CHAPTER ONE

INTRODUCTION

1.0 BACKGROUND TO THE STUDY

The World Health Organization (WHO, 2009) regards hand hygiene as an essential tool for the

prevention of nosocomial infections. Improper hand hygiene causes an increase in the incidence

of nosocomial infections among patients on the ward. This results in an increase in mortality and

morbidity among patients on the ward. To effectively address the mortality and morbidity issues

in relation to nosocomial infection, there is the need to ascertain the knowledge, attitude and

practices regarding hand hygiene among health care workers at the St Mary’s Hospital Drobo

(SMH). The most important measure in the prevention of healthcare-associated infections (HCAI)

is hand hygiene. Prevention and control of HCAI is enhanced by adherence to hand hygiene

protocols in hospital by nurses.

Hand hygiene represents a new term in the healthcare vocabulary emphasizing the central role an

organizational hand hygiene program has in preventing healthcare-associated infections (HAIs). It

replaces the narrow term “hand washing.” Hand hygiene is a more comprehensive term that

includes hand washing, hand antisepsis and actions taken to maintain healthy hands and

fingernails. One method of hand hygiene is hand washing, which entails removing soil and

transient microorganisms from the hands using soap and water. Another method of hand hygiene

is hand antisepsis, which includes removing or killing resident and transient microorganisms on

the hands using an antiseptic agent, by either rubbing hands with alcohol or hand washing with an

antiseptic soap. This latter process has also been referred to as antiseptic hand wash, antiseptic

hand-rubbing, hand decontamination and hand disinfection (Pittet, 2006). The use of an alcohol-

1
based hand rub (ABHR) is the preferred method of hand hygiene in healthcare settings(Boyce,

2002), unless exceptions apply (i.e., when hands are visibly soiled with organic material, if

exposure to virus and potential spore-forming pathogens such as Clostridium difficile is strongly

suspected or proven, including outbreaks involving these organisms).

In developed countries, HCAI concerns 5–15% of hospitalized patients and can affect 9–37% of

those admitted to intensive care units (ICUs) (Vincent, 2003).

Recent studies conducted in Europe reported hospital-wide prevalence rates of patients affected

by HCAI ranging from 4.6% to 9.3% (Di Pietrantoni et al., 2004). According to data provided by

the Hospital in Europe Link for Infection Control through Surveillance (HELICS) approximately

5 million HCAIs are estimated to occur in acute care hospitals in Europe annually, representing

around 25 million extra days of hospital stay and a corresponding economic burden of €13–24

billion. In general, attributable mortality due to HCAI in Europe is estimated to be 1% (50 000

deaths per year), but HCAI contributes to death in at least 2.7% of cases (135 000 deaths per year).

The estimated HCAI incidence rate in the USA was 4.5% in 2002, corresponding to 9.3 infections

per 1000 patient-days and 1.7 million affected patients; approximately 99 000 deaths were

attributed to HCAI (Klevens et al., 2002).The annual economic impact of HCAI in the USA was

approximately US$ 6.5 billion in 2004(Stone et al., 2005).

While HCAI surveillance is already a challenging task in highly resourced settings, it may often

appear an unrealistic goal in everyday care in developing countries. The magnitude of the problem

is particularly relevant in settings where basic infection control measures are virtually non-existent.

This is the result of the combination of numerous unfavourable factors such as understaffing, poor

hygiene and sanitation, lack or shortage of basic equipment, and inadequate structures, almost all

2
of which can be attributed to limited financial resources (Pittet et al., 2008). When referring to

endemic HCAI, many studies conducted in developing countries report hospital-wide rates higher

than in developed countries (Dumpis et al., 2003). For example, in one-day prevalence surveys

recently carried out in single hospitals in Albania(Fariaet al.,2007), Morocco(Jroundi et al., 2007),

Tunisia(Kallel et al., 2005)and the United Republic of Tanzania(Gosling et al., 2003), HCAI

prevalence rates were 19.1%, 17.8%, 17.9%, and 14.8%, respectively.

Nosocomial infections have long been neglected in Sub-Saharan Africa, and hand hygiene (HH)

is usually neglected in hospital settings. A study by Owusu-Ofori and colleagues in 2010 to gather

baseline data on hand hygiene (HH) practices in an African hospital with a newly established

infection prevention and control team found that HH was attempted in 12% of the five moments

of hand hygiene and was performed appropriately in 4% of the opportunities. Most main wards

(89%) had at least 1 functional HH station. The most commonly identified barriers to HH were

limited resources and lack of knowledge on appropriate times to perform HH.

In 2013, a study carried out by Yawson and colleagues in a hospital in Ghana to provide baseline

data on HH compliance among health workers also showed that Care-related HH compliance of

doctors and nurses was low and basic HH resources were deficient in all 15 service centres. Care-

related HH compliance among doctors ranged from 9.2% to 57% and 9.6% to 54% among nurses.

HH compliance was higher when risk was perceived to be higher (i.e., in the emergency and wound

dressing/treatment rooms and labour wards). The neonatal intensive care unit (NICU) showed the

highest level of compliance among health workers. Facilities for HH, particularly alcohol hand rub

and liquid soap dispensers were shown to be deficient.

3
Effective hand hygiene techniques are relevant in the fight against healthcare associated infections

(Ho et al., 2013).

1.1 PROBLEM STATEMENT

Hand hygiene is a fundamental action for ensuring patient safety, which should occur in a timely

and effective manner in the process of care. However, unacceptably low compliance with hand

hygiene is universal in healthcare (Pittet, 2003). This contributes to the transmission of microbes

capable of causing avoidable HCAIs. Better adherence to hand hygiene guidelines and policies has

been shown to reduce the spread of HCAIs (Harrison, 2003).

In resource-poor settings, rates of nosocomial infections can exceed 20% (Pittet, 2005), but

available data are scanty and more research is urgently needed to assess the burden of diseases in

developing countries like Ghana.

It is against this background that the study is to be undertaken to assess the knowledge, attitude

and practices of hand hygiene among health care workers at St Mary’s Hospital Drobo in the

prevention of nosocomial infection.

Some healthcare workers at the St Mary’s Hospital Drobo (SMH) are observed not practicing hand

hygiene before, during and after attending to patients. Hand hygiene are mostly ignored by these

healthcare workers before and after carrying out activities such as serving medication, giving

injection, assessing patients, and checking of vital signs. This can be attributed to the fact that the

hands of these healthcare workers do not become visibly soiled after these procedures and hence

them not seeing the need for hand hygiene. It was also observed that towels for drying hands were

4
not adequately available on the wards causing inconvenience for the healthcare workers after hand

washing.

1.2 PURPOSE OF THE STUDY

The aim is to know the knowledge and attitude of hand hygiene practice among health care workers

of St Mary’s hospital.

1.3 SIGNIFICANCE OF THE STUDY

The study is to assess the knowledge, attitude and practice of hand hygiene among healthcare

workers of St Mary’s Hospital Drobo (SMH). The study is aimed at creating consciousness in

healthcare workers at SMH about the importance of hand hygiene in the prevention of nosocomial

infections. It is also geared towards identifying the barriers to hand hygiene at the hospital thereby

helping to reduce the prevalence of hospital acquired infections that could have been prevented by

hand hygiene.

1.4 STUDY OBJECTIVES

1.4.1 GENERAL OBJECTIVE

The general objective of the study is to assess the knowledge, attitude and practices of hand

hygiene by health care workers in the prevention of nosocomial infection at the St Mary’s Hospital

Drobo.

1.4.2 SPECIFIC OBJECTIVES

The specific objectives of the study are to;

5
  Assess the knowledge of healthcare workers on hand hygiene as a means of preventing

nosocomial infection.

 Determine health care workers attitude towards hand hygiene.

 Assess the practice of hand hygiene among health care workers.

 Identify barriers to proper hand hygiene at healthcare facilities

1.5 OPERATIONAL DEFINITION OF TERMS

Alcohol: An organic chemical containing one or more hydroxyl groups. Alcohols can be liquids,

semisolids or solids at room temperature.

Alcohol-based hand rub (ABHR): An alcohol-containing preparation (liquid, gel or foam)

designed for application to the hands to remove or kill microorganisms.

