The effectiveness of education of methicillin-resistant Staphylococcus aureus (MRSA) infection prevention and control (IPC) with directive discourse to improve handwashing compliance
Kusbaryanto
Master of Hospital Administration, Universitas Muhammadiyah Yogyakarta, Indonesia
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"documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Enferm Clin. 2020;30 Supl 6:205-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "titulo" => "Utilization of emergency trolley in patient ward: Is not always for emergency reason" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "205" "paginaFinal" => "208" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Silvia Candradewi, Harun Al Rasyid, Viera Wardhani, Achmad Rudijanto" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Silvia" "apellidos" => "Candradewi" ] 1 => array:2 [ "nombre" => "Harun Al" "apellidos" => "Rasyid" ] 2 => array:2 [ "nombre" => "Viera" "apellidos" => "Wardhani" ] 3 => array:2 [ "nombre" => "Achmad" "apellidos" => "Rudijanto" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130862120303909?idApp=UINPBA00004N" "url" => "/11308621/00000030000000S6/v1_202010100748/S1130862120303909/v1_202010100748/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "titulo" => "The effectiveness of education of <span class="elsevierStyleItalic">methicillin-resistant Staphylococcus aureus</span> (MRSA) infection prevention and control (IPC) with directive discourse to improve handwashing compliance" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "209" "paginaFinal" => "212" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => " Kusbaryanto" "autores" => array:1 [ 0 => array:2 [ "apellidos" => "Kusbaryanto" "email" => array:2 [ 0 => "koesbary@yahoo.co.id" 1 => "pmc@agri.unhas.ac.id" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Master of Hospital Administration, Universitas Muhammadiyah Yogyakarta, Indonesia" "identificador" => "aff0005" ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Staphylococcus aureus</span> is an aerobic gram-positive coccus that acts as an important opportunistic pathogen (bacteria, viruses, fungi, or protozoa) in many animals, including humans. <span class="elsevierStyleItalic">S. aureus</span> is naturally abundant throughout the human body, with asymptomatic colonization of the skin and the oral, respiratory, and gastrointestinal systems being quite common. vergrowth of <span class="elsevierStyleItalic">S. aureus</span>, however, can result in life-threatening infection of the blood, gastrointestinal tract, or other organ systems.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S. aureus</span> remains a dangerous pathogen, causing a multitude of serious and sometimes life-threatening diseases around the globe. This microorganism is mostly due to widespread antibiotic resistance, which considerably complicates the treatment of <span class="elsevierStyleItalic">S. aureus</span> infections. MRSA strains, in particular, represent a major problem for public health systems. as they combine resistance to MRSA and other β-lactam antibiotics with relatively minor fitness costs. It results in high infiltration of hospital and community settings.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Infections caused by antibiotic-resistant strains of <span class="elsevierStyleItalic">S. aureus</span> have risen to epidemic proportions globally. The overall burden of disease caused by MRSA strains has reached alarming rates in many countries in both healthcare and community settings.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">MRSA resists nearly all beta-lactam antibiotics that have bactericidal activity. However, whether the actual used beta-lactams enhance MRSA infectious in vivo remains unclear.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a> The disadvantages resulted from MRSA infection including a high rate of mortality, hospitalization will be longer, and the cost will be higher.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">MRSA is a major cause of hospital-acquired infections. It is increasingly difficult to combat because of emerging resistance to all current antibiotic classes and increasing prevalence in the community.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The incidence rate of microbial exposure remains high among nurses in a variety of ways. Paramedics play a vital role as a transmission medium of nosocomial infection in the hospital, especially through direct contact. Nosocomial infections can be transferred through contact, air, needlestick, and other objects around us. Behavior changes require knowledge, which later affects the nurses’ compliance with standard precautions. Such knowledge will support the implementation of prevention attempts to microorganisms exposure while working.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">MRSA spreads through 3 variety of ways, i.e. (a) from patient to healthcare workers, (b) from patient to patient (healthcare workers as a medium), (c) from healthcare workers to patient. The spread occurs through skin contact. The bacteria will dwell for several weeks in the dead objects as on the table, electric switch, banister, clothes, health equipment, and plastic.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a> The most important prevention effort to avoid the spreading is handwashing. The handwashing compliance is necessary for healthcare workers particularly nurses.</p><p id="par0040" class="elsevierStylePara elsevierViewall">There are three types of handwashing, namely:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">(a)</span><p id="par0045" class="elsevierStylePara elsevierViewall">Social (routine) handwashing with soap and warm water: to remove dirt and organic material, dead skin and most transient organisms</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">(b)</span><p id="par0050" class="elsevierStylePara elsevierViewall">Antiseptic handwashing with an antiseptic handwash agent i.e. Hydrex: generally carried out for aseptic procedures on the ward and for areas of Isolation. Hygienic hand disinfection will remove and kill most transient microorganisms that are divided into antiseptic handwashing – with water and antimicrobial soap – and antiseptic hand rubbing – with alcohol –, and</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">(c)</span><p id="par0055" class="elsevierStylePara elsevierViewall">Surgical handwashing: requires the removal and killing of transient micro-organisms and substantial reduction and suppuration of the resident flora of the surgical team for the duration of the operation, in case a surgical glove is punctured/torn.