|Year : 2013 | Volume
| Issue : 2 | Page : 96-101
Hand hygiene practices among doctors in a tertiary health facility in southern Nigeria
Vivian Ossaidiom Omuemu1, Esohe O Ogboghodo2, Rosemary A Opene2, Phebe Oriarewo1, Orezimena Onibere1
1 Department of Community Health, College of Medical Sciences, Benin, Edo, Nigeria
2 Department of Community Health, University of Benin Teaching Hospital, Benin, Edo, Nigeria
|Date of Web Publication||24-Dec-2013|
Vivian Ossaidiom Omuemu
Department of Community Health, College of Medical Sciences,University of Benin, PMB 1154, Benin, Edo
Source of Support: None, Conflict of Interest: None
Background: Hand washing is a cheap and effective method of limiting the spread of health care associated infections, but compliance has been reported to be low worldwide, especially in developing countries.
Objective: To determine the knowledge and practice of hand hygiene among doctors in a tertiary health facility in southern Nigeria.
Materials and Methods: This cross-sectional, descriptive study was carried out among all cadres of doctors employed by the hospital. Data were collected using a pretested, semistructured, self-administered questionnaire as well as by direct observation of a subsample of the doctors using an observational checklist. Data analysis was done using the SPSS version 16.0 statistical package and level of significance was set at P < 0.05.
Results: A total of 326 doctors participated in the study and one third of these (108) were directly observed. Less than half of the respondents had good knowledge (43.9%) and good practice (48.2%) of hand hygiene. However, on direct observation, the overall compliance rate was 16.7%. Sex and specialty of the respondents were significantly associated with knowledge but not with practice of hand hygiene. The reasons mentioned for noncompliance included: Lack of hand hygiene materials like soap and water (65.0%), forgetfulness (35.0%), too busy/insufficient time (19.3%), inconvenient location of sinks (16.9%), the use of gloves (7.1%), and skin irritation from washing agents (4.6%).
Conclusion: This study revealed a very low hand hygiene compliance rate among doctors in a tertiary health facility in the southern part of Nigeria and also highlighted some of the contributory factors. It is recommended that an institution-wide hand hygiene promotion campaign be embarked upon.
Keywords: Hand hygiene, health care workers, Nigeria, practice, tertiary health facility
|How to cite this article:|
Omuemu VO, Ogboghodo EO, Opene RA, Oriarewo P, Onibere O. Hand hygiene practices among doctors in a tertiary health facility in southern Nigeria. J Med Trop 2013;15:96-101
|How to cite this URL:|
Omuemu VO, Ogboghodo EO, Opene RA, Oriarewo P, Onibere O. Hand hygiene practices among doctors in a tertiary health facility in southern Nigeria. J Med Trop [serial online] 2013 [cited 2019 Mar 25];15:96-101. Available from: http://www.jmedtropics.org/text.asp?2013/15/2/96/123579
| Introduction|| |
Hand washing, a process of decontaminating the hands, has become a major issue in health care settings due to the high incidence of Health care associated infections (HCAIs) also known as nosocomial infections. HCAIs affect hundreds of millions of patients worldwide annually  and are second only to medication errors as a cause of adverse events in hospitalized patients.  In developed countries, HCAIs have been reported to affect 5%-15% of hospitalized patients and 9%-37% of those admitted to intensive care units (ICUs), , while in developing countries where reliable data on HCAIs are limited, prevalence rates have been estimated to be between 14.8% and 19.1%. ,,, This is in addition to the fact that basic infection control measures are almost nonexistent in most settings due to many unfavorable factors such as understaffing, poor hygiene and sanitation, lack or shortage of basic equipment, etc., The impact of Health Care Associated Infections (HCAIs) implies prolonged hospital stay, long-term disability, increased resistance of microorganisms to antimicrobial agents, increase in mortality and additional financial burden on the patients, their families and the health system. Health care providers can also become infected during patient care. 
The Hungarian physician, Ignaz Semmelweis was the first to demonstrate that the simple act of hand washing could save lives especially when health care workers do it routinely and thoroughly.  Transmission of microorganisms by the hands of health care providers has been documented to be the main route of spread of HCAIs in most health care settings.  Contaminated hands of health care providers have been associated with endemic HCAIs  and several HCAIs outbreaks.  Health care providers can contaminate their hands or gloves with pathogens by performing ''clean procedure'' or touching intact areas of skin of hospitalized patients and the longer the duration of care, the higher the degree of hand contamination. 
