Factors Influencing Adherence To Hand Hygiene Practice Among Health Care Workers

Project and Seminar Material for Public Health

Factors Influencing Adherence To Hand Hygiene Practice Among Health Care Workers


Hand hygiene is an important measure to prevent and control infection particularly in developing countries, the identification of several risk factors associated with poor hand hygiene compliance is extreme importance. Alcohol based hand rube (ABHR) is simple measure to prevent the transmission of infection. This institutional based cross- sectional study focus on describing hand hygiene practice of nurses and provides base line information on the area. To assess hand hygiene practices among health care workers. Institution based quantitative cross sectional study design was used to assess hand hygiene practice and factor affecting compliance among health care workers. A total of 288 were included and selected by simple random sampling. Data collection was made by using self-administered structured questionnaire. The collected data was checked visually for its completeness and the response were coded and entered into the computer using EPI info version 3.5.1. Statistical package, and the 10% of the response was randomly selected and check for the consistency of data entry. Then data were exported to windows of Statistical Package for Social Science (SPSS) version 20 for data analysis. Descriptive statistics, bivariate logistic and multivariate logistic regression analysis was done to see association between factors and hand hygiene practice. A Total of 288 study participants filled the questionnaires with a response rate of 100%. Hand hygiene compliance of nurses was found 79% having knowledge about hand hygiene compliance(AOR[95%CI]= 2.873[1.258, 6.56]),availability of soap and water(AOR[95%CI]= 0.324[0.155, 0.678]), availability of ABHR(AOR[95%CI] = 0.293[0.125, 0.686]), availability of towel/tissue paper(AOR[95%CI]= 3.314[1.587, 6.918]), were significantly associated with hand hygiene compliance.

Table of Content

  • Title Page
  • Certification
  • Dedication
  • Acknowledgement
  • Table of Content
  • List of Tables
  • Abstract

Chapter One:


  • 1.1 Background of the Study
  • 1.2 Statement of the Problem
  • 1.3 Objective of the Study
  • 1.4 Research Questions
  • 1.5 Research Hypothesis
  • 1.6 Significance of the Study
  • 1.7 Scope of the Study
  • 1.8 Limitation of the Study
  • 1.9 Definition of Terms
  • 1.10 Organisations of the Study

Chapter Two:

Review of Literature

  • 2.1 Conceptual Framework
  • 2.2 Theoretical Framework
  • 2.3 Empirical Review

Chapter Three:

Research Methodology

  • 3.1 Research Design
  • 3.2 Population of the Study
  • 3.3 Sample Size Determination
  • 3.4 Sample Size Selection Technique and Procedure
  • 3.5 Research Instrument and Administration
  • 3.6 Method of Data Collection
  • 3.7 Method of Data Analysis
  • 3.8 Validity of the Study
  • 3.9 Reliability of the Study
  • 3.10 Ethical Consideration

Chapter Four:

Data Presentation and Analysis

  • 4.1 Data Presentation
  • 4.2 Analysis of Data
  • 4.3 Answering Research Questions
  • 4.4 Test of Hypotheses

Chapter Five:

Summary, Conclusion and Recommendation

  • 5.1 Summary
  • 5.2 Conclusion
  • 5.3 Recommendation
  • References

Chapter One


1.1 Background to the study

Hand hygiene in health care refers to any type of hand cleansing performed in order to render the hands free from any form of visible dirt, pathogens or microorganisms (WHO, 2012). The act of hand hygiene is a fundamental measure of reducing any infections that can be transmitted via contact. Despite it being uncomplicated action, inadequate act of hand hygiene in hospitals is a public health concern worldwide (WHO, 2010). Hand hygiene in health is measured through Health care provider self- reporting, directly observing the health workers and patient assessment patient while the indirect method involves measuring the usage of hand hygiene facilities like the automated sinks and soap dispenser (pittet et al., 2009). Direct observation is currently recommended method of measuring compliance since it is able to timely identify hand hygiene opportunities and actions taken (WHO, 2012).

Hand washing is the most effective way of preventing the spread of infectious diseases. But despite a Joint Commission requirement that Centers for Disease Control and Prevention hand hygiene guidelines be implemented in hospitals, compliance among health care workers remains low.

