|Year : 2019 | Volume
| Issue : 7 | Page : 1008-1013
Hand hygiene knowledge, training and practice: A cross-sectional study in a tertiary health institution, North-central Nigeria
NY Shehu1, KI Onyedibe2, JS Igbanugo3, MO Okolo2, SS Gomerep1, SE Isa1, DZ Egah2
1 Department of Medicine, Infectious Diseases Unit, Jos University Teaching Hospital, Plateau State, Nigeria
2 Department of Medical Microbiology, Jos University Teaching Hospital, Plateau State, Nigeria
3 Department of Pharmacy, Jos University Teaching Hospital, Plateau State, Nigeria
|Date of Acceptance||25-Mar-2019|
|Date of Web Publication||11-Jul-2019|
Dr. K I Onyedibe
Department of Medical Microbiology, Jos University Teaching Hospital and University of Jos, Plateau State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Hand hygiene (HH) is the single most important means of preventing hospital-acquired infections. We set out to determine the knowledge, training gaps, and practice of HH in a tertiary health institution in a resource constrained setting. Methods: This cross-sectional study was conducted among health care workers in a 600-bed capacity tertiary health centre. The study was conducted between April and November 2013. A multi-stage randomized sampling method was used to self-administer 322 WHO HH knowledge questionnaires. Information on HH training in the past 3 years, knowledge and practice of HH were obtained, and data were analysed using Epi-Info version 3.5.1. Results: A response rate of 98.5% was obtained for the HH knowledge assessment. Mean age of the study population was 39 ± 9.8. About 64% were females. Of all the respondents, only 16% had good knowledge of HH, 52% had moderate knowledge while 32% had poor knowledge. About 24% had formal training on HH. In terms of practice, only about 22% of the respondents self-reported routine practice of HH. Conclusions: The findings in this study suggest that there is sub-optimal HH knowledge, practice and training. It is imperative to improve the HH training and retraining of health care workers with a focus on attendants. Administrative controls and bold signage in healthcare institutions are also recommended.
Keywords: Attitude, hand-hygiene, knowledge, practice
|How to cite this article:|
Shehu N Y, Onyedibe K I, Igbanugo J S, Okolo M O, Gomerep S S, Isa S E, Egah D Z. Hand hygiene knowledge, training and practice: A cross-sectional study in a tertiary health institution, North-central Nigeria. Niger J Clin Pract 2019;22:1008-13
|How to cite this URL:|
Shehu N Y, Onyedibe K I, Igbanugo J S, Okolo M O, Gomerep S S, Isa S E, Egah D Z. Hand hygiene knowledge, training and practice: A cross-sectional study in a tertiary health institution, North-central Nigeria. Niger J Clin Pract [serial online] 2019 [cited 2019 Jul 22];22:1008-13. Available from: http://www.njcponline.com/text.asp?2019/22/7/1008/262513
| Introduction|| |
Health-care-associated infections are an important cause of morbidity and mortality among hospitalized patients worldwide. Such infections affect nearly 2 million individuals annually in the United States and are responsible for approximately 90,000 deaths each year. In the developed countries, it affects 5–15% of patients in the general wards and 50% of patients in intensive care units. The burden of hospital-acquired infection in Africa is expectedly high. In developing countries, the rates are 2 to 20 times higher, prevalence may be as high as 25%. The Study of the Efficacy of Nosocomial Infection Control demonstrated that a third of nosocomial infections might be prevented with appropriate infection control measures. Hand washing is the single most important means of preventing hospital acquired infection. The importance of hand hygiene (HH) in health care setting was pioneered by Semmelweis in 1847, where he observed mortality among women in labour ward; it was 18% in a hospital where hand washing was not practiced, compared to 3% in a hospital where hands of midwives were washed with chlorine water. Many factors have contributed to poor HH practice by health care workers, this include lack of knowledge about the importance of HH, in reducing the spread of infection, lack of understanding of correct HH technique, understaffing, overcrowding, poor access to hand washing facilities, irritant contact dermatitis associated with frequent exposure to soap and water, and lack of institutional commitment to good HH.,, To overcome these barriers, the Centres for Disease Control and Prevention's (CDC's) Healthcare Infection Control Practices Advisory Committee (HICPAC), published a comprehensive Guideline for Hand Hygiene in Health-Care Settings in 2002. Alcohol-based hand rub (ABHR) is the most effective means of HH and is the generally recommended method of HH., We set out to determine HH knowledge, training gaps, level of practice and factors influencing the practice of HH at a tertiary health centre in North-Central Nigeria.