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a></p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">There are two concepts of compliance, namely conformity, and obedience. The first refers to a tendency to change from the perceptions, opinions, and behavior that are derived from the existing norms or rules in a group. The factors associated with conformity are the influences of information, existing rules, size or large of a group, awareness of the existing rules in a group, age and sex differences as well as cultural influences. While obedience refers to behavior changes due to the instruction or command of the authority holder. The factors associated with it are leadership figures (the authority holder), responsibilities of each individual, escalation of possible dangers.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Hand hygiene is the primary measure proven to be effective in preventing health care workers and the spread of antimicrobial resistance. However, it has been shown that health care workers encounter difficulties in complying with hand hygiene indications at different levels. Over the last 20 years, many studies have demonstrated that effective interventions exist to improve hand hygiene compliance among health care workers, although the measurement has varied and it makes a difficult comparison. In terms of the definition of hand hygiene opportunity and the assessment of hand hygiene by means of direct observation or consumption of hand hygiene products.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The purpose of this research is to analyze the effectiveness of education regarding MRSA infection prevention and control with directive discourse to improve handwashing compliance among nurses in the hospitals.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Method</span><p id="par0075" class="elsevierStylePara elsevierViewall">The equipment required to conduct this research is CCTVs, computer monitors, checklists for monitoring nurse activities, checklists of handwashing compliance, LCDs, and stationery. This research is quasi-experimental research using a pretest-posttest non-control design.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a> A research subject is a group that consists of 25 nurses. The treatment consists of two training; the first training is about the danger of MRSA infection and the urgency as well as the handwashing procedures. While the second one is about auditing guidelines for MRSA infection prevention and control with directive discourse. This research has obtained the certificate of ethical approval issued by the hospital ethical committee.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">A Kolmogorov–Smirnov test is conducted in order to determine the measuring result of handwashing before and after the treatment. The results suggest from <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, that before the treatment <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.200 and after the treatment <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.200. It is concluded that these data are normal. Afterward, a t-test is undertaken to these data, and it obtains <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.018 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05), meaning that there is a difference in handwashing compliance before and after the treatment.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">In this research, statistical analysis results of the difference regarding handwashing compliance before and after the treatment are significant. The results suggest that the treatment in the form of training, as the main reference for auditing guidelines of MRSA infection prevention with directive discourse is proven effective to change the behavior of handwashing compliance. It is due to the acceptance of the training materials as positive reinforcement and a stimulus to the handwashing compliance.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a> Compliance subsequently increases as well since there is an increased awareness of the importance of handwashing.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a> The respondents become more obedient to the point where it generates a significant change after the treatment.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The education on this research is undertaken with a directive discourse method. It is an educational approach through attractive writing so that a behavior change truly occurs to the nurses.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> Education and training are effective to improve handwashing compliance. However, other research findings indicate that handwashing compliance gets influenced by several factors and the effect of the training itself will only result in short-term compliance.