|Year : 2020 | Volume
| Issue : 1 | Page : 32-39
Compliance to hand hygiene and its associated factors among health care provider in general hospital in Addis Ababa, Ethiopia
Ziyad Ahmed Abdo1, Meaza Gezu Shentema2, Mulugeta Tamire Awono2, Yohannes Lakew Tefera3
1 Department of Public Relation and Communication, Ethiopian Ministry of Health, Addis Ababa, Ethiopia
2 Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
3 Department of Maternal, Child Health and Nutrition, Ethiopian Ministry of Health, Addis Ababa, Ethiopia
|Date of Submission||31-Aug-2019|
|Date of Decision||12-Dec-2019|
|Date of Acceptance||27-Jan-2020|
|Date of Web Publication||23-Apr-2020|
Ziyad Ahmed Abdo
Postal Code: 1234 Addis Ababa
Source of Support: None, Conflict of Interest: None
INTRODUCTION: Globally, a significant proportion of healthcare providers and patients acquire nosocomial infections through contaminated hand. Failure to perform appropriate hand hygiene is considered to be the leading cause of healthcare-acquired infection worldwide.
OBJECTIVES: To describe compliance to hand hygiene and its associated factors among healthcare provider in general hospital in Addis Ababa, Ethiopia.
METHODOLOGY: An institutional based cross-sectional study was conducted among healthcare providers working in general hospitals in Addis Ababa. Multistage sampling system was used to select 708 participants. Data were collected using a self-administered structured questionnaire. Data were entered into Epi data version 3.1, and then exported to SPSS version 22 for data management and analysis. Multivariable logistic regression was performed to identify factors associated with healthcare providers hand hygiene practice.
RESULTS: A total of 651 healthcare providers were participated in this study, with a response rate of 91.9%. The overall good hand hygiene practice of healthcare providers were 50.4%. Educational status: master and above holders (adjusted odds ratio [AOR] [95% of confidence interval (CI)]) = 0.46 (0.26, 0.84) and first-degree holders (AOR [95% of CI]) = 0.43 (0.23, 0.82), attitude (AOR [95% of CI] = 1.61 (1.09, 2.38), knowing functionality of infection prevention committee (AOR [95% CI]) = 1.57 (1.03, 2.38), functionality of hand washing sink (AOR [95% of CI]) = 2.26 (1.07, 4.79), availability of running water (AOR [95% of CI]) = 1.86 (1.011, 3.432), and availability of hand hygiene guide (AOR [95% of CI]) = 1.66 (1.13, 2.43) were significantly associated with hand hygiene practice.
CONCLUSIONS: According to this study, good hand hygiene practice is low. This indicates that patients and healthcare providers are at high risk of acquiring nosocomial infection. Hence, government and management of the hospital must give emphasis on patient safety.