| Methods|| |
This cross-sectional study was conducted in a 600-bed tertiary care hospital in North Central, Nigeria between April and November 2013. The hospital serves as a referral tertiary care centre for a population of about 20 million inhabitants. The study was conducted among health care workers comprising pharmacist, nurses, doctors, laboratory scientists/technicians, and hospital attendants. There was an estimate of about 1100 relevant health care workers in the hospital. A multi-stage randomized sampling method was used to self-administer the WHO standardized HH knowledge questionnaire to 322 health workers. Information on demography, profession, training on HH in the preceding 3 years, practice of HH and knowledge of HH were obtained. Knowledge score of less than 40 was considered poor, 40–59 moderate and ≥60 was considered good knowledge.
Data were analysed using Epi-Info version 3.5.1 (CDC, Atlanta, Georgia). Continuous variables were expressed as means ± standard deviation, while categorical variables were expressed as proportions. The Chi-square test was used to compare categorical variables. Results were presented in figures and tables as appropriate. P values of <0.05 were considered significant.
Ethical clearance for the study was obtained from the Ethics Committee of the hospital. Data were de-identified and coded.
| Results|| |
A response rate of 98.5% was obtained; about 64% were females; and the mean age of the study population was 39 ± 9.8. Healthcare workers studied included 160 hospital attendants, other baseline parameters are presented in [Table 1].
|Table 1: Baseline parameters of the health workers' hand Hygiene knowledge, training and practice, North-central Nigeria|
Click here to view
Only 16% had good knowledge of HH, 52% had moderate knowledge, and 32% had poor knowledge. In terms of practice, only about 22% of the respondents had a self-reported routine practice of HH (doctors 25%, attendants 18%, nurses 14%, laboratory scientists and technicians 8%, and pharmacist 7%). About 23.5% of the respondents had received formal training on HH in the preceding 3 years (Attendants 53%, Nurses 25%, laboratory scientists and technicians 17%, doctors 4%, and pharmacist 2%). The mean knowledge score, and frequencies of practice and training in the last three years of the different categories of health workers are shown in [Figure 1]. Details of the HH knowledge results are shown in [Table 2]a and [Table 2]b. The result of factors independently associated with good HH practice is shown in [Table 3].
|Figure 1: Showing mean knowledge score, frequencies of practice and training in the last three years of health workers in a tertiary hospital, North-central Nigeria|
Click here to view
|Table 2: Showing knowledge of hand hygiene of health workers in a tertiary hospital, North-central Nigeria|
Click here to view
|Table 3: Bivariate and multivariate analysis showing factors influencing the practice of hand hygiene in Jos|
Click here to view
| Discussion|| |
In this study, we present gaps in practice, training, and knowledge of HH in a tertiary health care facility of a resource-constrained setting. We found about half of the healthcare workers in this study had moderate knowledge of HH. However, knowledge does not always translate to practice as only less than a quarter of our study participants reported the routine practice of HH. This may be due to the lack of regular formal training since we found that just a quarter of the health workers had formal training on HH in the last three years. Other factors that may have contributed to poor HH practice despite good knowledge may be due to the suboptimal HH hygiene facilities in the facility.
Our finding is at variance with a study in southern Nigeria that showed 44% of health care workers had good knowledge and 48% good practice of HH. The observed difference may be due to the differences in study population, as the above-mentioned study was done exclusively among doctors. Expectedly, good practice can only be seen when there is sufficient knowledge. However, it is possible for respondents to report good practice of HH even when it is not really practiced. This is confirmed by the aforementioned study which found only 17% HH practice on direct observation after reporting a 48% practice. Conversely, good HH knowledge and practice were seen in Kuala Lumpur (KL). In the KL setting, there was adequate HH facilities and regular training on HH. Additionally, reinforcement and motivation of health workers have contributed to good HH practice. Meta-analysis has posited factors essential for improved HH compliance which includes feedback, education, reminders, improved access to ABHR and administrative support. In resource-constrained settings, the most critical factors would include improved access to ABHR, education, and administrative support. These factors appear to be primary measures of improving HH compliance. The main barrier of HH compliance in these settings may be poor HH facilities as we have seen in this study. This challenge could be obviated through the development of innovative low-cost HH facilities like locally produced ABHR and good administrative support.
