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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 19  |  Issue : 2  |  Page : 93-100

A study to assess the knowledge, attitude and practices of hand hygiene in a health-care setting


Department of Microbiology, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India

Date of Web Publication26-Dec-2017

Correspondence Address:
Dr. Chithra Valsan
Department of Microbiology, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacm.jacm_42_16

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  Abstract 


CONTEXT: In the wake of a growing burden of health care associated infections (HAIs), health-care workers (HCWs) are advised to revert to simple tools like hand hygiene (HH).
AIMS: The aim of this study is to explore the existing knowledge, attitudes and practices with regard to HH, the total HH compliance and the various barriers to HH in our hospital so as to plan the strategies for bridging these gaps, thus improving patient care.
SETTINGS AND DESIGN: A cross-sectional study was conducted among 300 HCWs of Jubilee Mission Medical College and Research Institute, Thrissur, belonging to six different categories, for a period of 2 months.
MATERIALS AND METHODS: Knowledge, attitude and practices were evaluated using a validated WHO HH questionnaire, a self-structured attitude questionnaire and an observation checklist based on the concept of Five Moments of HH by WHO, respectively. Total compliance and the profile of missed opportunities were also assessed.
STATISTICAL ANALYSIS USED: SPSS was used for data analysis.
RESULTS: The knowledge on HH was good (190 out of 300, 63.3%), attitudes were poor with nursing staff having significantly better attitude than doctors (P < 0.05). In the observational study, physicians and nursing staff had better practice. Lack of time was the major barrier pointed out. The overall compliance was 46% among the HCWs of whom only 16% had proper HH practice. Rest of the 30% performed HH, but the technique was wrong.
CONCLUSIONS: The study highlights the need for reinforcing the existing HH training programmes to address the gaps in knowledge, attitude and practice and thereby improving the level of HH compliance and enhancing patient safety.

Keywords: Attitude and practice, hand hygiene, health care associated infections, health-care worker, knowledge


How to cite this article:
Jose GE, Valsan C. A study to assess the knowledge, attitude and practices of hand hygiene in a health-care setting. J Acad Clin Microbiol 2017;19:93-100

How to cite this URL:
Jose GE, Valsan C. A study to assess the knowledge, attitude and practices of hand hygiene in a health-care setting. J Acad Clin Microbiol [serial online] 2017 [cited 2018 Oct 22];19:93-100. Available from: http://www.jacmjournal.org/text.asp?2017/19/2/93/221505




  Introduction Top


“First do no harm,” is a conventional medical oath, which is rarely violated intentionally by any health-care worker (HCW). In spite of this notion, patients receiving health care, are at risk of HAI ranging from 6% to 27% in the developing and resource-poor settings.[1] The prevalence of HAIs due to poor hand hygiene (HH) is about 19% in developing countries.[2] Basically, HH depends on the attitude, behaviour and beliefs of an individual.[3] Hence, this study strives to focus on the knowledge, attitude and practices, which are the three main determinants of HH in a tertiary health-care set up. By measuring the HH compliance and identifying the barriers, effective protocols for infection prevention can be designed, implemented and taught to improve health-care outcomes in the future.


  Materials and Methods Top


Design

This is a descriptive type of study with cross-sectional study design conducted by the Infection Control team under the Department of Microbiology, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India for 2 months; June and July, 2015.

Aim

To assess the knowledge, attitude and practice of HH in our hospital among the various categories of health-care workers.

The objectives of the study include:

  1. Assess the knowledge of and attitude towards HH in senior and junior doctors, medical students, staff nurses, nursing students and housekeeping staff
  2. Assess the compliance and to find out the profile of missed opportunities in HH.


Sample size

According to a study done by Pittet et al., the average prevalence of HH was found to be 40% and hence using the formula 4pq/l 2 a sample size of 300 was arrived at.[4]

The study group consisted of senior and junior doctors, medical students, staff nurses, nursing students and housekeeping staff, with 50 samples from each category. As it was a short term and preliminary study to get an overall idea on the existing HH practise in our hospital, further categorisation of study groups such as intensive care units and high dependency units which may reflect a change in their priority towards HH was not done. In this three-tier study, the knowledge and attitude were assessed using the WHO's HH questionnaire for HCWs [5] and a self-structured attitude questionnaire adapted from previous studies, respectively.[6] Housekeeping staff were given a questionnaire in their language, omitting some of the questions which were not applicable to them. The responses were evaluated and knowledge was categorised as good (≥75%), moderate (50%–75%) and poor (≤50%) of the total score. The attitude statements were evaluated on the basis of a scale of 0–4, with 0 as “don't know” and 4 as “strongly agree.”[7] Statistical analysis of the data was carried out using the Chi-square test.

