Hand hygiene amongst health workers in a teaching hospital-A kap study

Though relatively simple procedure, Hand Hygiene compliance rates tend to be highly variable and poor. Material & Methods: cross-sectional KAP study was conducted at SMHS Hospital, a teaching hospital in Srinagar, India. Study subjects were the nursing staff working in different departments of the Hospital. Self-structured one plus WHO, s hand hygiene questionnaire for health care workers was administered. Almost 80% respondents skipped hand washing when in hurry. Only small percentage of 12 and 28 used to hand wash before touching a patient and before doing simple procedure respectively. Conclusion: This study depicts the poor compliance of health workers regarding hand hygiene. Introduction Every 1 in 20 hospitalised patients is affected by Health Care Associated Infections (HAI) [1]. Most of the infections are spread via health care worker’s hands and Hand Hygiene is the single most effective measure to prevent this spread. Though relatively simple procedure, Hand Hygiene compliance rates tend to be highly variable and poor [2]. Hand Hygiene is a general term referring to any action of hand cleansing by using water & detergent and/or the use of alcohol-based hand sanitization for the removal of transient micro-organisms from hands [3]. Annually, approximately 2.4 M deaths can be prevented by good hygiene practices, reliable sanitation & drinking water [4]. A Meta -analysis showed that improvements in hand washing reduced incidence of URTI and gastrointestinal illnesses by 21% and 31% respectively [5]. Though preventable with simple hand washing, Health Care Workers are reluctant to adopt recommended practices to curb the infection [6]. Lack of appropriate facilities, high staff to patient ratio, insufficient knowledge and attitude of staff may be the reasons responsible for lack of compliance to hand washing [7]. In India, especially in J&K there is paucity of studies exploring this subject, although the prevalence of HAI is high in whole Asia [8], JK being no exception. To improve Health Care Workers compliance with health Hygiene, it is therefore necessary to consider the hindering factors and attempt to improve them. With this background, this study was conducted to assess the level of knowledge, attitude and practices among healthcare workers of SMHS hospital and then to identify gaps and enhance good practices.


Introduction
Every 1 in 20 hospitalised patients is affected by Health Care Associated Infections (HAI) [1].Most of the infections are spread via health care worker's hands and Hand Hygiene is the single most effective measure to prevent this spread.Though relatively simple procedure, Hand Hygiene compliance rates tend to be highly variable and poor [2].Hand Hygiene is a general term referring to any action of hand cleansing by using water & detergent and/or the use of alcohol-based hand sanitization for the removal of transient micro-organisms from hands [3].Annually, approximately 2.4 M deaths can be prevented by good hygiene practices, reliable sanitation & drinking water [4].A Meta -analysis showed that improvements in hand washing reduced incidence of URTI and gastrointestinal illnesses by 21% and 31% respectively [5].Though preventable with simple hand wash-ing, Health Care Workers are reluctant to adopt recommended practices to curb the infection [6].Lack of appropriate facilities, high staff to patient ratio, insufficient knowledge and attitude of staff may be the reasons responsible for lack of compliance to hand washing [7].
In India, especially in J&K there is paucity of studies exploring this subject, although the prevalence of HAI is high in whole Asia [8], JK being no exception.To improve Health Care Workers compliance with health Hygiene, it is therefore necessary to consider the hindering factors and attempt to improve them.With this background, this study was conducted to assess the level of knowledge, attitude and practices among healthcare workers of SMHS hospital and then to identify gaps and enhance good practices.Annals of Epidemiology and Public health

Material and methods
This cross-sectional KAP study was conducted at SMHS Hospital, a teaching hospital in Srinagar, India.Srinagar is the summer capital of Jammu & Kashmir state and SMHS hospital provides tertiary health care for residents of Srinagar as well as patients referred from other districts.
Study subjects were the nursing staff working in different departments.Convenience sampling was used to select the 100 subjects.Participant selection was purely voluntary.The purpose of study was fully explained to the participants and verbal consent was obtained.Confidentiality was ensured by avoiding use of names of participants.
The study was approved by the Institutional ethical committee.The investigator visited the participants in the hospital wards and explained the nature of the study.Thereafter questionnaire was administered.It was a self-structured one plus WHO, s hand hygiene questionnaire for health care workers.Knowledge and attitude were assessed using 11 and 8 questions respectively.For the assessment of practices there were 15 questions to assess practical activities performed by respondents.Demographic information was also collected.Data analysis was done using SPSS version software.Descriptive statistics was used to calculate percentages for each of the responses given.

