A survey of hand hygiene knowledge, attitude and practices among health care workers in a tertiary hospital, Southwestern Nigeria

Background: Improper hand hygiene practices among Healthcare Providers (HCPs) are a common risk factor for and interventions to improve hygiene have proven to be effective strategy in reducing nosocomial infection. Hand hygiene has been described as the single most important, simplest and least expensive means of preventing nosocomial infections. Aim/Objectives: The studied was carried out to determine the knowledge, attitude and practice of hand hygiene among healthcare workers in a tertiary health facility. Materials/Methods: A crosssectional study was conducted among 368 doctors, nurses and ward attendants using multistage sampling technique. Data were collected with a set of selfadministered, modifi ed WHO questionnaire and analyzed using IBM and SPSS version 25 statistical package. Results: The mean age of respondents was 35.2±9.3 years, and majority of them were between 36-45years (33.6%). The male to female ratio was 1.6: 1. Most of the respondents were nurses (41.5%) and 370 (98.95%) of the respondents had a good knowledge of hand hygiene. Washing of hands before and after contact with patients was 44.65% and 56.2% respectively. Most of them have received training on hand washing in the last three years (53.4%), 222 (62.7%) respondents routinely used alcohol based hand rub. The main reason cited for not observing hand hygiene practices consistently were lack of running water (53.4%), unavailability of alcohol based hand rub(26.6%), and dirty water sinks (24.0%). Conclusion: Although knowledge, attitude and practice of hand hygiene were good among respondents in this study, lack of running water and unavailability of alcohol based hand rub remain major constraints. Hospital management should therefore provide adequate water supply and materials for sanitation and hand hygiene in healthcare facilities. Research Article A survey of hand hygiene knowledge, attitude and practices among health care workers in a tertiary hospital, Southwestern Nigeria RD Agbana1, SP Ogundeji2 and JS Owoseni3* 1Department of Community Medicine and Public Health, College of Medicine and Health Sciences, Afe Babalola University, Ado Ekiti, Nigeria 2Department of Haematology, College of Medicine and Health Sciences, Afe Babalola University, Ado


Introduction
Hand hygiene has been identifi ed as e an effective means of infection prevention and control in the hospital and even outside of the hospital environment as exemplifi ed by the preventive strategies employed to tackle the corona virus  pandemic ravaging the world [1,2]. Healthcare workers have been identifi ed as the most common vehicle for transmission of Hospital Acquired Infection (HAI) from patient to patient and within the healthcare environment [3,4]. Since Australian-Hungarian physician Ignaz Semmelweis discovered the importance of hand wash in 1858, good hand hygiene is Citation: Agbana  considered to reduce infection transmissibility in the hospital setting [5,6]. Although hand hygiene can be described as an effective, simple, cheap and not time consuming HAI control strategy most studies show low compliance rate of between 40% and 70% [7,8]. HCW have reported several factors that negatively impact their adherence with recommended practices including but not limited to; inadequate knowledge and lack of awareness, hand washing agents cause irritation and dryness, sinks are inconveniently located, lack of soap and paper towels, not enough time, over workload with understaffi ng, lack of knowledge of guidelines/protocols, and forgetfulness [9][10][11][12].
According to WHO an estimate1.4 million patients acquire HAI at any time and improper hand hygiene accounts for about 40 % of this incidence [13]. The prevalence of HAI varies from one region of the world to another. It affects 5-15% of hospitalized patients in developed country with higher fi gures quoted for developing countries [14,15]. Diarrhoea diseases and respiratory tract infections are among the leading contributors to the global burden of disease and poor water supply related to hand hygiene represents 7% of the risk factors [7].
The fact that hand hygiene signifi cantly reduces nosocomial infection is important in our environment where health facilities are ill-equipped to provide comprehensive support in terms of molecular diagnosis of infectious diseases and high antibiotic resistance due to widespread over the counter procurement [16].
The study was conducted to assess the knowledge, attitude and practice of hand washing among HCW at the Federal Teaching Hospital Ido Ekiti which is a tertiary health centre in Southwester Nigeria. The study further aimed to identify factors hampering the practice of hand washing among the respondents. The fi nding of this study would help the management as well as the infection control unit of the hospital to institutionalized appropriate measures to increase the compliance rate of hang hygiene thereby with the ultimate aim of reducing the prevalence of HAI.