According to the World Health Organization,  the indications for hand hygiene can be merged into five (5) moments during health care delivery. Adequate knowledge and recognition of these moments are the pillars for effective had hygiene. Therefore, it is possible to prevent health care associated infections by cross-transmission via hands if health care providers promptly identify these moments and comply with hand hygiene actions. 
Though an improvement in hand hygiene practices has been shown to reduce the incidence rates of HCAIs, , there continues to be low compliance rates reported among health care providers in both developed and developing countries. , Several risk factors for noncompliance have been reported  and physicians have consistently been shown to be the least compliant of all health care workers. , There is dearth of data on the hand hygiene practices of doctors in Nigeria; therefore, this study was carried out among doctors in a tertiary health facility to ascertain their knowledge and practice of hand hygiene as a way of providing baseline data on which intervention programs can be designed.
| Materials and Methods|| |
This was a cross-sectional, descriptive study carried out between January and May 2010 among doctors at the University of Benin Teaching Hospital, Benin City in Edo State in the Southern part of Nigeria. The University of Benin Teaching Hospital is a tertiary health facility that provides a wide range of specialist services to the people in the State as well as those in the neighboring States.
The study population comprised of all cadres of doctors (Consultants, resident doctors, and house officers) who were employed by the hospital at the time of the study. The minimum sample size required for the study was 192 based on a hand hygiene practice rate of 26% using the appropriate formula for sample size determination.  Informed verbal consent was sought and obtained from the participants. All the doctors employed by the hospital were eligible for participation in the study.
The tool for data collection was a pretested, semistructured, self-administered questionnaire. Information was collected on demographic characteristics, knowledge, and practice of hand hygiene.
Knowledge of hand hygiene was assessed by requesting the respondents to respond to the following questions: What is hand hygiene? What are the different types of hand hygiene? What is the minimum standard duration for each type of hand hygiene? What are the indications for hand hygiene? The knowledge of hand hygiene was scored as follows: Each correct response was scored one (1) point and each wrong response was scored zero (0). The total score ranged from 0 to 14 marks. The total score for each respondent was then expressed as a percentage of the maximum total score. Respondents were then categorized into those with poor knowledge (<50%), fair knowledge (50%-69.9%) and good knowledge (≥70%).
For the practice of hand hygiene, the responses given by the respondents to some questions related to hand hygiene practices were scored. The questions included: Indicate when you perform hand hygiene at work. What are the materials you perform hand cleansing with? What do you dry your hands with? Indicate the steps taken when performing hand hygiene. The practice of hand hygiene was scored as follows: Each correct response was scored one (1) point and each wrong response was scored zero (0). The total score ranged from 0 to 12 marks. The total score for each respondent was then expressed as a percentage of the maximum total score. Respondents were then categorized into those with poor practice (<50%), fair practice (50%-69.9%), and good practice e (≥70%).
The study also utilized a qualitative method which was direct observation of a subsample of the doctors. One-third of the participating doctors in each specialty were observed while delivering routine patient care by selected final year medical students who were trained for the purpose and who routinely come to the units for their clinical postings. A checklist adapted from the ''5 moments for hand hygiene'' was used to determine hand hygiene opportunities performed by each doctor where applicable.  These five moments include: Before touching a patient, before aseptic procedure, after body fluid exposure risk, after touching a patient, and after touching patient's surroundings. A count of the total number of hand hygiene actions performed by each doctor was done using the checklist. The total number of hand hygiene actions performed by each doctor was then divided by the total number of hand hygiene opportunities to give the observed compliance/adherence rate expressed as a percentage. Hand hygiene action, whether by hand washing or alcohol-based hand rubbing, was the desired outcome. Hand washing was defined as washing the hands with plain or antimicrobial soap and water and hand rubbing was defined as the application of an alcohol-based solution on hands.
Data were analyzed using the SPSS version 16.0 statistical package and level of significance was set at P less than 0.05.
| Results|| |
A total of 326 out of 454 eligible participants completed and returned questionnaire giving a response rate of 71.8%. The demographic characteristic of the respondents is shown in [Table 1]. Majority of them (55.2%) were in the age group 30-39 years with mean age of 33.7 ± 8.8 years. There were more males (69.9%) than females (30.1%) and the resident doctors constituted the highest cadre of doctors (56.7%).
