Compliance of Health Workers with Hand Hygiene Measures in a Tertiary Health Facility in Port Harcourt, Nigeria.

INTRODUCTION

Hand-washing with soap and water as a form of personal hygiene (Boyce & Pittet, 2002), and use of antiseptics hand cleansing agents have been advocated (Labarraque, 1829) several generations ago for physicians caring for patients with contagious diseases. Oliver Wendell Holmes demonstrated that dirt from the hands of health personnel contributed to the spread of puerperal sepsis (Rotter, 1999), and subsequently, a consensus was reached in several seminal studies that in preventing pathogen transmission in healthcare facilities hand-washing should be considered one of the most important measures (Boyce & Pittet, 2002).

By 1975/1985 the Centre for Disease Control had developed formal guidelines on hand-washing practices for hospitals (Steere & Mallison, 1975; Garner & Favero, 1986). These include use of non-antimicrobial soaps between patient contacts, and anti-microbial soap wash for care of high-risk patients. They are used before and after performing invasive procedures. By this time alcohol-based solutions were restricted for use when sinks were not available. All these efforts were intended to reduce the bacterial count on the skin of the hands so as to prevent infection transmission from patient to staff and staff to other patients.

The total aerobic bacterial count colonizing the hand of medical staff was estimated to be 3.9 x 10⁴ to 4.6 x 10⁶colony forming units per square centimetre (Boyce & Pittet, 2002; Price, 1938; Larson, 1984; Maki, 1978; Larson et al., 1998), as opposed to the counts in other parts of the body (Boyce & Pittet, 2002; Selwyn, 1980): scalp was reported in the same study to be 1 x 10⁶CFU/ cm²; forearm 1 x 10⁴ CFUs/cm²; abdomen 4 x 10⁴ CFUs/cm² and axilla 5 x 10⁵ CFUs/cm². It is interesting to note that the easily removed transient flora on superficial aspects of the skin are associated with infection as against the deep-seated resident flora which are less likely to be associated with infection (Boyce & Pittet, 2002).

Many hand lotions used as sanitizers are known to lessen the risk of cracking and scaling, and thereby negatively affect shedding of microbial organisms from the hands (Boyce & Pittet, 2002; Larson, 1999; Berndt et al., 2000; McCormick, 2000). Skin irritation from use of hand hygiene agents is an identified problem (Boyce & Pittet, 2002; Larson, 1985). However, alcohol-based agents are known to be less irritant to the skin than others.

Other factors have also been identified as possible reasons for poor hand hygiene practices and they include (Boyce & Pittet, 2002; Pittet, 1999; Larson & Killien, 1982; Conly et al., 1989; Dubbert et al., 1990): lack or inadequate supply of hand hygiene agents, insufficient time for hand hygiene, avoidance of staff-patient relationship interference, prioritizing patient care, use of latex gloves, forgetfulness, poor knowledge of standard practice, understaffing and increased workload, and absence of scientific information pointing to reduced infection rates following hand hygiene measures. Lack of water, funds, sink, etc. are also factors identified by another researcher (Samuel et al., 2005) as being part of the reasons for inadequate hand-washing practices.

Guidelines produced by Association for Professionals in Infection Control (Larson, 1988; Larson, 1995) in 1995 and the Healthcare Infection Control Practices Advisory Committee in 1996 broadened the scope of use of these agents including more use of alcohol-based hand rubs in clinical settings. Many hospitals are noted to have adopted the recommendations in these guidelines but adherence to practice have been low (Boyce & Pittet, 2002; Boyce, 1999; Selwyn, 1980). The holistic consensus recommendations of the WHO on hand hygiene covered broad areas (WHO & WHO Patient Safety,‎ 1999).

The aim of this study was to investigate compliance of health workers with hand hygiene measures in the surgical wards and clinics of a tertiary healthcare centre in Port Harcourt, by ascertaining knowledge on hand hygiene measures, extent of compliance, establishing the factors affecting compliance, and comparing the percentages of directly observed compliance and expressed compliance (from questionnaire) with hand hygiene measures.

MATERIALS AND METHODS

A cross-sectional descriptive study was done among health workers at the surgical wards and clinics of The University of Port Harcourt Teaching Hospital – a tertiary healthcare facility in Port Harcourt, in Nigeria. Port Harcourt is the capital of Rivers State, a petroleum oil-producing State in the South-South of the Federal Republic of Nigeria. The health facility renders services in surgery specialties like: general surgical, neurosurgical, otorhinolaryngologic, dental/oral-maxillo-facial, plastic surgical, cardiothoracic, orthopedic, obstetric and gynecologic, urologic, pediatric surgical, and laparoscopic surgical procedures.

