed that the intention to ask a physician about hand hygiene was less common than the intention to ask a nurse, as suggested in other studies.10‐12 Our study also adds important information by showing that explicit authorization is insufficient to correct the disparity between the intention to ask a nurse and the intention to ask a physician. Despite repeated observations revealing lower hand hygiene compliance among physicians than among nurses,16 patients appear more reluctant to challenge authority figures, even if openly invited to do so.
Bivariate analysis revealed that younger age was strongly associated with the intention to ask a HCW to perform hand hygiene, a finding consistent with data from previous studies.15,29‐33 However, this association disappeared after adjustment for other covariables in the multivariate analysis. The age‐related decrease in intention to ask a HCW to perform hand hygiene may be related to changing beliefs toward health care or could be due to intergenerational differences in health‐related beliefs.29
Interestingly, patients reporting no religious affiliation were more likely to intend to ask caregivers about hand hygiene. To our knowledge, no previous study has shown an association between this variable and the acceptance of patient‐participation initiatives. Patients with this characteristic may have views about new and unconventional behaviors such as xenotransplantation34 and euthanasia35 that are more favorable than those of religious patients and are more willing than religious patients to take part in clinical trials.36 On the other hand, practices related to hand cleansing are recommended in daily life and rituals by several religions.37 This may explain why belonging to the Jewish, Eastern Orthodox, or Buddhist faiths was independently associated with the intention to ask a nurse about hand hygiene.
Respondents with an expansive personality were more likely to intend to ask about hand hygiene than were those with reserved personalities. A study conducted in the United Kingdom showed that persons with an extroverted personality were twice as likely as persons with a nonextroverted personality to ask physicians to cleanse their hands.15 In contrast, other sociodemographic factors known to influence patient participation, such as sex,14,29‐33 education,14,29‐33,38 and employment status14 were not associated with the intention to ask HCWs about hand hygiene among patients at our institution. This could be due to a lack of study power or could reflect true differences between populations.
Patients who were worried about HAI had a more favorable view of patient participation than did unconcerned patients. Studies have shown that patients wish to participate in major and “fearful” decisions such as foot amputation and cancer care, but are less concerned about minor decisions (eg, prescription for bed rest).39 It is possible that some patients considers hand hygiene as trivial and do not wish to be involved in its promotion. However, a cause‐and‐effect relationship cannot be inferred from our study and, ethical issues notwithstanding, it is unclear whether instilling a fear of HAI among patients would be effective in increasing patient participation.40
Last but not least, the perception that asking about hand hygiene would help prevent HAI predicted the intention to ask caregivers. The perception of benefits is a well‐known predictor of health‐related behavior.20 On the other hand, an increased knowledge about hand hygiene or HAI was not associated with the intention to ask.
When considering these results, it must be kept in mind that this survey was conducted in a setting where no patient‐participation campaign has been introduced to improve hand hygiene. As such, the collected answers represent spontaneous beliefs. Whether these beliefs can be modified remains to be determined. It is possible that patients’ acceptance could dramatically increase by setting up a carefully designed campaign that addresses points of reticence determined in this study. In the few published studies assessing the impact of a patient‐education program to increase staff compliance with handwashing,10‐12 soap consumption increased by 34% to 94%.10,12 Furthermore, in surveys performed after discharge, 90%–100% of patients confirmed having asked a nurse about hand hygiene,11,12 and 31%–35% confirmed that they asked a physician.10,11 This suggests that patients may be convinced to participate despite their initial reluctance to do so.
Our study has some limitations. The study population was predominantly French‐speaking, white, and Christian, and our results might not be generalizable to other settings. Given the convenience‐based selection method of respondents, the results should be interpreted with caution. It is possible that patients excluded from the study perceive patient participation differently than patients who were included. This is most certainly the case for patients excluded because of cognitive impairment. Furthermore, there may be differences between responders and nonresponders to the survey. We were not able to obtain information from patients who refused or failed to answer. In addition, direct interview by trained HCWs might have biased the results toward opinions that were more socially acceptable. Other forms of participation were not assessed in this survey. For example, patients can also participate by acting as a group or as experts, and patient relatives and visitors can also participate in the improvement of care. Finally, patients’ intended behavior toward hypothetical situations used in this survey may not correlate with actual, real‐life behavior.