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Knowledge, attitudes, and actions are the components of behavior that can be changed in three ways, i.e. seriousness, starting from the nearest environment, and the existence of education. The changes consist of six phases, namely:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">(a)</span><p id="par0100" class="elsevierStylePara elsevierViewall">the unfreezing phase, i.e. individuals begin to consider accepting certain changes,</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">(b)</span><p id="par0105" class="elsevierStylePara elsevierViewall">the problem diagnosis phase, i.e. individuals begin to identify those who support and refuse changes,</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">(c)</span><p id="par0110" class="elsevierStylePara elsevierViewall">the goal-setting phase,</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">(d)</span><p id="par0115" class="elsevierStylePara elsevierViewall">the new behavior phase,</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">(e)</span><p id="par0120" class="elsevierStylePara elsevierViewall">the refreezing phase, and</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">(f)</span><p id="par0125" class="elsevierStylePara elsevierViewall">individuals’ permanent behavior.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a></p></li></ul></p><p id="par0130" class="elsevierStylePara elsevierViewall">The compliance of healthcare staff toward standard precautions, especially nurses and doctors are efficient for prevention. The prevention of a disease transmission caused by infection is not only for patient protection but also for the environment. Among the provision of standard precaution, hand hygiene is one of the most important actions.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The research regarding the determinants of compliance behavior to the standard precautions in the intensive care unit at Ghent University Hospital in Belgium aims to identify and examine the predictors and determinants of poor adherence to the hand-washing instruction in the intensive care unit among nurses. The research method is conducted by filling out questionnaires distributed to 148 nurses who work at the intensive care unit of Ghent University Hospital with a total of 40 beds. Out of 148 nurses who participate, only 73% of them that return the questionnaires. The compliance means 84%.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Research on behavior problems related to hand hygiene aims to examine the relationship between hand hygiene knowledge, beliefs, and actions of medical students. The research method uses questionnaires with total respondents of 1485 medical students and nursing students from 19 universities in Australia, Sweden, and Greece. The research findings reveal that hand hygiene compliance gets influenced by the belief of hand hygiene urgency to prevent infection, knowledge, and frequencies of hand hygiene assessment.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">One of the strategies to enhance adherence to the standard precautions is by understanding that it is vital to adhere the standard precautions. The hospital infection control officers can also clarify the misconceptions about the use of gloves and the issue of skin convenience constantly. Also, the use of posters, videos, images about handwashing and establishment of handwashing facilities are important to improve the handwashing compliance.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusion</span><p id="par0150" class="elsevierStylePara elsevierViewall">The education of MRSA infection prevention and control with directive discourse is effective in improving the handwashing compliance among nurses in the hospitals.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1396879" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1279958" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Method" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 7 => array:2 [ "identificador" => "xack485967" "titulo" => "Acknowledgment" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-11-08" "fechaAceptado" => "2020-06-02" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1279958" "palabras" => array:5 [ 0 => "Education" 1 => "MRSA" 2 => "Directive discourse" 3 => "Handwashing" 4 => "Compliance" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The incidence rate of microbial exposure remains high among nurses. Paramedics play a vital role in transmitting the nosocomial infection in the hospital. This research aims to analyze the education effectivity of MRSA IPC with directive discourse to improve handwashing compliance among nurses.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This is quasi-experimental research using a pretest–posttest non-control design and has obtained an ethical approval certificate issued by the hospital ethical committee. A research subject is a group of 25 nurses.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The data test uses the Wilcoxon test to determine the measuring result of handwashing compliance before and after the treatment. The value of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.018 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) means there is a difference before and after the treatment. As handwashing awareness increases, so does the compliance.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The education of MRSA IPC with directive discourse is effective to improve the handwashing compliance among nurses in the hospitals.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Peer-review under responsibility of the scientific committee of the 4th International Conference Hospital Administration (ICHA4). Full-text and the content of it is under responsibility of authors of the article.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Standard deviation \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Handwashing compliance before the treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Handwashing compliance after the treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.018<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2397347.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Significant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05), score ranges: 0–100.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Differences in handwashing compliance before and after the treatment.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0095" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> (MRSA) screening of hospital dental clinic surfaces" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A. 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