The study instruments were semi-structured questionnaires and a proforma for direct (covert) observation. The proforma only indicated whether or not hand hygiene measures were practiced by staff in-between or after patient care. All health staff who gave their consent were included in the study. Approximately 200 questionnaires were distributed and 183 were retrieved, meeting the minimum sample size of 176. This is based on the staff strength of the department of 266 as provided by the management, using the formula developed by Yaro Yamen: n = N/1+Ne². Data was analyzed using the Statistical Package for the Social Sciences (SPSS) version 20.0. A cut-off p value of ≤ 0.05 was used for the test instrument – chi square, and the direct (covert) observational aspect of the study was randomized.

RESULTS

This cross-sectional analytical study was carried out among staff of surgery department of the University of Port Harcourt Teaching Hospital, Rivers State, Nigeria. A total of 183 respondents who were doctors, nurses, medical students, and others (maids/cleaners) were included in the survey.

The demographic characteristics of the respondents summarized in Table 1.0 indicated that almost half (47.0%) of the respondents were less than 35 years of age and only 2.2% were between 55 and 54 years. Forty-four-point three percent were male and female respondents were 55.7%. More than half (56.3%) were married and majority were Christians.

In Table 2.0: seventy-four of the respondents (40.4%) have spent between 1 to 5 years in service, 38 of them (20.8%) spent 6 to 10 years, 34 spent 11 to 20 years (18.6%) and 25 (13.7%) had spent more than 20 years in service. Almost half - 84(45.9%) of the respondents worked in general surgery wards and clinics. Others were in Urology 6(3.3%), Orthopaedics 18(9.8%), Paediatrics surgery 41(22.4%), Cardiothoracic surgery 9(4.9%), Neurosurgery 14(7.7%), and Burns and Plastic 11(6.0%). A quarter - 46(25.1%) were medical doctors, nurses were 86(47.1%), Medical Student were 31(16.9%), while others were 20(10.9%).

Use of hand hygiene measures was analyzed and it was identified as indicated in Table 3.0 that virtually all respondents were aware about hand hygiene. Majority - 148(80.9%) affirmed that hand hygiene was practiced at their work place by hand washing, 18(9.8%) by hand sanitizers and 17(9.3%) by both hand-washing and hand sanitizers. 162 (88.5%) respondents asserted that they used hand hygiene measures after contact with patient and their immediate surroundings, while 157(85.8%) answered in the affirmative to use before performing a clean or aseptic procedure.

Table 4.0 showed the practices of hand hygiene when on duty. Majority 179 (97.8%) of the respondents affirmed to practice of hand hygiene when on duty. Out of these, 133(72.7%) asserted to doing it always, 27(14.8%) sometimes practice hand hygiene, while 23(12.6%) said their practice of hand hygiene was conditional. The respondents’ practice of hand hygiene shows that 111(60.7%) did so before patient's contact, 167(91.3%) before performing a clean or aseptic procedure, 175(95.6%) after exposure risk to bodily fluid and glove removal, 159(86.9%) after patient contact or their surroundings and 122(66.7%) after touching an inanimate object in the patient's immediate surroundings.

In Table 5.0 the factors responsible for poor hand hygiene practices in respondents’ department or facility from the responses given by respondents were analyzed. Majority - 136(74.3%) attributed it to negligence – forgetfulness, 132(72.1%) due to lack of water, 126(68.9%) to lack of hand lotions 122(66.7%) to absence of sanitizers, 107(58.5%) to none availability of enough soaps, 86(47.0%) claimed inconvenient sinks, and another 86(47.0%) affirmed that lack of towels contributed to their poor hand hygiene practices. Some 79(43.2%) and 75(41.0%) respondents claimed that lack of training and poor knowledge of standard practice respectively contributed to their poor hand hygiene practices.

In Table 6.0 the relationship between years in service and frequency of hygiene practice was presented. The results showed that 5(41.7%) out of 12 respondents who have been in service for less than 1 year always practice hand hygiene measures. Those who were 1 to 5 years in service who always practice hand hygiene were 46(62.2%) out of 74. 30(78.9%) out of 38 respondents with 6 to 10years of service always do hand hygiene practice. For those with 11 to 20years of experience it was 29(85.3%) out of 34, and 23(92.0%) out of 25 for those with more than 20 years of service experience. This relationship between number of years in service and frequency of hand hygiene practice was statistically significant (P<0.05).

Table 7.0 shows that 183 direct (covert) observations of staff at work place was carried out to ascertain use of any of the hand hygiene measures in between patient contact. Out of this total number, 78 (42.4%) were found to have practiced hand hygiene while 105 (57.6%) did not. The comparison indicated that there was a significant difference (P<0.005) between the respondents who uses hand hygiene measures in between patient care and those who do not even though all respondents affirmed awareness/knowledge of hand hygiene.