In conclusion, this study identifies numerous sociodemographic characteristics associated with patients’ intention to ask HCW to cleanse their hands, and it underscores the importance of an explicit invitation from caregivers to increase patient participation. Although a cause‐and‐effect relationship cannot be established, these findings have important implications and could serve to guide the development of future strategies. Further research is needed to assess whether the perceived intention translates into actual behavior.
Acknowledgments
We thank Americo Agostinho, Fabio Agrì, Christophe Akakpo, Cathy Bandiera‐Clerc, Véronique Camus, Marie‐Noëlle Chraiti, Pietro Gianella, Pascale Herrault, Sandrine Longet, Valérie Sauvan, Josiane Sztajzel, Sylvie Touveneau, Melissa Vetsch, and Thomas Zaugg, for conducting the interviews; and Rosemary Sudan, for editorial assistance.
Financial support. Y.L. is a postdoctoral fellow supported by the McLaughlin scholarship from Université Laval, Canada.
Potential conflicts of interest. All authors report no conflicts of interest relevant to this article.
References
- 1. Patient Self‐Determination Act, 42 USC §1395–1396a (1994).
- 2. World Health Organization (WHO). London Declaration: Patients for Patient Safety. Geneva, Switzerland: WHO; 2007. Available at: http://www.who.int/patientsafety/patients_for_patient/London_Declaration_EN.pdf. Accessed July 27, 2007.
- 3. President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Consumer Bill of Rights and Responsibilities: Executive Summary. Washington, DC: Agency for Healthcare Research and Quality, Department of Health and Human Services; 1998. Available at: http://www.hcqualitycommission.gov/final. Accessed July 15, 2009.
- 4. Coulter A, Ellins J. Patient‐Focused Interventions: A Review of the Evidence. London, United Kingdom: Picker Institute Europe; 2006.
- 5. Weingarten SR, Henning JM, Badamgarav E, et al. Interventions used in disease management programmes for patients with chronic illness—which ones work? Meta‐analysis of published reports. BMJ 2002; 325:925.
- 6. Guevara JP, Wolf FM, Grum CM, Clark NM. Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta‐analysis. BMJ 2003; 326:1308–1309.
- 7. Deakin T, McShane CE, Cade JE, Williams RD. Group based training for self‐management strategies in people with type 2 diabetes mellitus. Cochrane Database Syst Rev 2005(2):CD003417.
- 8. Weingart SN, Toth M, Eneman J, et al. Lessons from a patient partnership intervention to prevent adverse drug events. Int J Qual Health Care 2004; 16:499–507.
- 9. Moller T, Borregaard N, Tvede M, Adamsen L. Patient education—a strategy for prevention of infections caused by permanent central venous catheters in patients with haematological malignancies: a randomized clinical trial. J Hosp Infect 2005; 61:330–341.
- 10. McGuckin M, Taylor A, Martin V, Porten L, Salcido R. Evaluation of a patient education model for increasing hand hygiene compliance in an inpatient rehabilitation unit. Am J Infect Control 2004; 32:235–238.
- 11. McGuckin M, Waterman R, Storr IJ, et al. Evaluation of a patient‐empowering hand hygiene programme in the UK. J Hosp Infect 2001; 48:222–227.
- 12. McGuckin M, Waterman R, Porten L, et al. Patient education model for increasing handwashing compliance. Am J Infect Control 1999; 27:309–314.
- 13. Waterman AD, Gallagher TH, Garbutt J, Waterman BM, Fraser V, Burroughs TE. Hospitalized patients’ attitudes about and participation in error prevention. J Gen Intern Med 2006; 21:367–370.
- 14. Davis RE, Koutantji M, Vincent CA. How willing are patients to question healthcare staff on issues related to the quality and safety of their healthcare? An exploratory study. Qual Saf Health Care 2008; 17:90–96.
- 15. Duncanson V, Pearson L. A study of the factors affecting the likelihood of patients participating in a campaign to improve staff hand hygiene. J Infect Prevent 2005; 6:26–30.
- 16. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital‐wide programme to improve compliance with hand hygiene. Lancet 2000; 356:1307–1312.
- 17. Pittet D, Simon A, Hugonnet S, Pessoa‐Silva CL, Sauvan V, Perneger TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 2004; 141:1–8.
- 18. Ajzen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice Hall; 1980.