Antiseptic: A product with antimicrobial activity that is designed for use on skin or other

superficial tissues; it removes or kills both transient and resident flora.

Antimicrobial: A product that kills or suppresses the growth of microorganisms

Contamination: the act of making something impure or unsuitable by contact with something

unclean, bad or microorganisms transported transiently on body surface, such as on hands, on

formites, or in substances.

Cross transmission: The transfer of pathogens from one patient to the other by health care

workers or patients.

Hand antisepsis: A process for the removal or killing of transient microorganisms on the hands

using an antiseptic.

6
Hand hygiene: the various activities done to reduce microbial load on hand.

Hand washing: A process for the removal of visible soil/organic material and transient

microorganisms from the hands by washing with soap (plain or antiseptic) and water.

Healthcare associated infection (HAI): Infections that are transmitted within a healthcare setting

(also referred to as nosocomial) during the provision of health care.

Health Care Workers (HCWs): health professionals who have direct access to patients on the

ward at SMH.

7
 CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

This chapter reviews available literature related to knowledge, attitude and practices of hand

hygiene among healthcare workers in the prevention of nosocomial infection. The studied

literature relates to this study in a number of perspectives. The literature review will be on the

knowledge of healthcare workers on hand hygiene as a means of preventing nosocomial infection,

the healthcare workers attitude towards hand hygiene, the practice of hand hygiene among

healthcare workers and the barriers to proper hand hygiene.

2.1 Knowledge level on hand hygiene

In developed countries, HCAI concerns 5–15% of hospitalized patients and can affect 9–37% of

those admitted to intensive care units (ICUs) (Vincent, 2003).

Recent studies conducted in Europe reported hospital-wide prevalence rates of patients affected

by HCAI ranging from 4.6% to 9.3% (Di Pietrantoni et al., 2004). According to data provided by

the Hospital in Europe Link for Infection Control through Surveillance (HELICS) approximately

5 million HCAIs are estimated to occur in acute care hospitals in Europe annually, representing

around 25 million extra days of hospital stay and a corresponding economic burden of €13–24

billion. In general, attributable mortality due to HCAI in Europe is estimated to be 1% (50 000

deaths per year), but HCAI contributes to death in at least 2.7% of cases (135,000 deaths per year).

The estimated HCAI incidence rate in the USA was 4.5% in 2002, corresponding to 9.3 infections

8
per 1000 patient-days and 1.7 million affected patients; approximately 99 000 deaths were

attributed to HCAI (Klevens et al., 2002).The annual economic impact of HCAI in the USA was

approximately US$ 6.5 billion in 2004(Stone et al., 2005).

Health care-associated pathogens can be recovered not only from infected or draining wounds, but

also from frequently colonized areas of normal, intact patient skin (Bhalla et al., 2007). The

perineal or inguinal areas tend to be most heavily colonized, but the axillae, trunk, and upper

extremities (including the hands) are also frequently colonized (Bonten et al., 1996).

Environmental surfaces may contribute to transmission of nosocomial pathogens. Non-invasive

portable clinical items potentially shared among patients are part of the patient's immediate

surroundings and may pose a threat of pathogen transmission (Livshiz-Riven et al., 2015).

Regardless of ward type, surfaces located closest to the patient, specifically those associated with

the bed (side rails, bed control, and call button), were the most heavily contaminated (Choi et al.,

2014). Tap/faucet handles were more likely to be contaminated and to be in excess of benchmark

values than other parts of the station. This study emphasizes the potential importance of

environmental contamination on microbial cross contamination and pathogen spread (Griffith et

al., 2003). Mobile phones of healthcare workers (HCWs) could be colonized by potential bacteria

pathogens (Nwankwo et al., 2014). A similar study of hand contamination during routine neonatal

care defined skin contact, nappy/diaper change, and respiratory care as independent predictors of

hand contamination (Pessoa-Silva et al., 2004). Other studies have also documented that the hands

(or gloves) of HCWs may be contaminated after touching inanimate objects in patients rooms

(Bhalla et al., 2004).

Clostridium difficile-associated diarrhoea (CDAD) is common among hospital-acquired bacterial

diarrhoea. Its mortality and morbidity show an increasing trend in recent years. Adequate hand

9
hygiene of healthcare workers is an effective measure to prevent the outbreak of hospital-acquired

CDAD(Hu et al., 2008).Trick and colleagues (2003)did a comparative study of three hand hygiene

agents (62% ethyl alcohol hand rub, medicated hand wipe, and hand washing with plain soap and

water) in a group of surgical ICUs. They also studied the impact of ring wearing on hand

contamination. Their results showed that hand contamination with transient organisms was

significantly less likely after the use of an alcohol-based hand rub compared with the medicated

wipe or soap and water. Ring wearing increased the frequency of hand contamination with

potential health care-associated pathogens. Alcohol-based hand rubs play a key role in reducing

the transmission of pathogens in acute care settings, especially as part of a comprehensive hand

hygiene program (Schweon et al., 2013). Hand hygiene may be ineffective if an inappropriate

product is used (Kac, 2005).

2.2 Attitude of healthcare workers towards hand hygiene

Studies have consistently demonstrated rates of hand washing compliance are less than 50%. A

study conducted by Harris and colleagues to gain the following information about hand washing:

self-reported compliance; attitudes towards hand washing in different patient settings; and

attitudes towards interventions aimed at increasing compliance. A 74-question survey was

administered to healthcare workers in two tertiary care hospitals. One hundred and ninety nine

healthcare workers completed the survey and 89% reported that hand washing is an important

means of preventing infection. Sixty-four percent believed that they washed their hands as often

as their peers and 2% believed that they washed less often than their peers. Patients with diarrhoea,

10
AIDS or patients on antibiotics led to increased hand washing. Relative to potential interventions,

76% reported that rewards for hand washing would have no effect, 73% reported that punishment

would have no effect and 80% reported that easy access to sinks and availability of washing

facilities would lead to increased compliance. This survey suggests that

healthcare workers understand the importance of hand washing, but tend to overestimate their own

compliance. Healthcare workers are not in favour of interventions involving rewards and

punishments, but are more attracted to interventions that make hand washing easier.

According to Veena and colleagues in 2014, transmission of healthcare-associated pathogens

generally occurs via the contaminated hands of healthcare workers. Though preventable with a

simple hand washing, healthcare workers are reluctant to adopt recommended practices to curb

these infections. They further mentioned that training sessions regarding hand hygiene would also

translate in a behavioural change of attitudes and practices among healthcare workers especially

nurses, which would help in reducing the incidence of nosocomial infections.

A study showed that hand hygiene promotion program resulted in improved hand hygiene

compliance and perception toward hand hygiene among medical personnel. The improved

perception increased hand hygiene compliance. Especially, the perception of being a role model

for other colleagues is very important to improve hand hygiene compliance among clinicians

(Seung et al., 2014).

In 2013, a study conducted in Addis Ababa, Ethiopia among healthcare workers showed that the

majority of both physicians (93%) and nurses (92%) felt they would be less likely to transmit

infections to their patients if they performed hand hygiene; however, only 50% of healthcare

workers reported receiving hand hygiene training and only 30% thought their supervisors stressed

11
the importance of hand hygiene. The majority of healthcare workers, 77%, felt hand hygiene agents

(alcohol based sanitizer or soap and water) were not readily available and 67% of all healthcare

workers reported that available alcohol based hand sanitizers caused irritation and dryness(Tenna

et al., 2013).

In 2013, a study carried out by Yawson and colleagues in a hospital in Ghana to provide baseline

data on hand hygiene (HH) compliance among health workers also showed that Care-related HH

compliance of doctors and nurses was low and basic HH resources were deficient in all 15 service

centres. Care-related HH compliance among doctors ranged from 9.2% to 57% and 9.6% to 54%

among nurses. HH compliance was higher when risk was perceived to be higher (i.e., in the

emergency and wound dressing/treatment rooms and labour wards). The neonatal intensive care

unit (NICU) showed the highest level of compliance among health workers. Facilities for HH,

particularly alcohol hand rub and liquid soap dispensers were shown to be deficient.