Majority of the respondents (80.7%) correctly defined hand hygiene as washing the hands with plain or antimicrobial soap and water, while only 50.0% of them knew all the types of hand washing. The most commonly known type of hand hygiene was routine hand washing (89.0%), followed by antiseptic hand washing (79.1%), surgical hand washing (74.2%), and alcohol-based hand rubbing (56.7%). Only 100 (30.7%) of the respondents knew that the standard duration of hand washing should be at least 30 s. Majority of the respondents (96.0%) knew that hand washing should be done before and after patient contact, 62.9% and 62.6% knew that it should be done after contact with blood and body fluids and after taking off gloves, respectively. Only 24.4% of them knew that hand washing should be done immediately on arrival at work [Table 2]. The overall knowledge computed showed that 43.9% of the respondents had good knowledge, 41.1% had fair knowledge, and 15.0% had poor knowledge of hand hygiene. A greater proportion of the female respondents (55.1%) than the male respondents (39.0%) had good knowledge of hand hygiene, χ2 = 7.3, df = 2, P = 0.026. Good knowledge of hand hygiene was higher among respondents in radiology (70.0%), family medicine (52.2%), and obstetrics and gynecology (50.0%) than other specialties, χ2 = 29.8, df = 18, P = 0.04. Consultants (55.4%) constituted those with highest proportion of good knowledge compared with other cadres of doctors, χ2 = 10.3, df = 6, P = 0.114 [Table 3].
|Table 3: Overall knowledge of hand hygiene by selected demographic variables |
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The practice of hand hygiene among the respondents is shown in [Table 4]. Overall, 48.2% of the respondents reported good practice of hand hygiene, while 39.8% and 12.0% reported fair and poor practices, respectively. A greater proportion of the female respondents (53.1%) than the male respondents (46.1%) had good practice of hand hygiene, χ2 = 4.7, df = 2, P = 0.094. Good practice of hand hygiene was higher among respondents in psychiatry (71.4%), anesthesiology (63.2%), and community health (62.5%) than other specialties, χ2 = 18.2, df = 18, P = 0.442. Consultants (58.9%) had the highest proportion of those with good practice of hand hygiene compared with other cadres of doctors. χ2 = 7.9, df = 6, P = 0.244. In the study, high knowledge score was significantly associated with good practice of hand hygiene, χ2 = 6.9, df = 4, P = 0.141.
|Table 4: Overall practice of hand hygiene by selected demographic variables |
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Specifically, 10.4% of the respondents washed their hands immediately on arrival to work, 36.2% did so before examining a patient, 96.9% after examining a patient, 25.5% washed their hands between procedures on the same patients, and 88.0% did so after removing gloves. Majority highest proportion of the respondents (82.5%) reported using plain soap and water followed by 41.1% who reported using antimicrobial soap and water. A total of 11% and 1.5% of them reported using water only and alcohol hand rub, respectively. The mean duration of hand washing by the respondents was 37.1 ± 7 s. About 56.7% of them reported that they used reusable cloth towels, 20.9% air dried, 19.3% used their personal hand towels, 2.1% used their ward coats, and 0.9% used cotton wool.
For the direct observation, one-third of those who responded to the questionnaire were observed while delivering routine patient care. The overall compliance rate was 16.7% and highest among doctors in anesthesiology (49.0%), followed by obstetrics and gynecology (37.2%), surgery (35.2%), community health (11.4%), hematology (10.2%), psychiatry (6.8%) family medicine (6.1%), internal medicine (4.7%), pediatrics (3.0%), and lowest among those in radiology (2.3%). Compliance rate was highest among the consultants (31.6%), followed by the senior registrars (16.7%), registrars (13.5%), and house officers (10.7%), χ2 = 4.0, df = 3, P = 0.259.