In addition, our study found that formal training was independently associated with good HH practice. This is not surprising, seeing that in our setting doctors have better structures for training and re-training. However, a study by Al Sofiani et al. in Saudi Arabia did not find formal training associated with good HH practice. This may be due to comparatively fewer personnel (20%) who had no formal training in the facility. Their practice may have been influenced by the majority who had formal training. Additionally, we also found that being a doctor is independently associated with good HH practice. This is at variance with most studies that demonstrated nurses HH compliance is better than that of doctors. This may be due to our design of self-reported practice of HH, which may not be consistent if the direct observation of HH was done.
There is usually the interplay of cognitive, socioeconomic, and technical factors that may influence HH practice among health care workers. Most centres with very good HH practice have inculcated in their staff a high sense of responsibility towards HH through a combination of several training and retraining, administrative controls, and bold signage.
The inadequate HH facilities, high patient to health care workers ratio, and the lack of training in our setting may have significantly contributed to this gap. It is, therefore, evident that minimizing the knowledge gap and practice of HH in our setting is necessary to reduce or prevent healthcare-associated infections. A limitation of this study was that HH compliance was only determined through the self-reported practice of HH rather than direct observation which is more reliable. Additionally, attendants constituted about 50% of the study population. Although they are critical in the transmission of infection, this may underrepresent the general HH knowledge. Therefore, the strategy for improving HH in the hospital needs to focus more on attendants. This can be achieved through regular training and re-training through simulations, designation of HH champions, recognition, and awards to ward/unit with good HH compliance.
| Conclusions and Recommendation|| |
Going by the findings in this study, there is suboptimal knowledge, training, and practice of HH. It is imperative to provide training and retraining for health care workers. Implementation of multifaceted interventional and behavioural HH program is important for improving the practice of HH. Provision of innovative low-cost HH facilities and continuous education to raise awareness of HH is seriously advocated. Additionally, implementation of HH training programs for undergraduate doctors, house officers, pharmacists, nurses, and all other health care staff would go a long way in improving HH practice in our setting with a particular focus on attendants.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Magner LN. A History of the Life Sciences. 3rd
ed. New York: Marcel Dekker; 2002. p. 254-6.
Stone PW. Economic burden of healthcare-associated infections: an American perspective. Expert Rev Pharmacoecon Outcomes Res 2009;9:417-22. doi:10.1586/erp.09.53.
Shobowale EO, Adegunle B, Onyedibe K. An assessment of hand hygiene practices of healthcare workers of a semi-urban teaching hospital using the five moments of hand hygiene. Niger Med J 2016;57:150-4. doi:10.4103/0300-1652.184058.
] [Full text]
Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231-43.
Rotter M. Hand washing and hand disinfection. In: Mayhall CG, editor. Hospital Epidemiology and Infection Control. 2nd
ed. Baltimore: Williams and Wilkins; 1999. p. 1339-55.
Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Infection control program. Ann Intern Med 1999;130:126-30.
Boyce JM. It is time for action: Improving hand hygiene in hospitals. Ann Intern Med 1999;130:153-5.
Larson E, Killien M. Factors influencing handwashing behavior of patient care personnel. Am J Infect Control 1982;10:93-9.
Centers for Disease Control and Prevention. Guideline for hand hygiene in health-care settings: Recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. MMWR 2002;51(RR-16):1-56.
Picheansathian W. A systematic review on the effectiveness of alcohol- based solutions for hand hygiene. Int J Nurs Pract 2004;10:3-9.
Allegranzi B, Sax H, Pittet D. Hand hygiene and healthcare system change within multi-modal promotion: A narrative review. J Hosp Infect 2013;83(Suppl 1):S3-10.
Onyedibe K, Shehu NY, Odesanya R, Okolo M, Gomerep S, Makeup Y, et al
. On the spot hand hygiene and injection safety assessment in a tertiary hospital in Nigeria. Abstracts from the 4th
International Conference on Prevention & Infection Control (ICPIC 2017). Antimicrob Resist Infect Control 2017;6(Suppl 3):52.
Ho SE, Ho CCK, Hng SH, Liu CY, Jaafar MZ, Lim B. Nurses compliance to hand hygiene practice and knowledge at Klang Valley hospital. Clin Ter 2013;164:407-11.
Schweizer ML, Reisinger HS, Ohl M, Formanek MB, Blevins A, Ward MA, et al
. Searching for an optimal hand hygiene bundle: A meta-analysis. Clin Infect Dis 2014;58:248-59.
ALSofiani A, AlOmari F, AlQarny M. Knowledge and practice of hand hygiene among healthcare workers at armed forces military hospitals, Taif, Saudi Arabia. Int J Med Sci Public Health 2016;5:1282.
Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, et al
. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010;31:283-94.
[Table 1], [Table 2], [Table 3]