The observational study was conducted using a checklist based on the concept of “my five moments for HH” by the WHO [8] and the observations were made by the principle investigator using the parameters in this checklist which included the time taken to use an alcohol based hand rub, presence of any infection carriers such as rings, watches and bracelets worn by HCWs and the various areas of hand covered while performing HH. As a part of the second objective, a single-blinded study to assess the compliance and the profile of missed opportunities in HH was done using a set of 300 subjects (HCWs) who were selected randomly and observations were made using the checklist.[8]


  Results Top


A total of 300 HCWs were evaluated on their knowledge, attitude and practise of HH which consisted of senior and junior doctors, medical students, staff nurses, nursing students and housekeeping staff, with 50 samples from each category and this sample size was obtained using the formula 4pq/l 2. Since this was a short-term and preliminary study to get an overall idea on the existing HH practise in our hospital, further categorisation of study groups such as intensive care units and high dependency units., which may reflect a change in their priority towards HH were not done.

Knowledge study

Out of 300 participants, 190 (63.3%) had a total knowledge score of more than 75% which pertains to the whole study group from all 6 categories. Thirty-seven (74%) of both senior and junior doctors had good scores (above 75%), whereas 33 (66%) of both medical and nursing students, 28 (56%) of staff nurses and 22 (44%) of housekeeping staff also got good scores [Figure 1]. None of the HCWs had poor scores (<50%) except one house keeping staff (2%). The scores obtained for each question by each category of HCW is shown in [Table 1]. Only 19 (38%) of senior doctors, 26 (52%) of junior doctors and 7 (14%) of medical students have received proper formal training in HH in the past 3 years. About 44 (88%) of the staff nurses and 37 (74%) of the senior physicians preferred to use the alcohol based hand rub routinely instead of hand washing with soap and water. While looking for the important gaps in the clinical knowledge based on the responses to the individual questions we found that only 29 (58%) senior doctors, 22 (44%) junior doctors, 24 (48%) medical students, 19 (38%) staff nurses and 17 (34%) nursing students knew the minimal time (20 s) which was needed for an alcohol based hand rub to kill most germs on the hand
Figure 1: Comparison of total knowledge scores of hand hygiene among the six categories (the denominator is 50 HCWs in each of these categories)

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Table 1: Comparison of knowledge of hand hygiene among the 6 categories

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Attitude study

While assessing the attitudes among the HCWs, nurses seemed to have significantly better attitudes when compared to rest of the study population (P < 0.05). Respondents found that emergencies and other priorities often make it difficult for them to adhere to HH at all times and they often feel frustrated when they omit HH. As per the scoring system, both these statements scored an average above 3.5. Overall 78% (236/300) and 83.33% (250/300) of HCWs commented that they strongly agree (score 4) that infection prevention team has a positive influence on their HH and infection prevention notice boards remind them to perform HH, respectively.

Barriers to hand hygiene as suggested by the health-care workers

The survey showed that lack of time was the major barrier for 163 out of 300 HCWs (54.3%) [Figure 2]. Other barriers highlighted include lack of adequate facilities such as hand-wash, hand-rub and washbasin 137 (45.6%), staff shortage 133 (44.3%) and lack of awareness 98 (32.6%).
Figure 2: Comparison of barriers to hand hygiene among the various categories

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Observational study

Among the different moments of HH, moment V (after touching the patient's surroundings) was missed by 216 HCWs (72%) followed by moment I (before touching a patient) which was missed by 162 (54%) [Figure 3]. While performing HH, the wrist, fingertips and webs were frequently missed in (135) 45%, (111) 37% and (99) 33% of the HCWs, respectively. One hundred and forty-two of the total study population (47.3%) were found to wear infection carriers such as rings, watches and bracelets. The minimum recommended time for HH using an alcohol-based hand rub as described by WHO is 20 s. Only 51 HCWs (17%) performed HH in 20 s or more, whereas the rest took less than the time recommended raising concerns of adequacy of the task done.
Figure 3: Profile of missed moments in hand hygiene (The denominator is 300 HCWs in each of these moments)