Factors mentioned by the respondents as contributing to poor compliance with recommended hand hygiene protocol included: Lack of hand hygiene materials like soap and water (65.0%), forgetful (35.0%), too busy/insufficient time (19.3%), inconveniently located sinks (16.9%), the use of gloves (7.1%), and skin irritation from washing agents (4.6%).
| Discussion|| |
The importance of hand hygiene for protection of various forms of communicable diseases in health care settings cannot be overemphasized. This study has revealed a satisfactory level of overall knowledge of hand hygiene though specific knowledge of different aspects of hand hygiene was poor. Lack of knowledge is a barrier to good compliance of hand hygiene, since valid information and knowledge on hand hygiene has been shown to influence good practices among health care providers.  As has been reported elsewhere, the female respondents had a better knowledge of hand washing than their male counterparts . Also, the consultants had a better knowledge of hand hygiene than the other cadres of doctors. This may be attributed to the fact that the consultants were more experienced since a longer duration of experience is correlated with increased knowledge.  They may, therefore, serve as positive role models for their younger colleagues and influence their hand hygiene behavior.  It is worth noting that majority of the respondents did not know that hand hygiene should be done on arrival at work. This trend was also reflected in their practice of hand washing which showed that barely 10% of the respondents washed their hands on arrival at work. This corroborates some studies which reported that health care workers did not appreciate the fact that they can contaminate their hands while performing ''clean'' activities such as taking a patient's blood pressure or by coming in contact with inanimate objects in the proximity of the patients. 
The finding that less than half of the respondents reported good hand hygiene practice is a major cause for concern more so that there was poor practice of specific hand hygiene actions for specific indications. Similar to what has been reported by several studies , that self-reports of compliance do not correlate with compliance actually measured by direct observation, this study found an overall compliance rate (16.7%) on direct observation which was much lower than the self-reported compliance rate. The rates varied between the different specialties as has been reported elsewhere. , That the majority of the respondents washed their hands after examining a patient is similar to the findings in some studies that there seems to be better compliance among health care workers when there is a perceived significant threat to them. ,
Drying the hands is an essential step in hand cleansing and should be adequately done so that hands are not recontaminated. In the present study, the methods of hand drying reported by the respondents were suboptimal. Common hand drying methods that have been recommended include single use paper towels and hot air dryers. Reusing or sharing towels should be avoided because of the risk of cross-infection. Careful hand drying is a critical factor determining the level of bacterial transfer. This is because wet hands provide better condition for the transmission of microorganisms and recognition of this could improve significantly hand hygiene practices in clinical and public health settings. 
The reasons mentioned by the respondents for poor compliance of hand hygiene were consistent with the reports of earlier studies. , Of note is the common misconception that wearing gloves serves as a substitute for hand washing but the guideline specifically recommends that hand hygiene must be performed when appropriate regardless of the indication for glove use.  Busy schedule or insufficient time will not only reduce frequency of hand washing but in addition, the applied technique may be inadequate.
The limitation of the study is the potential that the doctors been observed might have been aware of the observer's presence and this could have influenced their hand hygiene behavior.
| Conclusion|| |
This study has revealed very low compliance rate of hand hygiene among doctors in a tertiary health facility in the southern part of Nigeria and also highlighted some of the contributory factors. It is recommended that an institution-wide hand hygiene promotion campaign be embarked upon. Periodic training programs to educate doctors on the recommended hand hygiene protocol and periodic evaluation of their hand washing practices are suggested. There is also the need for the institution to ensure that hand washing facilities are available and accessible to all health care providers.
| Acknowledgment|| |
The authors wish to express their appreciation to all the doctors who participated in the study and to the final year medical students who assisted in data collection.