2.3 Practice of hand hygiene among healthcare workers

The most important measure in the prevention of healthcare-associated infections (HCAI) is hand

hygiene. Prevention and control of HCAI is enhanced by adherence to hand hygiene protocols in

hospital by nurses. Effective hand hygiene techniques are relevant in the fight against healthcare

associated infections (Ho et al., 2013). Improper hand hygiene by healthcare workers (HCWs) is

responsible for about 40% of nosocomial infections resulting in prolonged illnesses, hospital stays,

long-term disability and unexpected high costs on patients and their families, and also lead to a

massive additional financial burden on the health-care system(Anargh et al., 2013). Nosocomial

infections cause considerable morbidity and mortality. Healthcare workers (HCWs) may serve as

12
vectors of many infectious diseases, many of which are not often primarily considered as

healthcare-associated. The probability of pathogen transmission to patients depends on several

factors, such as the characteristics of a pathogen, HCW and patient. Pathogens with high

transmission potential from HCWs to patients include norovirus, respiratory infections, measles

and influenza. In contrast, human immunodeficiency virus (HIV) and viral hepatitis are unlikely

to be transferred. The prevention of HCW-associated transmission of pathogens includes hand

hygiene surveillance (Huttunen et al., 2014).

A study by Mayank and colleagues (2009) revealed a high prevalence of P. aeruginosa infections

in the ICU attributed to cross transmission from patient to patient via hands of the HCWs. A study

by Barker and colleagues (2004) showed that fingers contaminated with norovirus could

sequentially transfer virus to up to seven clean surfaces and from contaminated cleaning cloths to

clean hands and surfaces.

Reservoirs of pathogens could establish themselves at forgotten sites on a ward, posing a continued

risk for transmission to patients via unwashed hands (Smith et al., 2012). Centers for Disease

Control and Prevention, Atlanta (GA), USA in 2011 stated that Health-care environmental

contamination represents a transmission risk, particularly through HCWs’ hands, that must be

taken into account in each situation requiring hand hygiene performance. For this reason,

maximum attention should be paid to the cleaning of the environment and to the cleaning,

disinfection and/or sterilization of critical, semi-critical, and non-critical items in according to

local and international recommendations. It is important to carry out training programmes on hand

hygiene regularly for health care workers as it has been associated with increased compliance to

hand hygiene practices and reduction of infection (Randle et al., 2006).

13
2.4 Barriers to proper hand hygiene

Barriers to proper hand hygiene occur across the various five moments for hand hygiene as

outlined by Boyce 2002 and reiterated by the World Health Organization (WHO) Guidelines on

Hand Hygiene in Health Care, 2009. These moments for hand hygiene are; before touching a

patient, before clean/aseptic procedure, after body fluid exposure risk, after touching a patient, and

after touching patient surroundings.

Barriers resulting in poor adherence to hand hygiene may be organizational, related to the

individual HCWs. Organizational barriers, such as a lack of accessibility, inadequate maintenance

of hand hygiene facilities and poor access to hand hygiene products, overcrowding and

understaffing, and a lack of role models, negatively affect adherence to hand hygiene (Pittet, 2001).

Several studies have linked overcrowding, understaffing or nursing workload to the cross

transmission of staphylococcal infections, including methicillin-resistant staphylococcus aureus

(MRSA)(Clements, 2008). Stegenga and colleagues in 2002 suggested that nurse understaffing is

a significant risk factor for the nosocomial spread of viral gastrointestinal infections in general

paediatric patients. They hypothesized that infection control practices might be neglected as a

result of increased patient acuity and/or workload, with a resultant increase in the HAI rate.

Health care workers' (HCWs) perceptions and attitudes affect implementation of precautions to

prevent transmission of drug-resistant pathogens such as methicillin-resistant staphylococcus

aureus (MRSA). Identification of challenges and barriers to recommended practices is a critical

component of promoting a safe clinical environment of care. The purposive sample of 26 acute

care HCWs (16 registered nurses; 1 physician; 6 allied health professionals; and 3 support staff)

14
self-selected from 276 responding to a questionnaire on MRSA. Analysis identified 18 themes

across seven categories. Most participants reported feeling responsible for preventing

transmission, and having the knowledge and desire to do so. However, many also reported

challenges to following consistent hand hygiene and use of contact precautions. Barriers included

patient care demands, equipment and environmental issues such as availability of sinks, time

pressures, the practices of other HCWs, and the need for additional signs indicating which patients

require contact precautions (Seibert et al., 2014). Compliance of health care workers to adhere to

correct hand hygiene are reported to be poor in Africa as well as other countries (Trampuz et al.,

2004).

While healthcare associated infection (HCAI) surveillance is already a challenging task in highly

resourced settings, it may often appear an unrealistic goal in everyday care in developing countries.

The magnitude of the problem is particularly relevant in settings where basic infection control

measures are virtually non-existent. This is the result of the combination of numerous unfavourable

factors such as understaffing, poor hygiene and sanitation, lack or shortage of basic equipment,

and inadequate structures and overcrowding, almost all of which can be attributed to limited

financial resources (Pittet et al., 2008). When referring to endemic HCAI, many studies conducted

in developing countries report hospital-wide rates higher than in developed countries (Dumpis et

al., 2003). For example, in one-day prevalence surveys recently carried out in single hospitals in

Albania(Fariaet al., 2007), Morocco(Jroundiet al., 2007), Tunisia(Kallel et al., 2005)and the

United Republic of Tanzania(Gosling et al., 2003), HCAI prevalence rates were 19.1%, 17.8%,

17.9%, and 14.8%, respectively.

Nosocomial infections have long been neglected in Sub-Saharan Africa, and hand hygiene (HH)

is usually neglected in hospital settings. A study by Owusu-Ofori and colleagues in 2010 to gather

15
baseline data on hand hygiene (HH) practices in an African hospital with a newly established

infection prevention and control team found that HH was attempted in 12% of the five moments

of hand hygiene and was performed appropriately in 4% of the opportunities. Most main wards

(89%) had at least 1 functional HH station. The most commonly identified barriers to HH were

limited resources and lack of knowledge on appropriate times to perform HH.

16
 CHAPTER THREE

METHODOLOGY

3.0 INTRODUCTION

This chapter describes the study setting, the study population, the study design, the sample size

and sampling method, the data collection and data analysis. The chapter also describes the validity

and reliability of the study findings and ethical considerations.

3.1 STUDY SETTING

The study was carried out at the wards and units of the St Mary’s Hospital Drobo located at Jaman-

south district in the Brong Ahafo region. The hospital is a district hospital that receives patients

from Jaman, Drobo and its environs. The St Mary’s Hospital Drobo has patient bed capacity of

ninety-two (92) and staff strength of two hundred and ten (270). The hospital has clinical and non-

clinical directorates. The clinical directorates include; General Out-Patient Department, Medical

Directorate, Surgical Directorate, Dental Clinic, X-Ray Department, Laboratory, Theatre,

Sexually Transmitted Infections Clinic, Labour Wards, Maternity Department, Mother and Baby

Unit(MBU), DOT Centre, Pharmacy and Theatre. The non-clinical directorate comprises of the

General Office, the General Administration and the Accounts Department.

3.2 STUDY DESIGN

The study is a non-experimental, descriptive, quantitative survey. This involves the collection of

data by asking and giving the questionnaire to the respondents to answer questions concerning the

current knowledge, attitude and practices of hand hygiene among health care workers in the

17
prevention of nosocomial infections. The study is aimed at identifying the actual situation as it

exists at the time of the study. It provides information on which to base sound decision.

3.3 STUDY POPULATION

The study population was health workers at the St Mary’s Hospital Drobo in Jaman South. The

health workers included doctors, nurses and all hospital staff who come into direct contact with

patients.

3.4 SAMPLE SIZE

A total of fifty health workers at St Mary’s hospital Drobo was taken as the sample size for the

study. The sample size consist of five (5) medical officers, ten (10) nurses, ten (10) midwives, five

(5) community health nurses, five (5) health assistance, five (5) laboratory technicians, five (5)

pharmacists, and five(5) non clinical directorates out of total population of 270 of this category of

staffs.

3.5 SAMPLE TECHNIQUE

The study participants were drawn from the various wards and unit in the hospital. At the wards,

participants were selected by the convenient sampling methods where selection were based on

their willingness to participate in the study and the fact that they fall within our target population.