- 19. O’Boyle CA, Henly SJ, Larson E. Understanding adherence to hand hygiene recommendations: the theory of planned behavior. Am J Infect Control 2001; 29:352–360.
- 20. Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and the Health Belief Model. Health Educ Q 1988; 15:175–183.
- 21. Jaccard J, Weber J, Lundmark J. A multitrait‐multimethod analysis of four attitude assessment procedures. J Exp Soc Psychology 1975; 11:149–154.
- 22. Katz MH. Multivariable Analysis: A Practical Guide for Clinicians. Cambridge, United Kingdom: Cambridge University Press; 2006.
- 23. World Health Organization (WHO). WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft). Geneva, Switzerland: WHO; 2006.
- 24. Hibbard JH, Peters E, Slovic P, Tusler M. Can patients be part of the solution? Views on their role in preventing medical errors. Med Care Res Rev 2005; 62:601–616.
- 25. Annas GJ. The patient’s right to safety—improving the quality of care through litigation against hospitals. N Engl J Med 2006; 354:2063–2066.
- 26. National Patient Safety Agency (NPSA). Achieving our Aims: Evaluating the Results of the Pilot Clean Your Hands Campaign. London, United Kingdom: NPSA; 2004.
- 27. World Health Organization (WHO). World Alliance for Patient Safety, Global Patient Safety Challenge 2005–2006: Clean Care is Safer Care. Geneva, Switzerland: WHO; 2005.
- 28. McGuckin M, Waterman R, Shubin A. Consumer attitudes about health care‐acquired infections and hand hygiene. Am J Med Qual 2006; 21:342–346.
- 29. Levinson W, Kao A, Kuby A, Thisted RA. Not all patients want to participate in decision making: a national study of public preferences. J Gen Intern Med 2005; 20:531–535.
- 30. McKinstry B. Do patients wish to be involved in decision making in the consultation? A cross sectional survey with video vignettes. BMJ 2000; 321:867–871.
- 31. Stiggelbout AM, Kiebert GM. A role for the sick role: patient preferences regarding information and participation in clinical decision‐making. CMAJ 1997; 157:383–389.
- 32. Gaston CM, Mitchell G. Information giving and decision‐making in patients with advanced cancer: a systematic review. Soc Sci Med 2005; 61:2252–2264.
- 33. Rothenbacher D, Lutz MP, Porzsolt F. Treatment decisions in palliative cancer care: patients’ preferences for involvement and doctors’ knowledge about it. Eur J Cancer 1997; 33:1184–1189.
- 34. Hagelin J, Hau J, Schapiro SJ, Suleman MA, Carlsson HE. Religious beliefs and opinions on clinical xenotransplantation—a survey of university students from Kenya, Sweden and Texas. Clin Transplant 2001; 15:421–425.
- 35. Suarez‐Almazor ME, Belzile M, Bruera E. Euthanasia and physician‐assisted suicide: a comparative survey of physicians, terminally ill cancer patients, and the general population. J Clin Oncol 1997; 15:418–427.
- 36. Advani AS, Atkeson B, Brown CL, et al. Barriers to the participation of African‐American patients with cancer in clinical trials: a pilot study. Cancer 2003; 97:1499–1506.
- 37. Allegranzi B, Memish ZA, Donaldson L, Pittet D. Religion and culture: potential undercurrents influencing hand hygiene promotion in health care. Am J Infect Control 2009; 37:28–34.
- 38. Willems S, De Maesschalck S, Deveugele M, Derese A, De Maeseneer J. Socio‐economic status of the patient and doctor‐patient communication: does it make a difference? Patient Educ Couns 2005; 56:139–146.
- 39. Mansell D, Poses RM, Kazis L, Duefield CA. Clinical factors that influence patients’ desire for participation in decisions about illness. Arch Intern Med 2000; 160:2991–2996.
- 40. Witte K, Allen M. A meta‐analysis of fear appeals: implications for effective public health campaigns. Health Educ Behav 2000; 27:591–615.
-
The views expressed in this article are those of the authors and do not necessarily represent the decisions or stated policy of the World Health Organization.
Presented in part: 48th Interscience Conference on Antimicrobial Agents and Chemotherapy and 46th Infectious Diseases Society of America Annual Meeting; Washington, DC; October 2008 (Abstract K‐4081).