Keywords: Compliance, hand hygiene, healthcare providers, infection prevention
|How to cite this article:|
Abdo ZA, Shentema MG, Awono MT, Tefera YL. Compliance to hand hygiene and its associated factors among health care provider in general hospital in Addis Ababa, Ethiopia. BLDE Univ J Health Sci 2020;5:32-9
|How to cite this URL:|
Abdo ZA, Shentema MG, Awono MT, Tefera YL. Compliance to hand hygiene and its associated factors among health care provider in general hospital in Addis Ababa, Ethiopia. BLDE Univ J Health Sci [serial online] 2020 [cited 2020 Aug 13];5:32-9. Available from: http://www.bldeujournalhs.in/text.asp?2020/5/1/32/283085
Healthcare-associated infections (HCAIs) led to a serious risk to both the patients and healthcare provider., Hand hygiene is a practice that applies to hand washing with plain soap and water, antiseptic soap and water, antiseptic hand rub, or surgical hand antisepsis., Common pathogens can easily transmit through healthcare workers' (HCWs) hands, equipment, supplies, and unhygienic practices.,,
Hand hygiene is one of the standard precautions which is considered to be the primary measure necessary for reducing HCAI. It contributes significantly to keeping patients safe., It is a simple, low-cost action to prevent the spread of all microbes that cause HCAI., While hand hygiene is not the only measure to counter HCAI, compliance with it alone can extremely enhance patient safety, because there is considerable scientific evidence showing that microbes causing HCAI are spread between patients through hands of HCWs.,
Different studies show that compliance of healthcare professionals to hand hygiene practice can prevent high percentage of HCAI risks with readily available, relatively inexpensive, and simple strategies., Hence compliance of HCW to hand hygiene practice is one of the major healthcare quality assurance strategies that need emphasis.,,
Globally, a significant proportion of healthcare providers and patients acquire HCAIs. It is estimated that more than 1.4 million people worldwide are suffering from infections acquired in hospitals. The burden of HCAI is different at different setting. In some developing countries, the proportion of patients affected by a healthcare-acquired infection can exceed 25%. It is also a major public health problem in Ethiopia and their prevention has been made a priority as reported by a study on 1383 obstetrics and gynecologic patients at a referral hospital in north west Ethiopia; 246 (17.8%) developed hospital-acquired infections.
Even though failure to perform appropriate hand hygiene is considered to be the leading cause of HCAI, HCW compliance to hand hygiene practice is less than optimal. In critical care situations where there are severe time constraints and the workload is higher, compliance to good hand hygiene practices might be as low as 10%, with compliance levels most frequently well below 40%.
Studies done in different part of Ethiopia on infection prevention and control measure show that compliance of HCW to hand hygiene practice is low which most of them focus on public health institution.,, Similarly, in Addis Ababa, different report shows that low hand hygiene compliance is recognized to be common in both public and private healthcare institutions. Because of these facts this study aimed to fill the gap by focusing on this sensitive issue which describes compliance of healthcare professionals with hand hygiene practice and its associated factors among general hospital in Addis Ababa, Ethiopia.
| Methodology|| |
Study area and period
The study was conducted in Addis Ababa city, Ethiopia. The total area of the city is 54,000 hectares. According to the 2013 population estimation, the total population of Addis Ababa is more than 4 million. Regarding health institutions, the city has 134 private primary clinics, 437 private medium clinics, 265 private specialty clinics, and 117 government health centers, 12 public hospitals, 24 private general hospitals.
Institutional-based cross-sectional study design was used to describe the level of compliance with hand hygiene practice and its associated factors among general hospital in Addis Ababa, Ethiopia.
Source and study population
The source population was all healthcare providers working in general hospital in Addis Ababa. The study population was all healthcare providers working in selected general hospital in Addis Ababa and who were on active duty during data collection time.
By using double proportion formula sample size was calculated.
Where P = p1 + p2)/2
Proportion was taken from similar study done in India  with compliance of hand hygiene practice at public hospital (66%) and at private (76%). Finally, the sample size for each group calculated was 354 including 10% for nonrespondent. Therefore, total sample size for this study was 708.
Independent variables: compliance to hand hygiene. Dependent variables: sociodemographic characteristics, personal characteristics (knowledge and attitude), administrative characteristics, and availability of hand hygiene facilities.
Multistage sampling techniques were used to select study participants. First, general hospitals were divided into public and private strata. Then, 3 public hospitals and 6 private hospitals were selected from 5 public and 24 private general hospitals by simple random sampling techniques, respectively. Then, healthcare providers were selected from different ward proportionally to the total healthcare provider in the ward.
Data collection tool and procedure
The standard self-administered questionnaire was adapted from World health organization hand hygiene compliance assessment questionnaire and the questionnaire was customized and developed to assess current hand hygiene compliance and associated factors. The questionnaire was developed in English and translated to local language Amharic version again, then Amharic version was translated back to English version by different translator to check correctness and consistency of translation. The questionnaire was pretested (with 5% of the sample size) in hospital not included in the study. Based on finding of pretest done, sequence of questions and vague questions were corrected. Data collection was facilitated by four diploma nurse and one supervisor who have BSc. in environmental health.