18
3.6 RESEARCH INSTRUMENT

The main tool that was used for data collection was self-administered questionnaire. This tool was

used because it permits anonymity of participants; it is less expensive, time saving and devoid of

interviewer bias.

The questions on the questionnaire included questions on demographic characteristics, knowledge

in infection prevention and hand hygiene. Other questions were on attitude of healthcare workers

to hand hygiene and what influence them to perform hand hygiene. We used close ended, open

ended and multiple choice questions and these questions were closed using dichotomous scale

style. Participants were approached in the mid-morning when the ward was a bit calm. Purposeful

designed questionnaire were administered to the participants to collect the data. They were given

ample time; a day or two to complete the questionnaire after which the questionnaires were taken

from them to be analyzed.

3.7 DATA ANALYSIS

Being a quantitative study, the data was analyzed using SPSS (Statistical Package for Social

Sciences) version 16. The drawing of graphs and charts was done using Microsoft Excel (Office

2010). The results were displayed using a variety of graphs and charts including bar charts, line

graphs, pie chart and tables.

3.8 PRE TEST OF INSTRUMENTS

The questionnaires were given to some workers that were not among of my target group prior to

issuing of final distribution of questionnaire to help detect hindrances that could alter the study.

19
Detect problems such as ambiguous questions were dealt with accordingly. This makes the

instruments hosen valid reliable and consistent.

3.9 VALIDITY AND RELIABILITY

Validity refers to the property of the tool for data collection (questionnaire) to measure what it is

purported to measure. Reliability is defined as the consistency, accuracy and precision of

measurements taken. In order to ensure reliability and validity, the questionnaire were given to our

supervisor for the necessary corrections to be made. Some of our questionnaires were pre-tested

among health workers at the hospital in Jaman-south district. The necessary redesigning of

questionnaires was done before they were administered to our respondents.

3.10 ETHICAL CONSIDERATIONS

Ethical approval was sought from the Committee on Human Research Publication and Ethics

(CHRPE). Also, permission was sought from the Medical Superintendent of the St Mary’s Hospital

Drobo and the Deputy Director of Nursing Service (DDNS) to use the facility and the staff for the

study. Permission was also sought from the in-charges of the various wards and units. The

participant was informed consented by signing or thumb printing. Confidentiality and anonymity

of participants were ensured. Participants who were not willing to continue the study were allowed

to drop out of the study.

20
3.11 LIMITAIONS

 Language barrier could not allow me to effectively carry out this study, since there could

be a possibility of the interpreter giving inaccurate explanations.

 The cost of transportation and printing of the work was expensive.

21
 CHAPTER FOUR

STUDY RESULTS

4.0 INTRODUCTION

This chapter talks about the study results. The results are analysed on the following;

demographic characteristics, knowledge on general infection prevention, knowledge on hand

hygiene, attitude of health care workers towards hand hygiene, hand hygiene

practicessatisfaction of facilities for hand hygiene. The results are analysed using narratives,

tables and figures.

4.1 Demographic characteristics

A total of hundred respondents (25) who are healthcare workers at the St Mary’s Hospital Drobo

in Jaman-south district were given self-administered questionnaires.

From figure 4.1, most 15 (60%) of the respondents were between the age range 20-29, followed

by 5 (20%) respondents in the age range 30-39, 5 (20%) respondents in the age range 40-49 and

the least 0 (0%) respondent in the age range 50-59.

22
 70%

60%

50%

40%

30% 60%

20%

10% 20% 20%

0% 0
20-29 30-39 40-49 50-59

Figure 4.1: A bar chart showing the age distribution of respondents

Source: Authors’ filled survey

From figure 4.2, majority of the respondents were females healthcare workers accounting for 15

(60%) of the total population and the number of male healthcare workers was 10 (40%).

Sex of respondents

40%

60% Male
Female

23
 Figure 4.2: A pie chart showing sex of respondents.

Source: Authors’ filled survey

From figure 4.3, the professional distribution of the respondents indicated that 8 (32%) of

respondents were nurses, 6 (24%) were midwives, 6 (24%) were healthcare assistants, 4 (16%)

were medical laboratory technicians and 1 (4%) were doctors. This figures indicate that majority

of the respondents were nurses.

Sales

doctors
medical
4%
laboratory Nurses
16% 32% Nurses
midwives
health
health assistants
assistants
24% medical laboratory
midwives
doctors
24%

Figure 4.3: A pie chart showing profession of respondents.

Source: Authors’ filled survey

4.2 Knowledge on general infection prevention

Table 4.1 shows the knowledge of the healthcare workers of the St Mary’s Hospital Drobo on

general infection prevention. Out of the 25 respondents, 23 (92%) answered correctly the question;

24
there is evidence that aprons, gowns and masks are effective in preventing hospital acquired

infections, 4 (16%) answered wrongly the question that gloves reduce the contamination of the

hands, but do not prevent it completely and 15 (60%) correctly indicated it is false that wearing

gloves when handling sharp instruments protects against needle stick accident.

Table 4.1: General knowledge on infection prevention

Variable True % False %

There is evidence that aprons, gowns and masks are effective in 23 92.0 2 8.0

preventing hospital acquired infections.

Gloves reduce the contamination of the hands, but do not prevent 21 84.0 4 16.0

it completely

Wearing gloves when handling sharp instruments protects against 10 40.0 15 60.0

needle stick accident.

25
Source: Authors’ filled survey

Table 4.2 shows the respondents responses when they were asked to indicate sources of infection

in a healthcare centre. The options were health personnel, contaminated equipment,

contaminated air, other patients and all the above for if the respondents believe all the four are

sources of infection.

Ten respondents (40%) indicated correctly that all the four items thus health personnel,

contaminated equipment, contaminated air and other patients can be a source of infection at the

healthcare centre. Five respondents (20%) indicated only contaminated equipment is a source of

infection, 2 respondents (8%) indicated other patients only, 4 respondents (16%) indicated

contaminated equipment and other patients only, 1 respondents (4%) indicated health personnel,

contaminated equipment and other patients and 3 respondents (12%) also indicated contaminated

equipment, contaminated air and other patients as the source of infection at a healthcare centre.

Table 4.2: Sources of infection in a healthcare centre

What are the sources of infection in a Number of respondents Percentage (%)

healthcare centre?

Contaminated equipment only 5 20%

26
 Other patients only 2 8%

Contaminated equipment and Other patients 4 16%

Health personnel, Contaminated equipment 1 4%

and Other patients

Contaminated equipment, Contaminated air 3 12%

and Other patients

All of the above 10 40%

Source: Authors’ filled survey

Figure 4.4 shows responses on assessing the knowledge of our respondents on general infection

prevention. A question on the route of transmission of pathogens at the healthcare center was

asked. Majority17 (68%) of the respondents answered correctly that healthcare workers hands

when not clean can cause infection. Only 3 (3%) answered wrongly that healthcare workers hands

when rubbed for 20seconds can cause transmission of pathogens. On the question of whether

contaminated clothes of healthcare workers can cause transmission of pathogens, 14 (56%)

answered wrongly that it cannot. Majority 23 (92%) answered correctly that healthcare workers

hands when cleaned cannot cause transmission of pathogens at a healthcare center.

27
 yes no

92%
88%

68%
56%
44%
32%

12%
4%

health care workers health care workers contaminated clothes health care workers
hand when not clean hand after alcohol of health care hand when cleaned
hand rub for 20 workers
seconds

Figure 4.4: A bar chart showing the route of transmission of pathogens in a healthcare

center.

Source: Authors’ filled survey

4.3 Knowledge on hand hygiene

From figure 4.5, the respondents’ knowledge on circumstances that require hand hygiene actions

was assessed. In a quest to find out if the healthcare workers are abreast with the moments of hand

hygiene by Pittet and reiterated in the WHO guidelines on hand hygiene, 2009, we asked these

questions. The responses were excellent. Majority 23 (92%) answered correctly that hand hygiene

is required before touching a patient, 24 (96%) answered correctly that hand hygiene is required

before a clean/aseptic procedure, 24 (96%) answered correctly that hand hygiene is required

immediately after a risk of body fluid exposure, 23 (92%) also answered correctly that hand

28
hygiene is required after touching a patient and 20 (80%) correctly that hand hygiene is required

after exposure to immediate surroundings of a patient.