Results
A total of 106 Health workers participated in the study.Males were 20 in number with 16 above 30 years of age while females were 86 and 50 among those were more than 30 year old.65% participants claimed to have received training in hand hygiene.
About half of respondents believed unclean hands of Health workers as main route of cross-transmission of infection between patients in a health facility while none believed that using same apparatus for different patients is a main route of cross transmission.91% of respondents had knowledge that hand hygiene before touching a patient and immediately before aseptic procedure prevents transmission of germs to patient while all believed that hand hygiene after touching a patient prevents transmission of germs to health worker.78% respondents believed that hand washing and hand rub are to be performed in sequence while 61 respondents believed that hand rub is more effective and rapid than hand wash.43% participants believed that 20 seconds is the minimum time required for Alcohol based hand rub to kill more germs on hand.60% believed that hand rub should be used before abdominal palpation.Around 20% had knowledge that no hand hygiene method is to be used before abdominal palpation.72% participants believed in washing hands after emptying bed pan & after making patient's bed.Likewise 68 believed in washing hands with soap and water after visible exposure to blood.Only 60% had knowledge that damaged skin increases likelihood of colonization of hands with germs.42% respondents were of opinion that steps of hand washing are 4 and equal percentage believed it to be 5.Only 7% tick marked all the dirty areas of hand mentioned in questionnaire.
Attitude: 64% of respondents had a perception that they have sufficient knowledge about hand hygiene while 52% believed that they practice correct hand hygiene all times.Almost 80% respondents skipped hand washing when in hurry while 41% reused gloves after removal.
Practices: Only small percentage of 12 and 28 respectively used to hand wash before touching a patient and before doing simple procedure.94% participants had facility for hand wash at their workplace and 80% had gloves available.Motivation to hand washing in majority was fear of contracting infection while major barrier to hand washing was "forget to wash"

Discussion
Our study group had relatively good knowledge and attitude but poor practice of hand hygiene.Though majority recognised the importance of hand hygiene but practically compliance regarding the same was poor.Study results show that most of respondents maintained hand hygiene but inadequately.Main reason for skipping hand hygiene was 'forget to wash'.Similar findings were seen in other studies as well [9,10].Other barriers were lack of soap & water, and lack of time.Similar findings were seen in other studies as well [9,10].'Forgetfulness' factor can be removed by regular sensitising of the hospital staff via displaying posters on walls., CME,s and trainings and retraining.Hospital authorities should ensure availability of facilities including water, soap, tissue papers sanitizers etc.
Main motivation factor for hand hygiene among workers was fear of contracting infection.This is consistent with other studies [11,12].Our study showed that 57% of respondents washed hands before meals while 61% washed hands after going to wash room.In an earlier study it was 46.5% and 61% respectively [13].Only 34% respondents had availability of towel/ paper for drying hands.This is despite the fact that hands drying are as important as hand washing in maintenance of hand hygiene.Our results regarding rates of hand washing with soap and water before interacting with patients was consistent with yet another study [13].

Conclusion
This study depicts the poor compliance of health workers regarding hand hygiene, emphasising the need for immediate adopting of such measures so that knowledge, attitude and practices of Health workers improve.A multi-pronged approach ,including keeping facilities available, regular trainings, reinforcement, education especially motivational programs need to be adopted and implemented in order to ensure strict hand hygiene compliance.Also more research is advocated so as to design interventions for improving compliance.

Table 1 :
Age & sex distribution of Health workers.

Table 2 :
Training received in hand hygiene.

Table 3 :
Knowledge regarding Hand Hygiene.
Annals of Epidemiology and Public health

Table 4 :
Attitude towards hand washing.

Table 5 :
Practices of health workers.

Table 6 :
Facilities available & Practices of health workers.