The reasons of lack of compliance to hand washing include: lack of appropriate equipment, low staff to patient ratios, allergies to hand washing products, insufficient knowledge among staff about risks and procedures, the time required and casual attitudes among HCWs towards bio- safety.

In most developed countries the compliance rate for hand hygiene practice rarely goes beyond fifty percent (Mani et al., 2010; Maxfield & Dull, 2011). Like in the case of United Kingdom compliance rate is 32%, in the USA the 50%, and in Switzerland 42% (Takahashi & Tulare, 2010). Effective compliance to hand hygiene standards in hospitals is essential in inhibiting the spread of Hospital infections, multi-drug resistant pathogens and to generally promote patient safety (Rocha, 2012).The possibility of getting HCAI is global and colonizes most of the hospitals worldwide. Furthermore, the exact burden that these infections inflict to the health system cannot be ascertained, this is based on the difficulty in data collection, variability in health systems throughout the world and on the argument that the diagnostic procedures of HCAI differ worldwide and most of the countries lack surveillance system (De Wandel, Maes, Labeau, Vereecken & Blot, 2010).

Approximately, two hundred thousand Healthcare Associated Infections (HIAs) in healthcare setting is reported annually in Australia (Jain et al., 2015). In European Union 4 million Healthcare Associated Infections (HIAs) occurs annually with 37000 death and 16 million lengthened hospital days due to the infections (Takahashi & Tulare, 2010). Despite the inadequate data on HCAI prevalence in Africa, the studies that were conducted in Algeria, Ethiopia, South Sudan, and Burkina Faso indicated the prevalence rates to be ranging from 2.5% to 48 % (Dia et al., 2008) with a higher incidence in surgical wards. Hand cleansing is identified to be economical, simple and the most feasible measure of minimizing infections yet compliance rate is low worldwide (Maingi, 2015).

Health Care-Associated Infections (HCAI) are common in that about 5% to 10% of hospitalized patients are at threat of getting the infection and it causes death worldwide (Grayson, 2009). The incidence of these infections is documented to be averagely 12.7 per hundred patients universally (Sinsam, 2016). Health Care- Associated Infections (HCAI) lengthens the hospitalization period of the patients, causes preventable deaths and incurs huge financial burden to not only an individual but their families and the nation at large. Moreover, in the USA about 80,000 deaths due to HCAI occurs yearly, and the health care cost in 2007 ranged from 28.4 – 33.8 billion US dollars (Aziz, 2014). The prevalence of HCAI in USA hospitals is about 722,000 cases plus seventy five thousand deaths as a result of the infections with intensive care unit reporting a higher number of cases than any other work unit. (Hebden et al., 2016).

In developing countries, the burden is much higher than those of Europe and USA, the prevalence rate is estimated to be 15.5 per 100 patients (Allegranzi, 2011). An estimated 1.5 million cases of HCAI is reported in which 25% of all infections acquired occurs in developing the world (Baqi et al.,2009) and on average 5% of patients hospitalized are at risk of getting HCAI worldwide (Muhumuza et al., 2015). In emerging world, the weight of HCAI is high, therefore, there is need to re- examine the infection control strategies and improve on the surveillance system of HCAI (Allegranzi et al., 2010).

1.2 Statement of the Problem

The hands of health care providers are documented to be highly colonized by pathogens, therefore, serving as a media in cross- contamination. This is due to health care providers touching surfaces, substances, body fluids and patient skin during their routine practices (Ndegwa, 2014).Though it has been shown that the practice of hand cleansing is a key measure verified to be operative in averting HCAI and the transmission of antimicrobial resistance, literature report that health care providers come across challenges in observing hand hygiene standards. Inappropriate hand hygiene practices act as a media of infection spread in hospital wards ( De almeida, 2012) and accurately following hand hygiene procedures helps in curbing the spread of infections (Grayson, 2009) but compliance among health care providers remains a big challenge ( Joshi et al., 2013). Unsatisfactory or minute hand hygiene compliance rates in developing has been documented, Nigeria being one of the countries where compliance to WHO standards is only at 38.7% (Ndegwa, 2014).

