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Abstract

Improper HH by health care workers is responsible for about 40% of nosocomial infections resulting in prolonged illnesses. A cross-sectional study was carried out in three hospitals to identify the knowledge and practice of HH. There was a significant difference in the level of knowledge among the health care workers (p < .05). There was a positive association (r = 0.247) between knowledge and practice skill of health care workers. Nearly three quarters of the health care workers (74.2%) had been trained for infection prevention. Soap was the most popular agent (57.5%) for HH. The health care workers had good level of knowledge (77.3%) and practice (91.7%) on HH. However, half of the health care workers were unaware of all of the steps of HH and they were lacking in knowledge and practice skill regarding important components of HH. Therefore, there is an urgent need for continuing medical education for infection prevention, to increase their awareness and compliance toward HH.

Keywords

HH knowledge practice health care workers Nepal

Introduction

Hands of the Health Care Workers (HCWs) play a significant role in the transmission of nosocomial pathogens (Kampf & Kramer, 2004). Improper hand hygiene (HH) by HCWs is responsible for about 40% of nosocomial infections (Inwerebu, Dave, & Pittard, 2005). Health care–associated infections (HAIs) due to poor HH is a major cause of increasing morbidity, mortality, and health care costs among hospitalized patients worldwide (Sydnor & Perl, 2011; Trampuz & Widmer, 2004; World Health Organization [WHO], 2002). On average, health care providers clean their hands less than half of the times they should (Centre of Disease Control and Prevention, 2016).

Hand Hygiene (HH) is an effective way of preventing the spread of infectious diseases and the spread of antimicrobial resistance (Anderson et al., 2008; WHO, 2009a, 2009b, 2009c). Improved compliance in HH, with proper use of alcohol-based hand rubs (ABHR) can reduce the nosocomial infection rate by as much as 40% (Kampf, Loffler, & Gastmeier, 2009). A systematic review study on HH in domestic settings showed that Hand Washing (HW) with soap reduces diarrheal morbidity by 44% and respiratory infections by 23% (Curtis, Danquah, & Aunger, 2009). The spread of HAIs can be controlled if HCWs wash their hands properly before touching patients, before aseptic procedures, after body fluid exposure, after touching patients, and after touching patients surroundings, with soap and water or with ABHR (Bischoff, Reynolds, Sessler, Edmond, & Wenzel, 2000).

HH is therefore the most important measure to avoid the transmission of harmful germs and prevent HAIs. Any person involved in direct or indirect patient care (HCWs, caregiver) therefore needs to be concerned about HH and should be able to perform it correctly at the right time (WHO, 2009c). Unfortunately, compliance with recommended HH procedures for HCWs has been poor, with mean baseline rates as low as 5% and an overall average of 38.7% (WHO, 2009c).

Several factors are associated with poor compliance of HH (WHO, 2009c). These factors are lack of awareness and knowledge with regard to importance, techniques, methods and quality of HH, presence of individual towel/tissues, availability of HH agent, automated sinks, location of sinks, workload, or lack of institutional priorities (WHO, 2004). However, the reasons for low compliance with HH have not been defined in developing countries probably due to limited studies on HH (Karabay et al., 2005).

The present study attempts to describe the HCWs knowledge and practice regarding HH in three different hospitals of Chitwan, Nepal. This article could be a landmark study in Nepalese locality helping to develop HCWs HH practice.

Method

Study Site

Chitwan district is selected for this study purposively because of growing medical advances in the district. In fact, Bharatpur (Capital city) of Chitwan is considered as a Medical City in Nepal.

Study Design and Selection of Participants

A cross-sectional, self-administered, questionnaire-based study was conducted among 132 HCWs of three different levels (doctors, sisters, and staff nurses) in three different hospitals (B.P. Koirala Memorial Cancer Hospital [BPKMCH], Chitwan Medical College [CMC], and Bharatpur Hospital [BH]) of Chitwan, Nepal.