120

100

80

60

40

20

0
before touching a befor clean/aseptic immediately after after touching a after exposure to
patient procedure body fluid exposure patient immediate
risk surronding of a
patient

Yes No

Figure 4.5: A bar chart showing the results of circumstances that require hand hygiene.

Source: Authors’ filled survey

29
From table 4.3, the knowledge of the respondents on the major hand hygiene procedures namely

hand rubbing and hand washing was not that encouraging. Only 15 (60%) answered correctly that

hand rubbing is more rapid for hand cleansing than hand washing, 20 (80%) answered wrongly

that hand rubbing causes skin dryness more than hand washing, 17 (68%) answered correctly that

hand rubbing is not more effective against germs than hand washing and 10 (40%) answered

correctly that hand washing and hand rubbing are not recommended to be performed in sequence.

Which of the following statements on alcohol-based hand True False Uncertain

rub and hand washing with soap and water are true?

Hand rubbing is more rapid for hand cleansing than hand 15 6 4

washing.

Hand rubbing causes skin dryness more than hand washing 20 3 2

Hand rubbing is more effective against germs than hand 5 17 3

washing

Hand washing and hand rubbing are recommended to be 10 10 5

performed in sequence

Table 4.3: Statements on alcohol-based hand rub and hand washing with soap and water.

Source: Authors’ filled survey

30
Figure 4.6 shows the responses on the question “What is the minimal time needed for alcohol

based hand rub to kill most germs on your hands?” Only 16 (64%) of the respondents were able

to answer correctly as 20 seconds.

8% 8%

20%

64%

10 seconds 20 seconds 30 seconds 5 seconds

Figure 4.6: A pie chart showing minimum time taken for alcohol hand rub to act.

Source: Authors’ filled survey

From table 4.4, the knowledge of respondents on hand rubbing and hand washing was further

assessed. This time, they were asked to indicate which one is best for the following situations.

Before palpation of the abdomen; Hand washing 17 (68%), before giving an injection; Hand

rubbing 12 (48%), after emptying a bed pan; Hand washing 22 (88%), after making a patients bed;

Hand rubbing 10 (40%) and after visible exposure to blood; Hand washing 24 (96%).

31
Table 4.4: Hand hygiene method required in some situations

Which type of hand hygiene method is required in Hand % Hand %

the following situations? rub washing

Before palpation of the abdomen 8 32.0 17 68.0

Before giving an injection 12 48.0 13 52.0

After emptying a bed pan 3 12.0 22 88.0

After making a patient’s bed 10 40.0 15 60.0

After visible exposure to blood 1 4.0 24 96.0

Source: Authors’ filled survey

Figure 4.7 represents respondents’ responses when they were assessed on knowledge on

colonization of hands with germs in certain instances. With wearing jewellery; 18 (72%) had it

correctly that it contributes, Damaged skin; 19 (76%) had it correctly that it contributes, Artificial

fingernails 24 (96%) had it correctly that it contributes and Regular use of a hand cream 15 (60%)

were correct that it does not contribute to hand colonization.

32
 Yes No

24

19
18

15

10

7
6

Wearing jewellery Damaged skin Artificial fingernails Regular use of a hand

cream

Figure 4.7: A bar chart showing knowledge on colonization of hands with germs in certain

instances.

Source: Authors’ filled survey

4.4 Attitude of health care workers towards hand hygiene

Table 4.5 shows the general attitude of the respondents towards hand hygiene. The respondents

were asked to indicate whether they agree, disagree or uncertain about the following statements.

Hands should be washed before starting work on the ward, majority 25 (100%) indicated correctly

that they agree, visibly soiled hands must be washed with water and soap, 23 (92%) indicated

correctly that they agree, It is the duty of every hospital employee to keep their hands as free of

bacteria as possible, majority 23 (92%) indicated correctly that they agree, after handling of soiled

linen, hands must be washed or rubbed with alcohol, 22 (88%) indicated correctly that they agree

33
and finally sometimes, I have more important things to do than hand hygiene, 22 (88%) indicated

correctly that they disagree.

Table 4.5: Attitude of health care workers in some situations

Variables Agree Disagree Uncertain

Hands should be washed before starting work on the ward. 25 0 0

Visibly soiled hands must be washed with water and soap. 23 0 2

It is the duty of every hospital employee to keep their hands as free 23 1 1

of bacteria as possible.

After handling of soiled linen, hands must be washed or rubbed 22 2 1

with alcohol

Sometimes, I have more important things to do than hand hygiene 2 22 1

Source: Authors’ filled survey

34
From figure 4.8, eighteen respondents 18 (72%) disagreed with the statement that wearing of

gloves reduces the need for hand hygiene, 5 (20%) agreed and 2 (8%) were uncertain.

Wearing gloves reduce the need for hand hygiene

20
18

15

10
5
5

0 2
AGREE
DISAGREE
UNCERTAIN

Figure 4.8: A bar chart showing if wearing gloves reduce the need for hand hygiene.

Source: Authors’ filled survey

Figure 4.9 shows responses to a question of whether the respondents feel frustrated when others

omit hand hygiene. Majority 23 out of 25 respondents (92%) indicated Yes with only 2 (8%)

indicating No.

35
 Frustrated when others omit hand hygiene

100
90
80
70
60
50
40
30
20
10
0
Yes No

Figure 4.9: A bar chart showing feelings of respondents when others omit hand hygiene.

Source: Authors’ filled survey

From figure 4.10, majority 23 (92%) of the respondents admitted they feel guilty when they fail to

perform hand hygiene whiles only 2 (8%) said they have no guilt when they omit hand hygiene..

I feel guilty if I omit hand hygiene

8%

92%

Yes No

36
Figure 4.10: A pie chart showing feelings of respondents when they omit hand hygiene.

Source: Authors’ filled survey

Figure 4.11 shows that 16 (64%) of the respondents agree to the statement that emergencies and

other priorities make hand hygiene difficult at times, 6 (24%) disagree and 3 (12%) of the

respondents were uncertain.

Emergencies and other priorities make hygiene more difficult at

7%

45%

48%

Agree Disagree Uncertain

Figure 4.11: A pie chart showing if emergencies and other priorities make hygiene more

difficult at times.

Source: Authors’ filled survey

4.5 Hand hygiene practices

From table 4.6, minimum 10 (40%) of the respondents indicated that they agree to the fact that

they sometime miss out hand hygiene simply because they forget it, 23 (92%) said that hand

hygiene is an essential part of their role, 20 (80%) disagreed that the frequency of hand hygiene

37
required makes it difficult for them to carry it out as often as necessary, 18 (72%) agree that

infection prevention team have a positive influence on their hand hygiene practices and 9 (36%)

disagree that infection prevention notice boards remind them to do hand hygiene.

Table 4.6 Assessment on hand hygiene practices

Variable Agree Disagree Uncertain

Sometime I miss out hand hygiene simply because I forget it 10 15 0

Hand hygiene is an essential part of my role 23 1 1

The frequency of hand hygiene required makes it difficult for 3 20 2

me to carry it out as often as necessary.

Infection prevention team have a positive influence on my 18 5 2

hand hygiene practices

Infection prevention notice boards remind me to do hand 13 9 3

hygiene

Source: Authors’ filled survey

38
Figure 4.12 shows the responses of the respondents on who they think should take health education

or refresher training in hand hygiene for infection control in healthcare facilities. Majority 20

(80%) answered correctly that all healthcare workers whiles 5 (20%) gave other responses.

20%

80%

All health care workers other responses

Figure 4.12: A pie chart showing who should take part in refresher training on hand hygiene

in healthcare facilities.

Source: Authors’ filled survey

From figure 4.13, majority 17 (68%) of the respondents disagreed to the statement that time

pressure makes it difficult for them to attend hand hygiene courses, 5 (20%) of the respondents

agreed to the statement and 3 (12%) of the respondents were uncertain.

39
 70 68

60

50

40

30
20
20

10
12
0
AGREE
DISAGREE
UNCERTAIN

Figure 4.13: A bar chart showing if time pressures contribute to refusal of some healthcare

workers to attend hand hygiene courses.