Table 8.0 shows the number and percentage of those who asserted that they practice hand hygiene measures 179 (97.8%) and those who were actually observed to have practiced hand hygiene measures 78 (42.6%). There was a significant difference (P<0.005) between the respondents who asserted compliance with hand hygiene and those who were directly observed to comply.

Table 9.0 illustrates a comparison between the number of respondents who affirmed that they are aware/have knowledge of hand hygiene measures and those who were actually directly observed to have practiced the measures in the course of their daily work from one patient to another. Awareness 183 (100%) compared to actual practice which was 78 (42.6%). This comparison indicated that there was a significant difference (P<0.005) between the respondents who affirmed awareness/knowledge of hand hygiene and those who were directly observed to have practiced hand hygiene.

Table 1.0: Socio-demographic characteristics of respondents

Variables	Frequency	Percentage
Age
16- 24 Years	41	22.4
25- 34 Years	45	24.6
35 - 44 Years	52	28.4
45 - 54 Years	41	22.4
55 - 64 Years	4	2.2
Sex
Male	81	44.3
Female	102	55.7
Marital Status
Single	76	41.5
Married	103	56.3
Separated/Divorced	4	2.2
Religion
Christianity	181	98.9
Islam	2	1.1
Total	183	100.0

Table 2.0: Socio-economic characteristics of respondents

Variables	Frequency	Percentage
No of Years in service
Less than 1 year	12	6.6
1-5 years	74	40.4
6-10 years	38	20.8
11-20 years	34	18.6
More than 20 years	25	13.7
Unit in surgery department
General surgery	84	45.9
Urology	6	3.3
Orthopedics	18	9.8
Pediatric Surgery	41	22.4
Cardiothoracic surgery	9	4.9
Neurosurgery	14	7.7
Burns and Plastic	11	6.0
Health Staff Category
Medical doctors	46	25.1
Nurses	86	47.1
Others (Maids/Cleaners)	20	10.9
Medical Students (Clinical)	31	16.9
Total	183	*100.0*

Table 3.0: Awareness of respondents about hand hygiene measures

Variables	Frequency	Percentage
Knowledge of hand hygiene measures
Yes	183	100.0
How hand hygiene was practiced at work place
Hand washing	148	80.9
Hand Sanitizers	18	9.8
Both Hand washing and Hand Sanitizers	17	9.3
Total	183	100.0
When use hand hygiene measures
Before touching or coming into contact with a patient	129	70.5
Before performing a clean or aseptic procedure	157	85.8
After an exposure risk to bodily fluids and glove removal	151	82.5
After contact with patient and their immediate surroundings	162	88.5
After touching inanimate object in the patient's surroundings	137	74.9
All of the Above	114	62.3

Table 4.0: Practices of hand hygiene when on duty

Variables	Frequency	Percentage
Practice of hand hygiene on duty
Yes	179	97.8
No	4	2.2
Frequency of hygiene practice
Always	133	72.7
Sometimes	27	14.8
Depends on the condition	23	12.6
Practice hand hygiene before patient's contact
Yes	111	60.7
No	19	10.4
Sometimes	53	29.0
Practice hand hygiene before performing a clean or aseptic procedure
Yes	167	91.3
No	10	5.5
Sometimes	6	3.3
Practice hand hygiene after exposure risk to bodily fluid and glove removal
Yes	175	95.6
No	7	3.8
Sometimes	1	.5
Practice hand hygiene after patient contact or their surroundings
Yes	159	86.9
No	4	2.2
Sometimes	20	10.9
Practice hand hygiene after touching an inanimate object in the patient's immediate surroundings
Yes	122	66.7
No	6	3.3
Sometimes	55	30.1
Total	183	100.0

Table 5.0: Factors responsible for poor hand hygiene practices in respondents’ facility

	Variables	Frequency	Percentage
1	Absence of Sinks	68	37.2
2	Not enough sinks	56	30.6
3	Inconvenient sinks	86	47.0
4	No towels	86	47.0
5	Lack of hand lotions	126	68.9
6	Lack of training	79	43.2
7	Not enough soaps	107	58.5
8	Lack of water	132	72.1
9	No or Poor soap quality	59	32.2
10	Lack of funds	54	29.5
11	Overworked staff	54	29.5
12	Absence of sanitizers	122	66.7
13	Perceived lack of time	70	38.3
14	Negligence - Forgetfulness	136	74.3
15	Wearing of gloves	73	39.9
16	Insufficient time for hand hygiene	71	38.8
17	Avoidance of staff-patient relationship interference	33	18.0
18	Prioritizing patient care	33	18.0
19	Poor knowledge of standard practice	75	41.0
20	All of the above factors	22	12.0