The sampling was done in two stages. In the first stage, out of 12 total hospitals, three hospitals of Chitwan were randomly selected by using the lottery method. For the lottery method, names of all 12 hospitals were written in a separate, uniform-sized paper which was folded and put into a bowl. The papers were thoroughly mixed in the bowl. One by one, three papers were taken out. In the second stage, sampling unit (HCWs) was drawn by convenience sampling.

Data Collection

A self-administer questionnaire was developed from previous studies conducted in Nepal, India, and Nigeria (Anargh, Singh, Kulkarni, Katwal, & Mahen, 2013; Maheshwori et al., 2014; Timothy & Ifeoma, 2013). A total of 16 questions were developed, and the questionnaire was reviewed by the researcher who had previous experience in HH research. The final questionnaires were distributed to seven different wards (Medical, Surgical, Intensive Care Unit [ICU], Outpatient Department [OPD], Emergency, Operation Theater [OT], and Postoperative Ward) of the selected hospitals. Data were collected on the profile of HCWs as well as their knowledge and practice regarding HH.

Pilot testing was done among 20 HCWs at College of Medical Sciences Teaching Hospital, Chitwan, Nepal. The respondents included in the pilot testing were excluded from the study. After the pilot testing, necessary and appropriate modifications were done to the questionnaire (e.g., incorporating additional questions and changes to the language).

Data Analysis

To identify the level of knowledge and practice, scores were given to responses from the participants. For the scoring, “1” point was given for a response that indicated a “good level of knowledge” or “correct practice” and “0” point each was given for a response that indicated a “poor level of knowledge” or “incorrect practice.” A score of 75% and above was considered good, 50% to 74% was considered moderate/average/fair, and below 50% was considered as poor (Maheshwori et al., 2014).

Data were entered using Epi-data 3.1 software and analyzed using SPSS 16. The statistical analysis carried out was descriptive and bivariate (correlation and one-way ANOVA). One-way ANOVA test was applied to compare the mean knowledge and practice scores between the different hospitals. Correlation analysis between knowledge and practice was also performed. A p value less than .05 was considered significant.

Ethical Issues

Ethical approval for the study was obtained from Institutional Review Committee (IRC) board of CMC on May 4, 2013. HCWs who were currently working in health care facility and willing to give informed consent were included in the study.

Operational Definition

HH

We consider HH as generally performed either by hand rubbing with an alcohol-based formulation or HW with plain or antimicrobial soap and water.

Quick HH

Use of alcohol-based hand sanitizers such as spirit and povidone-iodine is considered as a quick HH technique as it takes only 20 to 30 s for completion.

Comprehensive HH

Use of soap and water is considered as comprehensive HH as it takes 40 to 60 s for completion.

Results

Table 1 presents the profile of HCWs according to their work experience, designation, and wards. Out of 132 HCWs, 80 were staff nurses. Majority of the participants were from CMC and BH. A total of 103 HCWs had less than 5 years of work experience.

Table 1.

Profile of Health Care Workers (n = 132).

		Hospitals			Total
		BPKMCH	CMC	BH	Total
		32	52	48	132
Work experience (years)	≤5	19	43	41	103
	6-10	8	5	7	20
	11-15	2	3	0	5
	>15	3	1	0	4
Designation	Doctor	6	17	11	34
	Sister	6	6	6	18
	Staff nurse	20	29	31	80
Ward/units	Medical	6	10	5	21
	Surgical	7	10	4	21
	ICU	0	14	21	35
	OPD	2	5	0	7
	Emergency	4	6	6	16
	OT	9	1	6	16
	Post op	4	6	6	16

Note. BPKMCH = B.P. Koirala Memorial Cancer Hospital; CMC = Chitwan Medical College; BH = Bharatpur Hospital; ICU = Intensive Care Unit; OPD = Outpatient Department; OT = Operation Theater; Post op = Postoperative Ward.

The profile of HH practice is presented in Table 2. A total of 113 (85.6%) HCWs had reported that they performed HH more than three times in a single duty shift of 6 hr. A total of 130 (98.5%) HCWs performed HH either for invasive or noninvasive procedure. More specifically, all HCWs had the habit of performing HH before and after each procedure. A total of 120 (90.9%) HCWs dried hands after each HH procedure.