Setting
The study was conducted at the Federal Teaching Hospital, Ido -Ekiti (FETHI), located in Southwestern Nigeria. The hospital was established in 1954 as a general hospital, upgraded to a Federal medical centre in 1988 and became a teaching hospital in 2014. It serves as a referral centre for all other health institutions in Ekiti and neighbouring states. The hospital comprises of 300 bed spaces including Intensive Care Unit (ICU).

Study population
This consists of 260 doctors, 400 nurses and 500 ward attendants as at when the study was carried out. All the doctors, nurses and ward attendants working in the hospital at the time of study and willing to participate were included in the sampling g frame. HCW who declined consent and those with injuries, bandages or any other barrier to hand washing were excluded.

Study design
This was questionnaire based cross sectional descriptive study. A multistage sampling g technique was used to select participants.

First stage
Six departments (Paediatric, Obstetric and Gynaecology, Community Medicine, Family Medicine, Psychiatry and Internal Medicine) were randomly selected from 11 clinical departments of the hospital using table of random numbers.

Second stage
At the departmental level, HCW in each department were stratifi ed in to doctors, nurses and ward attendants.
Questionnaire allocated to each department were subsequently allocated to each stratum.

Third stage
The list of HCW in each stratum was obtained via the departmental Heads and the questionnaire was then administered to participants using systematic random sampling after determining the sampling fraction.

Sample size determination
Sample size was determined using the Fishers formula to obtain a total of 368 based on 95% confi dence interval and 5%c margin of error. The sampling was limited to doctors, nurses and ward attendants whose hand hygiene practices can either minimize or perpetuate the transmission of infections.

Data collection
Data collection was done using a pretested, structured and self-administered questionnaire. The questionnaire consisted of 4 sections: with section A) exploring the socio-demographic characteristics, B) consisting of questions on the level knowledge and attitude of hand washing, C) consists of the prevalence and practice of hand washing and D) limitations and solutions to problems of hand washing practices. The investigators personally delivered the questionnaires to the participants after a detailed explanation of the study was provided. Written consent was obtained from those who consented and confi dentiality was ensured throughout the study.

Data analysis
Data was analysed using IBM and SPSS (statistical package for the social sciences) statistical version 25 using inferential statistics. The data was presented in percentages and frequency table. Results were interpreted and conclusions were drawn.

Ethical
Ethical approval was obtained from the Ethics and Research committee of the hospital.
Citation: Agbana  About 57.6% washed their hands over 5 times during their shift and 44.6% practiced hand-washing occasionally before interacting with patients while 56.2% said they practiced it always after having patient interactions. Lack of water was the most identifi ed reason (53.45%) limiting hand washing practice. In fact, about 60% of the HCW said water and soap were only readily available for hand -washing in their department's occasionally. However, 76.6% , 78.5%, and 57.3% of the respondents asserted that their heads of departments, colleagues and patients respectively attached a very high importance to optimal hand hygiene. Also, about 72.3 % thought that they always require substantial efforts to perform good hand hygiene.
Finally on how to improve hand-washing amongst HCWs at the studied centre, 68.1%, 52,8%, 34.7%, and 14.4% suggested provision of adequate alcohol-based sanitizers, provision of adequate soap and water supply, lectures and seminars on hand washing and formulation of fi rm hand-washing policies respectively.