| References|| |
|1.||World Health Organization. WHO Guidelines on hand hygiene in health care settings. Geneva, World Health Organization; 2005. |
|2.||World Alliance for Patient Safety. The Global Patient Safety Challenge 2005-2006 "Clean Care is Safer Care." Geneva, World Health Organization; 2005. |
|3.||Vincent JL. Nosocomial infections in adult intensive-care units. Lancet 2003;361:2068-77. |
|4.||Gosling R, Mbaita R, Savage A, Mulligan JA, Reyburn H. Prevalence of hospital-acquired infections in a tertiary referral hospital in northern Tanzania. Ann Trop Med Parasitol 2003;97:69-73. |
|5.||Faria S, Sodano L, Gjata A, Dauri M, Sabato AF, Bilaj A, et al. The first prevalence survey of nosocomial infections in the University Hospital Centre 'Mother Teresa' of Tirana, Albania. J Hosp Infect 2007;65:244-50. |
|6.||Kallel H, Bahoul M, Ksibi H, Dammak H, Chelly H, Hamida CB, et al. Prevalence of hospital-acquired infections in a Tunisia Hospital. J Hosp Infect 2005;59:343-7. |
|7.||Jroundi I, Khoudri I, Azzouzi A, Zeggwagh AA, Benbrahim NF, Hassouni F, et al. Prevalence of hospital-acquired infections in a Moroccan university hospital. Am. J Infect Control 2007;35:412-6. |
|8.||Ho PL, Tang XP, Seto WH. SARS: Hospital infection control and admission strategies. Respirology 2003;8:S41-5. |
|9.||Centre for Disease Control and Prevention. Guidelines for Hand Hygiene in Health-Care Settings. Recommendations of the Health Care Infection Control Practices Advisory Committee and the HICPAC/SHEA/C/IDSA Hand Hygiene Task Force. MMWR Recomm Rep 2202;51:1-44. |
|10.||Pittet D, Allengranzi B, Sax H, Dharan S, Pessosa-Silva CL, Donaldson L, et al. WHO Global Patient Safety Challenge, World Alliance for Patient Safety. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis 2006;6:641-52. |
|11.||Foca M, Jacob K, Whitter S, Della Latta P, Factor S, Rubenstein D, et al. Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit. N Engl J Med 2000;343:695-700. |
|12.||El Shafie SS, Alishaq M, Leni Garcia M. Investigation of an outbreak of multi-drug resistant Acinetobacter baumannii in trauma intensive care unit. J Hosp Infect 2004;56:101-5. |
|13.||Riggs MM, Sethi AK, Zabarsky TF, Eckstein EC, Jump RL, Donskey CJ. Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Clin Infect Dis 2007;45:992-8. |
|14.||Teare L, Cookson B, Stone S. Hand hygiene. BMJ 2001;323:411-2. |
|15.||Girou E, Legrand P, Soing-Altrach S, Lemire A, Poulain C, Allaire A, et al. Association between hand hygiene compliance and methicillin-resistant Staphylococcccus aureus prevalence in a French rehabilitation hospital. Infect Control Hosp Epidemiol 2006;27:1128-30. |
|16.||Pittet D, Mourouga P, Perneger TV. Compliance with hand washing in a teaching hospital. Infection Control Programme. Ann Intern Med 1999;130:126-30. |
|17.||Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol 2000;21:381-6. |
|18.||Bamigboye AP, Adesanya AT. Knowledge and practice of universal precautions among qualifying medical and nursing students: A case of Obafemi Awolowo University Teaching Hospital complex, Ile-Ife. Res J Med Med Sci 2006;1:112-6. |
|19.||Pittet D, Simon A, Hugonnet S, Pessosa-Silva CL, Sauvan V, Perneger TV. Hand hygiene among physicians: Performance, beliefs and perceptions. Ann Inten Med 2004;141:1-8. |
|20.||Suchitra JB, Lakshmi Devi N. Impact of education on knowledge, attitude and practices among various categories of health care workers on nosocomial infections. Indian J Med Microbial 2001;25:181-7. |
|21.||Lankford MG, Zembower TR, Trick WE, Hacek DM, Noskin GA, Petersen LR. Influence of role models and hospital design on hand hygiene of healthcare workers. Emerg Infect Dis 2003;9:217-23. |
|22.||Teare EL, Cookson B, French G, Gould D, Jenner E, McCullouch J, et al. Hand-washing: A modest measure with big effects. Editorial. BMJ 1999;318:686. |
|23.||Chittaro M, Coiz F, Faruzzo A, Fiappo E, Palese A, Viale P, et al. Compliance with handwashing in health care settings. Ann Iq 2006;18:109-15. |
|24.||Tait AR, Tuttle DB. Preventing perioperative transmission of infection: A survey of anaesthesiology practice. Anaesth Analg 1995;80:764-9. |
|25.||Pittet D, Hugonnet S, Habarth 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. |
|26.||Patrick DR, Findon G, Miller TE. Residual moisture determines the level of touch-contact-associated bacterial transfer following hand washing. Epidemiol Infect 1997;119:319-25. |
|27.||Pessosa-Silva CL, Posfay-Barbe K, Pfister R, Touveneau S, Perneger TV, Pittet D. Attitudes and perceptions towards hand hygiene among healthcare workers caring for critically ill neonates. Infect Control Hosp Epidemiol 2005;26:305-11. |
[Table 1], [Table 2], [Table 3], [Table 4]