Table 2.

Comparison of Responses for Practice Based Questions (n = 132).

Practice related to HH	Correct response	n (%)			Total
Practice related to HH	Correct response	BPKMCH	CMC	BH	Total
Frequency of performing HH in a single duty shift	More than thrice	30(93. 7)	45(86.5)	38(79.1)	113(85.6)
HH done for invasive/noninvasive procedure	During both invasive and noninvasive procedure	32(100)	52(100)	46(95.8)	130(98.5)
HH performed before and after each invasive or noninvasive procedure	Yes	32(100)	52(100)	48(100)	132(100)
Drying hands after HW	After each procedure	28(87. 7)	49(94.2)	43(89.5)	120(90.9)

Note. BPKMCH = B.P. Koirala Memorial Cancer Hospital; CMC = Chitwan Medical College; BH = Bharatpur Hospital; HH = Hand Hygiene; HW = Hand Washing.

Table 3 compares the prevailing knowledge on HH among HCWs. A total of 113 (85.6%) HCWs correctly stated when asked about the main purpose of HH. Hospital wise, only 38 (79.2%) HCWs from BH had correctly answered for what the main purpose of HH was. A total of 130 HCWs (98.5%) were confident that HH is effective against HAIs. A total of 122 (92.4%) HCWs were aware about the existence of WHO Guidelines on HH. A total of 128 (97%) HCWs knew the first step of HW (rub palm to palm) while only 46 (34.8%) HCWs were aware of all of the six steps of HW.

Table 3.

Comparison of Responses for Knowledge Based Questions (n = 132).

Knowledge related to HH	Correct response	n (%)			Total
Knowledge related to HH	Correct response	BPKMCH	CMC	BH	Total
Main purpose of HH	Prevent HAIs	30(93.7)	45(86.5)	38(79.2)	113(85.6)
Effectiveness in controlling HAIs	Yes	32(100)	52(100)	46(95.8)	130(98.5)
Protective to HCWs against nosocomial infections	Yes	32(100)	52(100)	48(100)	132(100)
HW superior than any other method to control HAIs	Yes	28(87.7)	49(94.2)	43(89.5)	120(90.9)
Provision of standard guidelines on HH	WHO standard	32(100)	43(82.6)	47(97.9)	122(92.4)
First step of HW according to WHO	Rub palm to palm	30(93.7)	51(98)	47(97.9)	128(97)
WHO recommended total steps of HW	Six steps	21(65.6)	10(19.2)	15(31.2)	46(34.8)

Note. BPKMCH = B.P. Koirala Memorial Cancer Hospital; CMC = Chitwan Medical College; BH = Bharatpur Hospital; HH = Hand Hygiene; HW = Hand Washing; HCWs = Hands of the Health Care Workers; HAIs = health care–associated infections; WHO = World Health Organization.

Figure 1 shows that 114 (86.3%) HCWs had received information on HH from the hospital while the rest obtained the information from books, Internet, and friends. Figure 2 shows that 98 (74.2%) HCWs had received training on infection prevention. In BPKMCH, less than half of the HCWs (38%) had received training.

Figure 1.

Sources of information on HH from hospital premises (n = 114).

Figure 2.

Course/training related to infection prevention (n = 98).

Figure 3 shows the prevailing patterns of HH (quick or comprehensive) among the HCWs. Almost the same number of HCWs from CMC were following either the quick or comprehensive method of HW. Only a total of five (10.4%) and 13(40.6%) HCWs from BH and BPKMCH performed the quick type of HH, respectively.

Figure 3.

Type of HH performed (n = 132).

Figure 4 shows the profile of usage of different HH products among HCWs. The respondents used different products such as soap, spirit, povidone-iodine, and water. Soap was the most popular agent among the HCWs in the three hospitals. A total of 22 of 53 HCWs from CMC were using spirit for HH. A total of 10 (7.5%) and 15 (11.3%) HCWs from three hospitals were using either povidone-iodine or plain water.