Table 6.0: Relationship between years in service and frequency of hygiene practice

	Frequency of hygiene practice
Number of years in service	Always	Sometimes	Depends on condition	Total	(X²)	P-Value
Less than 1 year	5(41.7%)	4(33.3%)	3(25.0%)	12	19.386	0.013
1–5 years	46(62.2%)	15(20.3%)	13(17.6%)	74
6–10 years	30(78.9%)	3(7.9%)	5(13.2%)	38
11–20 years	29(85.3%)	3(8.8%)	2(5.9%)	34
More than 20 years	23(92.0%)	2(8.0%)	0(0.0%)	25
Total	133	27	23	183

Table 7.0: Those who were observed to uses hand hygiene measures in between patient care and those who did not

	Observed Done	Observed Did Not	Total Observations	Degree of Freedom	P-Value
No of Each Group	78	105	183	182	0.000
Percentage (%)	42.4	57.6	100	182	0.000

Table 8.0: Comparison between the percentages of directly observed compliance and expressed compliance with hand hygiene measures

	Expressed Compliance	Observed Compliance	Degree of Freedom	P-Value
Total Number	179 (out of 183)	78 (out of 183)	182	0.001
Percentage (%)	97.8	42.6	182	0.001

Table 9.0: Comparison between the percentages of directly observed compliance and percentage of awareness/knowledge hand hygiene measures

Affirmed Awareness/Knowledge of Hand Hygiene

Observed Compliance

Difference

P-Value

Total Number

183 (out of 183)

78 (out of 183)

182

0.001

Percentage (%)

100

42.6

DISCUSSION

Knowledge of hand hygiene measures was good, hence similar to findings of Gwarzo (2018) in Kano and Jemal (2018) in Ethiopia. This study differs from others in that all affirmed to being aware of hand hygiene measures. Majority affirmed that they practiced these measures at work place. This again has a little similarity with Gwarzo’s study (Gwarzo, 2018) where compliance was reported good but differs from other works (Jemal. 2018; Ekwere & Okafor, 2013) were compliance was reported poor. The outcome of this study on knowledge/awareness is expected in a tertiary health care facility with on-going training and retraining of staff. However, the extent of practice of compliance with these measures showed that total compliance is lacking. The reasons affirmed to be responsible for this partial compliance were mostly forgetfulness, lack of water, lack of hand lotions, absence of sanitizers, none availability of enough soaps, and inconvenient sinks. This study agrees with previous studies (Boyce & Pittet, 2002; Larson & Killien, 1982; Pittet et al., 1999; Conly et al., 1989; Dubbert et al., 1990) on the negative role of these factors towards compliance with hand hygiene measures.

The relationship between number of years in service and frequency of hygiene practice of the respondents in this study showed that the proportion of respondents who always practice hand hygiene measures were higher among those with higher numbers of years in service. The more they stay in service the more their practice of hand hygiene improves. It is therefore reasonable to state that there is an association between number of years in service and frequency of hand hygiene practice. Knowledge and experience acquired over the years may have accounted for this improved compliance.

The number of respondents who actually complied with hand hygiene measures were less than those who did not comply. The proportion of respondents who expressed positive compliance (from questionnaire) were compare to the outcome of actual compliance (from directly observed compliance), and the actual compliance with hand hygiene measures was poor. This is an eye-opener, and seem to support the findings in an earlier study done by Balafama & Opara (2011) in the same center.

CONCLUSION

The knowledge/awareness of hand hygiene measures among health workers in the tertiary healthcare facility appear to be above average. Efforts should be made to ensure that the knowledge gained is put to practice by removing constraints and emphasizing practice of these measures.

RECOMMENDATIONS

Orientation of new staff and sustenance of on-going training and retraining of workers on hand hygiene measures will go a long way to sustain knowledge and improve practice. Supervising authorities should ensure availability of materials necessary for hand hygiene practices and ensure compliance.

LIMITATIONS:

1. For the purpose of this study, we reasoned that medical students who are undergoing their clinical postings are involved in the traffic of patient care. Hence, we considered that in a sensitive study such as this, involving hand hygiene measures in the surgical wards, though they are strictly not members of staff, medical students who accompany staff and also indirectly assist in patient care could not be possibly exempted from the study as their activities could also be a source of infection transmission just like the staff.

2. The study instrument (questionnaires) used to obtain the data for this study was not regular in age categorization – five-year and ten-year intervals. We therefore accept this as part of the limitations of this study.

Conflict of Interest: None

ETHICAL STATEMENT: The approval of the research ethics committee of the University of Port Harcourt Teaching Hospital was obtained before the study was carried out.

ACKNOWLEDGEMENT: We acknowledge the contributions of the head of department of surgery for his support, and colleagues in the department who helped in smooth sample collection.

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