Source: Authors’ filled survey

On the organizational barriers to hand hygiene, 15 out of the 25 respondents indicated that lack of

accessibility to hand hygiene facilities is a barrier to hand hygiene at the hospital, 13 out of 25 said

yes to inadequate maintenance of hand hygiene facilities, 19 out of 25 indicated poor access to

hand hygiene products, 13 out of 25 of the respondents indicated understaffing and 6 out of 25 of

the respondents mentioned overcrowding.

Figure 4.14 shows the cumulative percentages of the barriers to hand hygiene at the St Mary’s

Hospital Drobo as indicated by the respondents. Majority 28.79% identified poor access to hand

hygiene products as the main organizational barrier to hand hygiene at the hospital followed by

lack of accessibility to hand hygiene facilities which is 22.72%, 19.70% for inadequate

40
maintenance of hand hygiene facilities, understaffing contributed 19.70% and finally 9.09% for

overcrowding.

100.00%
80.00%
60.00%
40.00%
20.00%
0.00%
cumulaive frequencies of barriers to hand hygiene at
St Mary's Hospital Drobo

understaffing
overcrowding
poor access to hand hygiene products
inadequate maintenance of hand hygiene facilities
lack of acessibility to hand hygiene facilities

Figure 4.14: A chart showing the cumulative frequencies of the barriers to hand hygiene at

SMH.

Source: Authors’ filled survey

4.6 Satisfaction of facilities for hand hygiene

Figure 4.15 shows responses on satisfaction of facilities for hand hygiene at the hospital. The

respondents were torn between two perspectives as evidenced by their responses. 15 of the

respondents (60%) were satisfied with the facilities available in their units for hand hygiene and

10 (40%) were not satisfied.

41
 Satisfaction with the facilities available for hand hygiene

40%

60%

Yes No

Figure 4.15: A pie chart showing satisfaction with the facilities available for hand hygiene.

Source: Authors’ filled survey

Table 4.7 illustrates responses when respondents were asked whether they were satisfied with the

availability of some hand hygiene products/facilities. Majority 20 out of 25 of the respondents

were satisfied with the availability of infection prevention notices, 21 out of 25 were satisfied with

the availability of soap/antiseptic and water for hand washing, 17 out of 25 were satisfied with

availability of alcohol rub, 5 out of 25 were satisfied with the availability of paper/clothes for

drying hands, 19 out of 25 were satisfied with the availability of gloves, 17out of 25 were satisfied

with the availability of number of sinks with running water and finally 10 out of 25 were happy

with the training programmes on hand hygiene conducted by the hospital.

42
Table 4.7: Satisfaction with the availability of some hand hygiene facilities or products

Are you satisfied with the availability of the following? Yes % No %

Infection prevention notices 80.0 20.0

Soap/antiseptic and water for hand washing 84.0 16 .0

Alcohol rub 68.0 32.0

Paper/clothes for drying hands 20.0 80.0

Availability of gloves 76.0 24.0

Number of sinks with running water 68.0 32.0

Training programmes on hand hygiene conducted by the 40.0 60.0

hospital

Source: Authors’ filled survey

Figure 4.16 shows respondents general total impressions on hand hygiene in their facility. Minority

7 (28%) of the respondents indicated that it was bad, 15 (60%) said it was good whiles 3 (12%)

indicated it was very good.

43
 70

60

50

40

30

20

10

0
Bad Good Very Good

Figure 4.16: A chart showing the general impression of healthcare workers of St Mary’s

Hospital Drobo on hand hygiene.

Source: Authors’ filled survey

44
 CHAPTER FIVE

5.1 Discussion

The study group consisted of health care workers including nurses, doctors, midwives, medical

laboratory technicians, and health assistants who have direct contact with patients. It is important

to instil correct hand hygiene practices, good attitudes and correct knowledge regarding hand

hygiene in the healthcare workers mentioned above.

The total number of respondents in this study was 25 (100%). The respondents were between the

age group of 20 to 59 years of age, with the modal age group being 20 to 29 year. There were more

females in the study than males. On professionalism, majority of the respondents were nurses,

followed by midwives, health assistants, medical laboratory technicians, and then doctors. This

was not by chance but possibly due to the distribution of the various professionals on the ward.

There are more nurses on the wards than doctors and other professionals.

General knowledge on infection prevention was assessed with the aim that if the respondents’

knowledge on infection prevention is high then probably their knowledge on hand hygiene too will

be high since hand hygiene is a subset of infection prevention. Their knowledge on general

infection prevention was high as more than half of respondents were able to answer correctly all

the three questions asked. The worrying aspect here was that about one-quarter of the respondents

indicated that gloves can protect the healthcare worker against needle stick accidents which is not

true. Needle stick accidents can be avoided if one takes extra caution whiles working with needles.

To further assess the knowledge of respondents on general infection prevention, their knowledge

on sources of infection in the health care center was assessed. Their responses were encouraging.

About three-quarters of the respondents were able to correctly select that health personnel,

45
contaminated equipment, contaminated air and other patients are all sources of infection in the

health care center. This indicates that majority of the respondents are knowledgeable of the various

sources of infection in the health care center. Concerning the routes of transmission of pathogens

at the healthcare center, most of our respondents, averagely about 68%, were much aware that

unclean hands of healthcare workers could transmit pathogens to patients at the healthcare center.

However, 56% of the respondents do not believe that contaminated clothes of healthcare workers

could transmit pathogens to patients which are a false response.

To assess the respondents’ knowledge on the moments for hand hygiene as outlined by Boyce

2002 and reiterated by the World Health Organization (WHO) Guidelines on Hand Hygiene in

Health Care, 2009, a question was asked on the circumstances that require hand hygiene. It was

revealed that almost all of the respondents knew the moments for hand hygiene as on the average,

92% answered correctly the questions asked. Although majority of the respondents know the

moments for hand hygiene, the average 8% minority who do not carry out hand hygiene at the

various instances is a grave concern. The failure to carry out hand hygiene leads to the spread of

infectious microorganisms causing an increase in the incidence of nosocomial infections. This is

consistent with a study by Veena and colleagues in 2014 which stated that transmission of

healthcare-associated pathogens generally occurs via the contaminated hands of healthcare

workers and is preventable with simple hand hygiene.

The use of alcoholic hand rub solutions or gels has been shown to be effective for hand antisepsis

(Abd Elaziz et al. 2008).However the availability of hand rub solutions in hospitals are still

unsatisfactory. In our study, one-fifth were aware that hand rubbing is more rapid for hand

46
cleansing. Knowledge about hand washing as a more effective method against germs than hand

rubbing was found to be significantly good. It was a shocking revelation when they were asked if

hand washing and hand rubbing are recommended to be performed in sequence, a little over half

of respondents indicated that hand washing and hand rubbing should be done in sequence which

should not be the case. An unexpected finding also was that only (64%) knew that 20 seconds is

the minimum time required for effective hand hygiene as documented in the WHO guideline

(WHO, 2009). The respondents’ knowledge regarding the correct hand hygiene method of use

prior to performance of certain procedures was not encouraging especially for hand rubbing. For

instances such as palpation of abdomen, before giving an injection and after making a patient’s

bed, less than half of the respondents indicated hand rubbing as the correct hand hygiene method

of use. However, respondents have adequate knowledge that hand washing is the appropriate hand

hygiene method after emptying a bed pan (88%) and after visible exposure to blood (96%). The

overall correct responses regarding appropriate use of hand rub was unsatisfactory. One of the

reasons may be due to unavailability of hand rub solution in the hospital. It has been shown that

increased compliance to hand hygiene can be achieved by making the hand rub solutions available

at the bedside of patient (Randle et al 2006). The knowledge on colonization of hands with germs

in certain instances, the response was very encouraging. Majority of the respondents indicated

correctly that wearing jewellery, damaged skin, and artificial fingernails contribute to colonization

of hand with germs. This was consistent with a study by Trick and colleagues (2003) who found

out that ring wearing increased the frequency of hand contamination with potential health care-

associated pathogens. Also, 40% answered correctly that regular use of a hand cream does not

contribute to hand colonization of pathogens. According to McNeil et al. (2001), wearing artificial

acrylic fingernails can result in hands remaining contaminated with pathogens after use of either

47
soap or alcohol-based hand gel. This was consistent with the knowledge by our respondents as

96% answered that artificial fingernails contribute to hand colonization with germs.