Figure 4.

HH products used (n = 132).

Figure 5 shows the knowledge and practice level of HCWs with regard to HH. A total of 102 (77.3%) and 121 (91.7%) HCWs had good level of knowledge and practice skills respectively. A total of 29 (22%) and 12 (9%) HCWs fit into average and poor category, respectively.

Figure 5.

Knowledge and practice level (n = 132).

The correlation between knowledge and practice was statistically significant (p = .004, r² = .247). Table 4 compares the mean knowledge of the HCWs in the different hospitals. The mean difference in knowledge of HH was statistically significant (p = .003). The mean practice score of HH was not found to be significantly different between the hospitals.

Table 4.

One-Way ANOVA for Comparison of Knowledge Between Hospitals.

Hospital	M ± SD of knowledge	F value	p Value
BPKMCH	91.52 + 10.8^{a b}	5.962	.003
CMC	82.9 + 10.24^a
BH	84.52 + 12.9^b

Note. Post hoc Bonferroni. BPKMCH = B.P. Koirala Memorial Cancer Hospital; CMC = Chitwan Medical College; BH = Bharatpur Hospital.

Mean difference = 8.55 with p = .003 (BPKMCH vs. CMC).

Mean difference = 6.99 with p = .024 (BPKMCH vs. BH).

Discussion

HH is one of the most effective means of preventing infection in developing countries. Knowledge of good HH practice and compliance in HH as per WHO guidelines is essential for lowering HAIs (WHO, 2002, 2009c). Hence, this study was conducted to measure the HCWs knowledge of and practice regarding to HH.

In this study, none of the HCWs of the three hospitals denied the fact that HH was protective against HAIs, and this finding was similar to a study reported by Elaziz and Bakr in 2009 (96%; Abd Elaziz & Bakr, 2009).

More than 90% of the HCWs agreed that HH is the most effective method of infection control in the hospital settings as compared with other methods. A study done in 2004 revealed that HH would prevent more nosocomial infection (99%) than the use of sterile gloves (91%) and sterile central venous catheter care (96%; Kennedy, Elward, & Fraser, 2004). This finding was also similar to a study which revealed that 92% of HCWs considered HH as one of the effective method of controlling hospital acquired infection (Abd Elaziz & Bakr, 2009).

More than 80% of the HCWs in three hospitals knew that prevention of nosocomial infection was one of the main purposes of HH. This could be because of greater emphasis and advocacy on HH by WHO (WHO, 2009c, 2015). Almost all of the HCWs were well aware of the first step of the WHO recommended guideline for HW which was “rub palm to palm.” However, half of the HCWs were unaware of all of the steps of HW advocated by the WHO guideline. These findings were similar to a study conducted in 2015, which revealed that HCWs (anesthesia workers) had knowledge deficits on one or more components of HH steps (Fernandez et al., 2015). These findings may be due to lack of education, regular in-service education, training regarding infection prevention, easy access to HH supplies (sinks/soap/medicated detergents), praise by superior, appropriate feedback, or lack of hospital protocol or policy on strict adherence to WHO recommended HH guidelines. These findings indicate that HCWs need more rigorous, comprehensive, and regular education and training on HH and infection prevention to the HCWs. There must be provision of adequate supply of water, HH products, and appropriate feedback.

Almost all HCWs (95%) in the three hospitals agreed that HH would prevent HAIs which was similar to the findings conducted in a study (98.5%; Joshi, Joshi, Park, & Aryal, 2013).

A total of 74% of the HCWs had received training regarding infection prevention. This percentage was lower than the findings in Anargh et al. study (91%) but higher than the findings in a study conducted by Ekwere and Okafor (56.5%) in 2013 (Anargh et al., 2013; Timothy & Ifeoma, 2013).