Discussion
This study assessed the knowledge, attitude and practice of hand washing among HCW in a tertiary hospital setting unlike most previous studies which were community based.
HAIs are an important causes of morbidity and mortality in clinical practice and pose ethical challenge to healthcare delivery (''nonmalefi cence -fi rst, don no harm") [17]. One of the easily identifi ed routes of transmission of HAI is the hands of HCW [18,19]. HAI are a burden to both physicians and patients, as they lead to complications in therapy, overall increase in admission days, increase healthcare costs and may result in mortality [4,20]. only about 56.2% practiced hand-washing after interacting with patients and 5.6% said they never did. The reasons for this could include lack of continuous educational programme on hand hygiene; unfortunately, HCW in developing countries such as ours consider such programme as mundane. A similar study shows that despite the various advancement in infection control, HCW still do not fully adhere to the recommended hand hygiene practices and as such compliances was still low [5]. In a systematic review by Erasmus, et al. [22], on hand hygiene practices, it was discovered that in ICUs and general wards, the compliance rate was 40% among physicians. This goes to show that even in critical care units in hospitals compliance with hand hygiene is still a topical issue.
The limiting factors in the practices of hand-washing before and after patients contact mentioned by the respondents like lack of water, unavailability of alcohol-based hand-rub, dirty water sinks, forgetfulness among others were in congruous with reports from an earlier study [21]. Hand hygiene has therefore been promoted as one of the tools that will help to mitigate rise in antimicrobial resistance [23].
In this present study, we observed that several personnel did not perform hand hygiene before conducting an invasive procedure but simply went on to don their gloves. This fi nding buttress the fact that for them hand hygiene was basically for their own protection and not that of the patient or immediate environment.
The behavioural pattern is also seen on our study with low levels of compliance with the WHO fi ve moments of hand hygiene [24,25]. A worrisome trend is the high noncompliance rates of hand hygiene after touching patients at hands of HCW could then become reservoir for the transmission of pathogens among patients. The several infection causing microorganisms are regularly mutating and as such antimicrobial resistance rates are higher in HAI compared to the community [14,26,27]. Such pathogens may therefore enter into the local community via 3 means : HCW, discharged patients who become asymptomatic carrier or the relatives who had visited the hospital.
At the moment, the situation in developing countries is such that hand-washing facilities are suboptimal [28]. Non availability of suffi cient sinks and running water are also recognized impediment. In addressing hand hygiene, however, alcohol-based hand rubs are become handy. Furthermore, educational programmes must also be supplemented with the presence of an effective infection control team. There must also be active surveillance system in place to rapidly detect cases of HAI and nip further ones in the bud [29][30][31]. Such surveillance system may also use personnel who have high rates of patient contact to drive the process.
The highest rates of direct patient contact in this study were in the nurses and the anaesthetists. These two categories of HCW are points of easy access to both patients and other heathcare personnel and as such interventional measures may be designed around them.
The WHO has recommended guidelines [2,30], for hand hygiene and its central theme is to wash hands with soap and water when it is visibly dirty or soiled with blood or other body fl uids or after toilet use. The guidelines recommend washing with water and soap or an alcohol-based hand rub. Studies on effi cacy of alcohol-based hand rub show that they have good effi cacy when the concentration of alcohol ranges from 62% to 95% thus ensuring that they are rapidly bactericidal [32].
Promoting the use of alcohol-based hand rubs in hospital in developing countries such as ours may help drive down the rates of HAI as running water is not always available. Such alcoholbased hand rubs can be constituted in local pharmacies and made available on a regular basis for hospital use.

Conclusion
This study established that the participants have good knowledge of hand hygiene but compliance ratneeds to be improved upon. The main identifi ed limitations are non availability of hand washing kits; soap, running tap water, alcohol rub, and towel or hand dryers.
We recommend the provision of these basic needs as well educational sessions to further drive the importance of hand washing to the care givers and patients which will go a long way in improving their attitude towards hand hygiene. This we believe would curb preventable infections, reducing hospital stay and cost. Therefore, information, education, and communication should be intensifi ed among HCW in clinical settings to reduce HAI.