Despite the existence of such condition, and the possible impact of HCAI on the patients, inadequate studies have been done to accurately determine the hand hygiene compliance rate in the Rural Counties (Mortell, 2012). According to Ndegwa (2014), eighty percent of HCAI has been reduced due to compliance with hand cleansing recommendations in certain health facilities whereas non-compliance has been witnessed in epidemiological studies, to be the main risk aspect for poor hand hygiene amongst other factors or reasons were given by the health care providers.

Hand hygiene prior to and following patient contact is a key infection control strategy included in many official national and international infection control guidelines.

Most infection control programs in developing countries with limited resources are understaffed and hand washing depends mostly in having soap, towels, and sinks available (21).Poor compliance with hand hygiene is common among HCWs .

The provision of healthcare worldwide is always associated with a potential range of safety problems and patients remain vulnerable to unintentional harm in hospitals because of poor hand hygiene. For that reason, the current study sought to define the baseline level of hand hygiene compliance based on history of being the most operational method of averting HCAI in health care. The study also sought to determine the factors that enhance or hinder hand hygiene practice amongst the health care providers.

1.5 Objectives of the Study

The main objective of the study is to assess the factors influencing adherence to hand hygiene practice among health care workers. The specific objectives are

  1. To determine the level of compliance to hand hygiene standards amongst the healthcare providers in selected public hospitals in Enugu north LGA
  2. To find out the influence of socio-demographic factors on compliance with hand hygiene standards by healthcare providers in selected public hospitals in Enugu north LGA
  3. To establish the influence of hand hygiene knowledge on compliance with hand hygiene standards amongst healthcare providers in selected public hospitals in Enugu north LGA
  4. To examine the influence of hand hygiene facilities on compliance with hand hygiene standards amongst healthcare providers in selected public hospitals in Enugu north LGA

1.4 Research Questions

  1. What is the level of compliance to hand hygiene standards amongst the healthcare providers in selected public hospitals in Enugu north LGA?
  2. What influence do socio-demographic factors have on compliance with hand hygiene standards by healthcare providers in selected public hospitals in Enugu north LGA?
  3. What influence does hand hygiene knowledge have on compliance with hand hygiene standards by healthcare providers in selected public hospitals in Enugu north LGA?
  4. 4. What influence do hand hygiene facilities have on compliance with hand hygiene standards by healthcare providers in selected public hospitals in Enugu north LGA?

1.5 Hypothesis of the Study

  • H1: socio-demographic, knowledge and environmental factors on hand hygiene practice among health workers is good
  • Ho: socio-demographic, knowledge and environmental factors on hand hygiene practice among health workers is not good

1.6 Significance of the Study

Results from this study are beneficial to the policy formulators majorly the Health sector and county government of Enugu north LGA in that they are able to rethink their available strategies in order to curb hospital infections which are a burden to the health care system. The study also provides a foundation for future researchers and improves on the present literature for reviews.

1.7 Scope of the Study

The sole purpose of this study was to assess the factors influencing adherence to hand hygiene practice among health care workers in selected public hospitals in Enugu north LGA. The study assessed the influence of socio-demographic factors, knowledge on hand hygiene and availability of hand hygiene facilities such as clean water, soap, hand wipes and hand rub. The influence of religious beliefs, cultural practices, behavior, perceptions, attitudes, health facilities internal cultures and administration or supervision was not studied due to time and resource constraint.

1.8 Limitations of the Study

This study focused on the health care providers in selected public hospitals in Enugu north LGA only and excluded any health care provider either working in private health facility or outside Enugu north LGA. This is due to limited study timeline and finance. Also, the study did not include study of the health care associated infections which is closely associated with hand hygiene.

1.9 Definition of Terms


Refers to an act of conforming to certain established regulation, guidelines, policy or legislation in this case the WHO hand hygiene standards.

Hand Cleansing:

Refers to an act of performing hand hygiene with the aim of doing away with any form of dirt, microorganisms or organic matter.

Hand Hygiene:

Refers to any act of cleansing hands.

Hand Washing:

Refers to the cleaning of hands using water with either antimicrobial soap or plain soap.