Hand hygiene: it refers to any method that removes or destroys microorganisms on hands. Knowledge of hand hygiene: it refers to healthcare provider's awareness in relation to questions in the questionnaire per hand hygiene guideline. It was measured based on 12 hand hygiene and infection prevention related questions. Good knowledge: it refers to HCW who scored the mean and above the mean value of the knowledge questions value, low knowledge: refers to HCW who scored below the mean of the total knowledge questions value.
Attitude toward hand hygiene is defined as subjective feelings of healthcare providers about the validity of an idea or set of facts related to the recommended hand hygiene and healthcare-acquired infection. It was evaluated based on Likert scale (namely; 1 – strongly disagree, 2 – disagree, 3 – not sure, 4 – agree and 5 – strongly agree) measurement systems through 24 hand hygiene and healthcare-acquired infections related attitude questions. Good attitude: refers to HCW who scored the mean and above the mean value of hand hygiene attitude score, Low Attitude: refers to HCW who scored below the mean value of hand hygiene attitude score.
Hand hygiene compliance: refer to hand hygiene practice measured based on 14 CDC standard questions of hand hygiene practices using Likert scale measurement system. Healthcare provider could be considered as “good” when they score equal or above mean score of hand hygiene practice, and considered as “low” when they score below mean score of hand hygiene practices.
Data management and analysis procedures
The data was entered into Epi data version 3.1, and then exported to SPSS version 22 for data management and analysis. Descriptive statistics, percentages, and mean was carried. In addition, bivariate analysis was performed to identify variables that associate with dependent variable and then the variables with P < 0.25 were taken to multiple logistic regressions to determine factors associated with compliance to hand hygiene practice by controlling potential confounding variables. Statistical significance were considered at P < 0.05 was used to see the association between factors and compliance to hand hygiene practice.
Ethical clearance was obtained from Addis Ababa University, college of health sciences research and ethics committee and Addis Ababa health bureau. A formal letter obtained from Addis Ababa health bureau was submitted to all hospitals included in study. The purpose of study was well explained to the study participants and informed consent was obtained. Omitting names of the participant from the questionnaire and as no personal details was recorded or produced on any documentation related to the study help to assure confidentiality of the information and respondents. Participation was totally voluntarily.
| Results|| |
A total of 651 healthcare providers were participated in the study, with response rate of 91.9%. Of which, 335 (51.46%) were from private hospital and 316 (48.5%) were from public hospital. About 445 (68.4%) and 205 (31.5%) were female and male, respectively. Majority of respondents – 399 (61.3%) and 373 (57.3%) were nurses andfirst-degree educational level, respectively. Mean ages of respondents were 32.06 with ± standard deviation (SD) of (7.58) years. Mean work experiences were 8.59 with ± SD of (1.84). Detail result of sociodemographic characteristics is depicted in [Table 1].
|Table 1: Sociodemographic characteristics of respondents in general hospital in Addis Ababa, Ethiopia|
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Knowledge related to hand hygiene
Regarding to knowledge of hand hygiene responses, about 368 (56.5%) of respondents had good knowledge of hand hygiene guide line and 122 (43.5%) had low knowledge. About 194 (61.4%) and 122 (38.6%) healthcare professional from public hospitals had good and low knowledge of hand hygiene respectively, while 174 (51.9%) and 161 (48.1%) of healthcare professionals from private hospital had good and low knowledge of hand hygiene, respectively.