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Overall compliance

The overall compliance among the HCWs to adhere to correct HH practices were noted to be 46% (138 of 300), with again high rates of compliance seen among staff nurses 78% (39 of 50) and nursing students 64% (32 of 50) when compared to the rest of the study population. Fifty-four percent of HCWs (162 of 300) omitted HH in the indicated situations whereas 46% (138 of 300) performed the act of HH. Among them, only 48 (16% of 300) had proper HH practice which is the true compliance of this study, whereas rest 90 (30%) performed HH poorly.


  Discussion Top


The medical community all over the world witnessed a tandem unprecedented advancement in the understanding of pathophysiology of Hospital Acquired Infectious (HAI) diseases due to its increasing influence on the magnitude of problems such as morbidity, mortality and hospital economy. Compliance with HH guidelines has been considered to be the most important strategy to reduce the transmission of HAIs in health-care settings for many years.[4] In spite of the overwhelming evidence demonstrating the negative consequences of HAIs and on-going education emphasising the importance of performing HH, low HH compliance rates among the HCWs continue to prevail.

In our study, knowledge of HH seemed to be good with 63.3% (190 HCWs) having more than 75% score when compared to a similar Indian study where in 74% of the study population, the knowledge was between 50% and 75% of total score.[6] Majority of the study population still calls on the need for formal training in HH which was strongly evident in their response to the question of whether they had received any formal training in HH in the last 3 years. Only 38% of senior doctors, 52% of junior doctors and 14% of medical students had received proper formal training in HH in the past 3 years. Forty-four (88%) of the staff nurses and 37 (74%) of the senior physicians preferred to use the alcohol-based hand rub routinely instead of hand washing with soap and water. This practice of using alcohol based hand rub has been recommended strongly by the WHO in the past few years, as it is a less cumbersome procedure with more residual effect and very useful in a hospital setting where uninterrupted water availability is a question. However, there were some gaps in the clinical knowledge, of which an important finding was that only a minority of the population knew the minimal time (20 s) needed for an alcohol-based hand rub to kill most germs on the hand. It was known to only 29 (58%) of senior doctors, 22 (44%) of junior doctors, 24 (48%) of medical students, 19 (38%) of staff nurses and 17 (34%) of nursing students.

While assessing the attitude statements, overall results were disappointing. Our findings suggest that nursing students and staff nurses have significantly better attitudes (P < 0.05) 78% and 84% when compared to all the other categories of HCWs, which was found to be similar with the reports from Cairo (96.0%) and Italy (86.2%).[9] Lack of compliance due to forgetfulness can be countered by placing reminders such as posters, installing wash scans or digital screening of hands, through HH auditing with regular feedbacks and also by ongoing education processes. Among all HCWs, 78% commented that infection prevention team has a positive influence on their HH and 83.33% of HCWs said that infection prevention notice boards remind them to perform HH. Lack of time (54%) has been highlighted as the major barrier for adequate performance of HH, especially by the nursing community in our study as was shown in a previous study by Barret and Randle also.[10]

Like most of the previous studies, our study also showed that the overall compliance to HH by HCWs was <50%.[11] The overall true compliance of this study based on method of doing HH, was just 16% (48 of 300), which was found to be low when compared to a study that showed a median HH compliance rate for all HCWs as 40%.[12] All HCW categories have lower rates of HH compliance before contact with a patient (moment I) when compared to compliance rates after patient contact (moment IV). The reason for this finding may be that those who performed HH were more likely to be motivated out of the concerns of their own safety rather than concern for the safety of the patients. While coming to the correct steps of hand washing and the different areas covered during the procedure, wrist, fingertips and webs were frequently missed in 45%, 37% and 33% of the cases where HH practice is performed. These findings are consistent with previous studies suggesting that often missed areas during HH are wrists and webs between the fingers.[7]

An important limitation of our study was that further categorisation of the study groups into intensive care units, high dependency units etc., which may reflect a change in their priority towards HH, was not done. Hence, this warrants further follow up studies on individual units.