Healthcare Worker:

Refers to nurses, doctors, and clinicians who directly handle the patients.

Higher Level Health Facilities:

Refers to any hospital that offers complex clinical care with specialized facilities and receive referrals from the lower-level hospitals.


Refers to entry and multiplication of a pathogen into the human body or any host.

Lower Level Health Facilities:

Refers to any hospital that offers basic clinical care to the patients due to lack of specialized equipment and personnel. They include; dispensaries, clinics, and health centers

1.10 Organization of the Study

The study is categorized into five chapters. The first chapter presents the background of the study, statement of the problem, objective of the study, research questions and hypothesis, the significance of the study, scope/limitations of the study, and definition of terms. The chapter two covers the review of literature with emphasis on conceptual framework, theoretical framework, and empirical review. Likewise, the chapter three which is the research methodology, specifically covers the research design, population of the study, sample size determination, sample size, abnd selection technique and procedure, research instrument and administration, method of data collection, method of data analysis, validity and reliability of the study, and ethical consideration. The second to last chapter being the chapter four presents the data presentation and analysis, while the last chapter(chapter five) contains the summary, conclusion and recommendation.

Chapter Five

Summary, Conclusion and Recommendation

5.1 Summary

Hand hygiene is a core element and one of the most effective ways to prevent, control and reduce health care associated infection. Poor hand hygiene compliance of nurses with hand hygiene; however, is a major problem in hospital. Although infection is most prevalent in patients up on admission, nurses also act as potential vectors for pathogenic agents. Hospitals provide a favorable transmission pathway for the spread of nosocomial infections, poor infection control practice of hand hygiene among nurses in one hand and overcrowding of patients in most clinical settings on the other. The number of scientific evidence that hand is the most important vehicle for transmission of nosocomial pathogens. This study tried to assess hand hygiene practiceand factors affecting compliance among nurses.

Good Hand Hygiene compliance of nurses as measured by this study was found to be 79%. This is a little bit greater than study conducted inGondar (48.4%), Kenya and Ghana- which showed that the overall hand hygiene practice was (65%)(70%) (55,53). But this finding was lower than other studies done in Trivandrum countries(98%) (56);

Knowledge to hand hygiene guideline was found to be associated with hand hygiene compliance. Those who had good knowledge on hand hygiene has 2.8 times more compliance than poor knowledge which has similarity with other studies done in Kuwait which showed that knowledge of nurses weresignificantly associated with good hand hygiene practice. knowledge on hand hygiene practice will help to hand hygiene compliance with recommended way, Knowledge of nurses will help to identify risk and benefit practice onthe way of HCAIs transmission and how to prevented.

The presence of ABHR was positively associated with Hand hygiene practice in which those who had access for ABHR in their ward/department had 0.2 times more likely to compliance than those who had not access on ABHR. This is similar with other studies done in Taiwan, the availability of ABHR resulted significant improvement of hand hygiene practice. This might be related to the presence of ABHR during patient care that will remind the nurses to do hand hygiene, ABHR it is easy and simple to implementing.

The availability of towel/tissue paper in the working area was associated with hand hygiene practice. Those who had availability of towel/tissue paper in their ward are 3.3 times more likely compliance to hand hygiene than who had not available which is similar with study done in Australia and Ghana, the availability of towel/tissue will improve hand hygiene practice.

5.2 Conclusion

Health workers good hand hygiene compliance was indicated โ€˜afterโ€™ caring for a patient whereas poor hand hygiene compliance was reported โ€˜beforeโ€™ having direct contact with a patient.

Nurses hand hygiene practice was influenced by the knowledge they have for hand hygiene indications as per hand hygiene guideline.
There was no statistical significant variations on hand hygiene practice score across nurses in different wards

5.3 Recommendations

The following actions are recommended by the study

  1. Efforts need to be focused to awareness of the impact of HCAI and implications of hand hygiene.
  2. Provision of working wards/department with hand hygiene facilities like, sink, ABHR Jul, glove, and towel for better hand hygiene practice.
  3. Give training and re- training programme on hand hygiene guidelines.
  4. Infection prevention and control in Health care settings should be corporate in to nurses Performance contra ting to help improve hand hygiene compliance rate.

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