A much lower percentage of HCWs of BPKMCH had received training regarding infection prevention as compared with HCWs of the other two hospitals. This observation may be due to several factors such as lack of hospital policy to provide training on infection prevention to the established and newly recruited members to staff, high turnover rate of HCWs, and lack of sufficient human resources leading to the work overload. As BPKMCH is a tertiary hospital for cancer treatment, the turnover of patients is very high which may create excessive demand on HCWs time to make infection prevention training sessions a low priority.

Most of the HCWs (89%) used HH agent available to them, which was similarly reported in Joshi et al. (2013) study (87.5%).

The percentage of HCWs following the quick method of HH was much more in CMC than in the remaining two hospitals. This finding is similar to the findings in other studies which have reported an increased use of quick method of HH (alcohol-based hand sanitizers) in health care settings especially in high demand situations and in crowded areas of hospitals (Heqde, Andrade, & Bhat, 2006; Hugonnet, Perneger, & Pittet, 2002). A study conducted in India showed that 85% HCWs considered hand rubbing with alcohol-based rubs to be more rapid and less time-consuming than HW with soap and water (Anargh et al., 2013).

In this study, all HCWs from the three hospitals performed HH before and after each (invasive/noninvasive) procedure. Similarly, hand drying practice after HH was well performed in all the hospitals. This result was similar to the 2013 study by Ekwere and Okafor which reported that 97.7% of respondents wash their hands after contact or bedside procedure and 82.5% of respondents dry their hands after washing (Timothy & Ifeoma, 2013).

In this study, HCWs had an overall good level of knowledge (77.2%) and good level of practice skills (92%) regarding HH. In contrast, in a study by Ekwere and Okafor in 2013, 83% reported good knowledge and 69.9% reported good HH practices (Timothy & Ifeoma, 2013). There was a significant association (p = .004) between knowledge of and practice of HH. We found that there was significant difference in the level of knowledge of HH of HCWs of BPKMCH (p = .003) as compared with that of HCWs in the other two hospitals. However, there was no significant difference in the level of practice skills of HH among the three hospitals.

The present study has some limitations. HH practice was evaluated on the basis of information provided by the HCW, instead of actually observing the HH practice. This could have led to bias in the study. A cross-sectional study design was used to collect data on knowledge of and practice toward HH; a longitudinal study design could have helped us better evaluate the HH practice over an extended period of time. The sampling unit was selected as per convenience; random sampling could have made the sampling more representative and thus could have enhanced the quality of research. In Nepal, very few articles have been published regarding HH, and therefore, it was difficult to compare and contrast our findings with other research findings from Nepal. The findings of this study are difficult to generalize as this study was conducted only in three selected hospitals of Nepal.

Further research is recommended to explore the factors associated with knowledge and compliance with HH practices. Additional research could be done to study the factors which determine the association between knowledge and compliance with HH practices among HCWs and among different health care settings.

Conclusion

HCWs had an overall good level of knowledge of and practice regarding HH. However, they lacked knowledge and practice skills regarding some important components of HH. Therefore, there is a need for adequate supply of HH products, preemployment training, regular training on infection control measures, performance feedback, verbal reminders for performing HH, provision of infection control policy, and strict adherence to infection control policies.

Only a few articles have been published in Nepal related to HH among HCWs. Hence, this article could be a landmark study in understanding the awareness of HH among the HCWs of Nepal.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Funding

The author(s) received no financial support for the research,authorship,and/or publication of this article.

Author Biographies

Gayatri Khanal is a lecturer of Public Health in School of Public Health and Community Medicine Department of Chitwan Medical College,Nepal. She holds a degree of masters in public health from Punjab University,Chandigarh,India. She has been involved actively in research activities in the rural areas of Nepal.

Suman Thapa is a consultant ENT surgeon in Chitwan Medical College holding Masters degree (MS) from Post Graduate Institute of Medical Science and Research (PGIMER),Chandigarh,India. He is a young dynamic surgeon having a special intrerest and concern on infection prevention in ward and operation theatre.

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Awareness of Hand Hygiene Among Health Care Workers of Chitwan,Nepal