The study showed that the general attitude of the respondents towards hand hygiene was positive.

This was picked from the responses gathered from actions in various situations when asked.

Almost all of our respondents agreed correctly to the following statements; hands should be

washed before starting work on the ward, visibly soiled hands must be washed with water and

soap, it is the duty of every hospital employee to keep their hands as free of bacteria as possible,

and after handling of soiled linen, hands must be washed or rubbed with alcohol. Finally with the

statement; Sometimes, I have more important things to do than hand hygiene; majority indicated

correctly that they disagree. In our study, majority of our respondents also disagree correctly that

wearing of gloves reduces the need for hand hygiene. This is evidence that the respondents have a

good attitude towards hand hygiene. A question of whether the respondents feel frustrated when

others omit hand hygiene was also asked. Almost all of the respondents indicated that they feel

frustrated and guilty when others omit hand hygiene and when they also omit hand hygiene. About

whether emergencies and other priorities make hand hygiene more difficult at times, respondents

were evenly divided as 16 out of the 25 respondents agreed, 6 out of the 25 respondents disagreed

and 3 out the 25 respondents were uncertain about the statement. These responses affirm the good

attitude of the respondents towards hand hygiene.

The respondents were assessed for hand hygiene practices, it was noticed that they have a generally

good hand hygiene practices. This was identified in the various responses such as 60% indicated

that they disagree to the statement that they sometime miss out hand hygiene simply because they

forget it, almost all of the respondents agreed that hand hygiene is an essential part of their role,

48
and only a few indicated that the frequency of hand hygiene required makes it difficult for them to

carry it out as often as necessary. Three-quarters of the respondents appreciated the role of

infection prevention notice board sin the practice of hand hygiene. The importance of taking health

education or refresher training in hand hygiene by healthcare workers cannot be overemphasized

when it comes to the role it plays in infection prevention. This can only be realized if the healthcare

workers see the need for such trainings. A question of who the respondents think should take health

education or refresher training in hand hygiene for infection control in healthcare facilities was

posed. Majority of the respondents correctly answered that all healthcare workers need to take

health education or refresher training in hand hygiene. In the everyday life of healthcare workers,

time is a luxury they do not have. We therefore enquired from our respondents if time pressures

contribute to refusal of some healthcare workers to attend hand hygiene courses. Two-thirds of the

respondents disagreed to time pressure hindering them from attending these courses.

Healthcare workers may have adequate knowledge on hand hygiene, exhibit a good attitude

towards hand hygiene and have good hand hygiene practices but if there are factors that inhibit

them from carrying out hand hygiene all these knowledge, attitude and good practice will not be

enough to prevent infections that are caused by transmission of pathogens by healthcare workers

hands. Our study therefore enquired from the healthcare workers the organizational barriers to

hand hygiene at their facilities. Cumulatively, poor access to hand hygiene products was identified

as the main barrier to hand hygiene at the St Mary’s Hospital Drobo followed by lack of

accessibility to hand hygiene facilities, inadequate maintenance of hand hygiene facilities,

overcrowding and understaffing as the least barrier. This was consistent with findings from a study

by Pittet (2001), who identified organizational barriers to hand hygiene, such as a lack of

49
accessibility to hand hygiene facilities, inadequate maintenance of hand hygiene facilities, poor

access to hand hygiene products, overcrowding and understaffing, and a lack of role models.

The respondents’ satisfaction with facilities available for hand hygiene was moderate among the

study group. A little over half of the respondents were satisfied with the facilities available in their

facility for hand hygiene. A question was further asked to find out from our respondents particular

hand hygiene products/facilities they were satisfied with or otherwise with regards to its

availability. Majority of the respondents were satisfaction with the availability of infection

prevention notices, availability of soap/antiseptic and water for hand washing, availability of

gloves and the number of sinks with running water available at the hospital. Satisfaction with the

availability of alcohol hand rub and availability of paper/clothes for drying hands was moderate.

Satisfaction with the training programmes on hand hygiene conducted by the hospital is nothing

to write home about, almost one-thirds of the respondents were dissatisfied. The respondents’

dissatisfaction with some of these hand hygiene products/facilities can be attributed to inadequate

financial resources to procure these products/facilities which is a major challenge for developing

countries. Limited financial resources have been linked to major barriers affecting hand hygiene

practices and infection prevention which include lack or shortage of basic hand hygiene products

and inadequate facilities for hand hygiene (Pittet et al, 2008). Most healthcare workers will be

reluctant to perform hand washing especially when their hands are not visibly soiled if there are

no paper/clothes to dry their hands afterwards. In order to ensure or develop good hand hygiene

practices among healthcare workers, it is important to make proper hand hygiene facilities

available. When these professionals are facing situations requiring urgent patient care, they are

more likely to omit hand hygiene practices when facilities are not easily accessible to them.

Increasing the supplies of hand hygiene products and institutional support is essential in combating

50
substandard practices in hand hygiene. It has been shown that increased compliance to hand

hygiene can be achieved by making the hand rub solutions available at the bedside of patient

(Randle et al 2006).

Finally, when respondents were asked about their general total impressions on hand hygiene in

their facility, majority of the respondents indicated that it is good but called for improvement in

the availability of the hand hygiene products

51
 CHAPTER SIX

6.0 Introduction

This chapter further talks about the survey. It contains the nursing implication, summary and

conclusion and recommendations we made after the study.

6.1 Nursing Implication

Proper hand washing is an input for health and development. It is a contributory factor to

infection prevention. It is used to break the transmission pathway of micro-organisms. Proper

hand washing reduces nosocomial infection. In other word, it reduces cross-infection, ailment

and insure better healthy lives.

According to the centers for the diseases control (2006), hand washing is the simplest most

effective measure for preventing the spread of bacteria, pathogen and viruses. In view of this,

WHO (2006) says even health care professionals fail to wash their hands or do not wash

according to the protocol. According to WHO 1.8 million children die every year from diarrhea

disease and 90% of these are aged less than five years from countries. The study finding suggest

that half of those lives could be safe if people involved in hand washing does it thoroughly. It

suggests that various public promotion of hand washing, particularly among those without

reliable clean water suppliers, could have a major impact on health.

In our finding, it was realized that all respondents hand knowledge on hand washing. If health

professionals are able to acknowledge the importance of proper hand washing and put it into

practice, there will be reduced number in transmission and spread of bacteria, viruses and other

pathogens that cause infection resulting from hospital treatment.

52
Finally, this will bring about reduction in nosocomial infection since proper hand washing

technique has been practiced.

6.2 Summary and Conclusion

The health care workers generally had good knowledge on hand hygiene but the knowledge on the

minimum time for effective alcohol rub was woefully poor. The respondents also showed good

attitude towards hand hygiene especially with majority of them indicating wearing of gloves does

not reduce the need for hand hygiene. The healthcare workers had good hand hygiene practices

because almost all of them identified hand hygiene to be an essential part of their role and only a

few indicated that the frequency of hand hygiene required makes it difficult for them to carry it

out as often as necessary.

However, major organizational barriers to hand hygiene were identified with poor access to hand

hygiene products and lack of accessibility to hand hygiene facilities topping the list. The healthcare

workers satisfaction with some hand hygiene products/facilities is moderate. Availability of

paper/clothes for drying hands and alcohol hand rub is woefully not encouraging.

Training programmes on hand hygiene conducted by the hospital is inadequate if not completely

absent.

6.3 Recommendations

Based on the study findings, the following are recommended for improvement in practice and for

future studies.

53
Hand hygiene training programmes need to be conducted more frequently for healthcare workers

by the hospital management with continuous monitoring and performance feedback to encourage

them to follow correct hand hygiene practices.

Again, were commending that the infection prevention team of the hospital ensure that the

standards for infection prevention are adhered to. The team should also do timely up dates of

infection prevention notices especially those on proper hand hygiene practices.

In addition, the hospital needs to improve on the availability of the hand hygiene products/facilities

that have been identified by the study to be barriers to proper hand hygiene.

Last but not least, future studies on hand hygiene should include the use of observation as data

collection method.

54
 Bibliography

Anargh V, Singh H, Kulkarni A, Kotwal A, Mahen A.(2013); Hand hygiene practices among

health care workers (HCWs) in a tertiary care facility in Pune. Med J Armed Forces

India, 69(1):54-6.