Attitude of healthcare provider to ward hand hygiene and healthcare-acquired infection
According to response on attitude toward hand hygiene and healthcare-acquired infection rated based on Likert scale measurement system, around 301 (46.2%) of heath care provider had good attitude and 350 (53.8%) had low attitude. Accordingly, 159 (50.3%) of respondents from public hospitals had good attitude, while 157 (49.7%) of them had low attitude. Similarly, about 142 (42.4%) respondents from private hospital had good attitude, while 193 (57.6%) had low attitude.
Administrative characteristics of the hospitals
About 579 (88.9%) of the respondents knew that their hospitals allocated budget for infection prevention activities. More than half of respondents 377 (57.9%) reported that they had taken training on hand hygiene practices. About 549 (84.3%) of respondents knew that presence of infection prevention committee in the hospital. About 242 (37.2%) respondents said there was motivation for compliance with hand hygiene practice. Detail of administrative characteristics of the hospitals is shown in [Table 2].
|Table 2: Administrative characteristics which may affect hand hygiene practice in general hospital; Addis Ababa, Ethiopia|
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Availability of hand hygiene facilities in the hospitals
About 615 (94.5%) of respondents reported sink was available in the working ward. Similarly 521 (80.0%) of respondents reported running water was available. About 526 (80.8%) reported that alcohol based hand rub was available. Around 400 (61.4%) reported hand hygiene posters are displayed in the working areas as reminder. Summary of availability of hand hygiene facilities in the hospital is shown in [Table 3].
|Table 3: Availability of hand hygiene facility in general hospital in Addis Ababa, Ethiopia|
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Healthcare provider hand hygiene practice
This study revealed that the overall good hand hygiene compliance was found 328 (50.4%) and poor hand hygiene compliance were 323 (49.6.9%). Accordingly, about 179 (56.6%) and 137 (43.4%) of respondent from public hospital had good and poor hand hygiene compliance respectively. Similarly, about 149 (44.5%) and 186 (55.6%) respondents from private hospital had good and poor hand hygiene compliance, respectively. Out of hand hygiene practice situations highest score was reported when healthcare professionals look or feel dirty – 4.56 (91.2%) and least hand hygiene was reported before entering isolation room – 2.69 (53.8%). Result of each label score for each hand hygiene questions is shown in [Table 4].
|Table 4: Mean hand hygiene practice of respondents in general hospital in Addis Ababa, Ethiopia|
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Factors associated with hand hygiene compliance among healthcare provider of General hospitals in Addis Ababa, Ethiopia
Bivariate analysis was conducted to see the association of one independent variable with the dependent variable. Based on this, variables with P < 0.25 during the bivariate analysis were included in the multivariate logistic regression analysis to see the association of variables with compliance to hand hygiene practices by controlling confounding variables. Accordingly after computing multivariable analysis educational level, working department, attitude, functionality of sink, availability of running water, knowing functionality of infection prevention committee and availability of hand hygiene guide line were significantly associated with hand hygiene practice of healthcare provider. Detail is described in [Table 5].
|Table 5: Factors associated with hand hygiene compliance among healthcare provider of General hospitals in Addis Ababa, Ethiopia|
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| Discussion|| |
This study revealed that the overall good hand hygiene compliance was 50.4% which is lower than study done in North India with total compliance of 86.0%. The reason might be due to heath system strengthen of Ethiopia might be weaker than that of India. In other way, the result of this study is higher than study done in Dubti referral hospital in Ethiopia which showed 43% of staff practice had adequate hand washing facility. This might be due to Addis Ababa is capital of Ethiopia and the health professionals working in Addis Ababa have more experience than Dubti which is peripheral hospitals, another the regulatory attention at Addis Ababa is much higher than Dubti.
Hand hygiene compliance of healthcare professionals of the two groups was different; those from public hospitals comply 56.6% which is higher than private hospitals. This study is different from study done in North India which was private hospital were more compliant than public one. The difference might be in India many private hospitals give services to many people came from abroad which force them to keep quality.