In the current study, in spite of the discrepancies in the high levels of knowledge and poor levels of attitudes and compliance, the nursing community is far ahead of the physicians [Figure 1]. This may be due to the longer time of interaction with the patients during their nursing procedures. Furthermore, infection control lessons are being taught in their nursing curriculum itself along with better exposure to proper HH techniques repeatedly right from a very early stage. Hence, we would like to highlight the importance of improving the current training programmes targeting HH practices among medical and nursing students and the commonly missed out category of housekeeping staff. Teaching of elementary HH practices along with coupling of lectures in the undergraduate curriculum can be done so as to prime the medical students to this basic necessity of performing HH.[13] Mentor's attitude at bed side which has a strong influence in moulding the behaviour of young medical and nursing students should be exploited to serve as role models for them. Provision of adequate staff and facilities for hand washing with easy access should also be guaranteed.


  Conclusions Top


HCWs are being asked to return to the basics of infection prevention by adhering to simple measures like HH. The present study identified good rates of HH knowledge; while attitudes and practices of HH were found to be unsatisfactory on the whole. Hence, we highlight the urgent need for introducing and upgrading the existing measures to improve the knowledge, attitude and practise of HH among the HCWs. Moreover, institutional support for providing necessary incentives for adhering to HH should also be guaranteed in every hospital setting.

Acknowledgement

We wish to extend our heartfelt gratitude to the Indian Council of Medical Research (ICMR), New Delhi for recognising our work and for providing us with grants.

Financial support and sponsorship

ICMR.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Danchaivijitr S, Dhiraputra C, Santiprasitkul S, Judaeng T. Prevalence and impacts of nosocomial infections in Thailand. J Med Assoc Thai 2001;88:S1-9.  Back to cited text no. 1
    
2.
WHO The Burden of Health Care-Associated Infection Worldwide. A Summary. Available from: http://www.who.int/gpsc/country_work/summary_20100430_en.pdf3. [Last accessed on 2014 Dec 26].  Back to cited text no. 2
    
3.
Ariyaratne MH, Gunasekara TD, Weerasekara MM, Kottahachchi J, Kudavidanage BP, Fernando SS. Knowledge, attitude and practices of hand hygiene among final year medical and nursing students at the University of Sri Jayewardenepura. Sri Lankan J Infect Dis 2013;3;15-25.  Back to cited text no. 3
    
4.
Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Infection control program. Ann Intern Med 1999;130:126-30.  Back to cited text no. 4
[PUBMED]    
5.
WHO Hand Hygiene Knowledge Questionnaire for Health-Care Workers (Revised August 2009). To Assess Knowledge on the Essential Aspects of HH. Available from: http://www.who.int/gpsc/5may/tools/evaluation_feedback/en/. [Last accessed on 2014 Dec 30].  Back to cited text no. 5
    
6.
Shinde MB, Mohite VR. A study to assess knowledge, attitude and practices of five moments of hand hygiene among nursing staff and students at a tertiary care hospital, Karad. Int J Sci Res 2014;3:311-21.  Back to cited text no. 6
    
7.
van Dalen R, Gombert K, Bhattacharya S, Datta SS. Mind the mind: Results of a hand-hygiene research in a state-of-the-art cancer hospital. Indian J Med Microbiol 2013;31:280-2.  Back to cited text no. 7
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8.
WHO “My Five Moments for HH” by the World Health Organisation. (Revised August 2009). Available from: http://www.who.int/gpsc/5may/background/5moments/en/. [Last accessed on 2014 Dec 30].  Back to cited text no. 8
    
9.
Nobile CG, Montuori P, Diaco E, Villari P. Healthcare personnel and hand decontamination in intensive care units: Knowledge, attitudes, and behaviour in Italy. J Hosp Infect 2002;51:226-32.  Back to cited text no. 9
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10.
Barrett R, Randle J. Hand hygiene practices: Nursing students' perceptions. J Clin Nurs 2008;17:1851-7.  Back to cited text no. 10
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11.
Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection control programme. Lancet 2000;356:1307-12.  Back to cited text no. 11
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12.
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.  Back to cited text no. 12
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13.
Handwashing Liaison Group. Handwashig - A modest measure with big effects. Br Med J 1999;318:686.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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