Bonten MJM et al (1996). Epidemiology of colonisation of patients and environment with

vancomycin-resistant Enterococci. Lancet, 348:1615–1619

Dumpis U et al (2003). Prevalence of nosocomial infections in two Latvian hospitals.

Eurosurveillance, 8:73–78

Griffith CJ et al (2003). Environmental surface cleanliness and the potential for

contamination during handwashing. AmericanJournal of Infection Control,

31:93–96.

Pittet D. (2001). Improving adherence to hand hygiene practice: A multidisciplinary

approach. Emerg Infect Dis; 7:234-40.

Pittet D Infection control and quality health care in the new millennium(2005), American Journal

of Infection Control, 33(5):258–267

World Health Organization (2009). WHO guidelines on hand hygiene in health care. Geneva;

2009.

Yawson AE, Hesse AA. (2013) Hand hygiene practices and resources in

a teaching hospital in Ghana. J Infect Dev Ctries.; 7(4):338-47.

55
 QUESTIONNAIRE

We are final year students from Holy Family Nursing and Midwifery Training College

Berekum conducting a study on the knowledge, attitude and practices of hand hygiene among

healthcare workers of St Mary’s Hospital Drobo. Your responses will be treated confidentially

and all information will be reported as collective data. Hence, you are not required to write your

name. There are no wrong or right answers. This is just to seek your opinion on the subject. Kindly

tick the appropriate spaces provided or write what you think in the open-ended questions. The

questionnaire will take approximately 30 minutes at most to be completed. I will be grateful if you

can answer all questions to the best of your ability.

Please tick [ √ ] or write where appropriate

DEMOGRAPHIC CHARACTERISTICS

1. Age: 20-29 [ ] 30-39 [ ] 40-49 [ ] 50-59 [ ]

2. Sex: Male [ ] Female [ ]
3. Profession: Doctor [ ] Nurse [ ] Healthcare assistant [ ] Orderly [ ]
Medical laboratory technician [ ] Others (specify)…………………………......

4. Unit …………………………………………………………………………
5. Rank ………………………………………………………………………….
6. Specialty………………………………………………………………………

56
KNOWLEDGE ON GENERAL INFECTION PREVENTION

Personal hygiene and personal protective equipment

1. There is evidence that aprons, gowns and masks are effective in preventing hospital acquired
infections. True [ ] False [ ]

2. Gloves reduce the contamination of the hands, but do not prevent it completely.
True [ ] False [ ]

3. Wearing gloves when handling sharp instruments protects against needle stick accident.
True [ ] False [ ]

4. What are the sources of infection in a health care center?

a. Health personnel [ ]
b. Contaminated equipment [ ]
c. Contaminated air [ ]
d. Other patients [ ]
e. All of the above. [ ]

5. Which of the following are the routes of transmission of pathogens at a healthcare center?
a) Health care workers hands when not clean [ ]
b) Health care workers hands after alcohol handrub for 20 seconds [ ]
c) Contaminated clothes of health care workers [ ]
d) Health care workers hands when cleaned [ ]

KNOWLEDGE ON HAND HYGIENE

1. Do the following circumstances require hand hygiene actions?

i. Before touching a patient. Yes [ ] No [ ]
ii. Before clean/aseptic procedure Yes [ ] No [ ]
iii. Immediately after body fluid exposure risk Yes [ ] No [ ]
iv. After touching a patient Yes [ ] No [ ]
v. After exposure to immediate surroundings of a patient. Yes [ ] No [ ]

2. Which of the following statements on alcohol-based hand rub and hand washing with
soap and water are true?
i. Hand rubbing is more rapid for hand cleansing than handwashing.

57
 True [ ] False [ ] Uncertain [ ]
ii. Handrubbing causes skin dryness more than handwashing
True [ ] False [ ] Uncertain [ ]
iii. Handrubbing is more effective against germs than handwashing
True [ ] False [ ] Uncertain [ ]
iv. Handwashing and handrubbing are recommended to be performed in sequence
True [ ] False [ ] Uncertain [ ]
v. What is the minimal time needed for alcohol based hand rub to kill most germs on
your hands?
20 seconds [ ] 10 seconds [ ] 5 seconds [ ] 30 seconds [ ]

3. Which type of hand hygiene method is required in the following situations?

i. Before palpation of the abdomen. Handrub [ ] Handwashing [ ]
ii. Before giving an injection. Handrub [ ] Handwashing [ ]
iii. After emptying a bed pan. Handrub [ ] Handwashing [ ]
iv. After making a patients bed. Handrub [ ] Handwashing [ ]
v. After visible exposure to blood. Handrub [ ] Handwashing [ ]

4. Which of the following should be avoided, as associated with increased likelihood of

colonization of hands with harmful germs?
i. Wearing jewellery Yes [ ] No [ ]
ii. Damaged skin Yes [ ] No [ ]
iii. Artificial fingernails Yes [ ] No [ ]
iv. Regular use of a hand cream Yes [ ] No [ ]

ATTITUDE ON HAND HYGIENE

Please state if you agree with the following statements:

1. Hands should be washed before starting work on the ward.

Agree [ ] Disagree [ ] Uncertain [ ]

2. Visibly soiled hands must be washed with water and soap.

Agree [ ] Disagree [ ] Uncertain [ ]

3. It is the duty of every hospital employee to keep their hands as free of bacteria as
possible. Agree [ ] Disagree [ ] Uncertain [ ]

4. After handling of soiled linen, hands must be washed or rubbed with alcohol.

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 Agree [ ] Disagree [ ] Uncertain [ ]

5. Sometimes, I have more important things to do than hand hygiene

Agree [ ] Disagree [ ] Uncertain [ ]

6. Wearing gloves reduce the need for hand hygiene

Agree [ ] Disagree [ ] Uncertain [ ]

7. I feel frustrated when others omit hand hygiene

Yes [ ] No [ ]

8. I feel guilty if I omit hand hygiene yes [ ] no[ ]

9. Emergencies and other priorities make hand hygiene more difficult at times
Agree [ ] Disagree [ ] Uncertain [ ]

HAND HYGIENE PRACTICES

1. Sometime I miss out hand hygiene simply because I forget it

Agree [ ] Disagree [ ] Uncertain [ ]

2. Hand hygiene is an essential part of my role

Agree [ ] Disagree [ ] Uncertain [ ]

3. The frequency of hand hygiene required makes it difficult for me to carry it out as often
as necessary.

Agree [ ] Disagree [ ] Uncertain [ ]

4. Infection prevention team have a positive influence on my hand hygiene

Agree [ ] Disagree [ ] Uncertain [ ]

5. Infection prevention notice boards remind me to do hand hygiene

Agree [ ] Disagree [ ] Uncertain [ ]

6. Who do you think should take health education or refresher training in hand hygiene for
infection control in Healthcare facilities? Give reasons to your answer?

………………………………………………………………………………………

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 ……………………………………………………………………………………….

………………………………………………………………………………………

7. It is difficult for me to attend hand hygiene courses due to time pressure

Agree [ ] Disagree [ ] Uncertain [ ]

8. Which of the following organizational barriers to hand hygiene apply to your facility?
(Tick if applicable)
 lack of accessibility to hand hygiene facilities [ ]

 inadequate maintenance of hand hygiene facilities [ ]

 poor access to hand hygiene products [ ]

 overcrowding [ ]

 understaffing [ ]

SATISFACTION OF FACILITIES FOR HAND HYGIENE

1. Are you satisfied with the facilities available for hand hygiene Yes [ ] No [ ]

Satisfaction with the availability of the following;

2. Infection prevention notices Yes [ ] No [ ]

3. Soap/antiseptic and water for hand washing Yes [ ] No [ ]
4. Alcohol rub Yes [ ] No [ ]
5. Paper/clothes for drying hands Yes [ ] No [ ]
6. Availability of gloves Yes [ ] No [ ]
7. Number of sinks with running water Yes [ ] No [ ]
8. Training programmes on hand Hygiene conducted by the hospital Yes [ ] No [ ]

Your general impressions on hand hygiene in your facility…………………….........................

………………………………………………………………………………………………….

THANK YOU.

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