This study show that, out of hand hygiene practice opportunities heath care professionals show more compliant if there hand look or feel dirty (91.2%), after touching potentially contaminated objects (89.6%), after contact with blood or blood fluid (88.2), after contact with a patient's secretions (88.0%) and after caring for a wound (86.8%). This study is similar with many studies done previously in different places: study done in Nigeria, study done in Behirdar city, and study done in Mekele city. Similarly, this hand hygiene practice opportunities was higher for both groups (public and private) of this study.
In other way, healthcare providers show low hand hygiene compliance in opportunities like before entering an isolation room (53.8%), before patient contact (55.0%), after existing an isolation room. This is supported by studies done previously at Mekele, India. However, in contrast, one study shows that HCW were more compliant with hand hygiene practice before touching patient, before aseptic procedure. The difference might be the later study was done in healthcare institutions which have strong rule and regulation on patient safety.
Based on the diverse nature of factors, WHO (2009) stresses that successful HH improvement requires multiple strategies to address the different barriers. Among strategies identified by the world health organization as critical components of programs aimed to improve HH, workplace reminders, training and education, evaluation, and feedback play a major role. However, result of this study show no significant association of hand hygiene practice with these three variables in multivariate analysis. This might be due to not emphasis was given in performing this activities.
Finding from this study shows that there was significant association between hand hygiene practice and educational level of heathcare professionals with diploma holders practice more thanfirst-degree and master/above holders. This is supported by study done at Gonder and Debre Markos hospitals with nurses who have diploma were about 2 times more likely to practice surgical site infection prevention activities as compared to those who have bachelor degree or higher.
Finding from this study shows that there was significant association between hand hygiene practice and department/ward they are working in with healthcare professionals working in medical ward, surgical ward, emergency department respectively practice hand hygiene higher than those working in laboratory department. This study is different from study done in Mekele which show those working in laboratory department comply more. The difference might be in latter study strengthening laboratory management transaction toward accreditation system applied.
Among factors which may affect hand hygiene practice attitude of healthcare providers to ward hand hygiene and healthcare-acquired infection play its own role. This study also show that hand hygiene practice was positively associated with attitude of healthcare providers which show that those with Good attitude were practice hand hygiene 1.76 times higher than those with low attitude. This is similar with result of study done in Nigeria which those with Good attitude comply more.
Study done at Mekele town on standard precaution show that type of healthcare professionals was statistically significant with practice of standard precaution. However result of this study show that there is no significant association was observed between professions and hand hygiene practice. The reason might be on former one HCWs emphasis on this issue in there working team.
Findings of this study showed that healthcare providers who know presence and functionality of infection prevention committee were positively associated with hand hygiene compliance. This finding is consistent with study done at Gondar university hospital, Bahirdar city, Mekele special zone, Tikur Anbessa (Black Lion) Hospital and St. Paul's Hospital in Addis Ababa. This indicated that the presence of functional infection prevention committee have a role to plan for infection prevention activity of the hospitals, build the capacity of health worker on infection prevention and have role to avail infection prevention materials. This will link the association of hand hygiene practices with presence of infection prevention committee.
| Conclusions and Recommendation|| |
According to this study good hand hygiene practice is low. This study show that educational level, working department/ward, attitude toward hand hygiene and healthcare-acquired infections, functionality of sink, availability of running water, knowing functionality of infection prevention committee and availability of hand hygiene guide line are determinant factors for hand hygiene practice. Providing on job educational training on infection prevention is essential to increase awareness, attitude and practice of hand hygiene, and ensuring functionality of washing sink, continues availability of running water as well as the availability of infection prevention guidelines in working department should be effective and important interventions to improve hand hygiene practice of healthcare provider which in turn strength infection prevention activities. Additionally infection prevention committee should well communicate and monitor healthcare provider as remainder to strength infection prevention system. Future researchers should consider well organized observational study to validate the self-reported hand hygiene practice of healthcare provider and prevalence of healthcare-acquired infections as result of poor hand hygiene practice.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]