Compliance to Hand Hygiene Practices, its Barriers, and Influences - a Qualitative Study among the House Surgeons of a Tertiary Care Centre in Bengaluru, Karnataka

Introduction

Globally, health care associated infections (HAIs) affect millions of people every year, which is completely avoidable. In the world, no country how much ever developed or sophisticated it may is free of HAI. According to the report by World Health Organization (WHO), for every 100 patients, 7 in high- and 15 in low-/ middle-income countries (LMIC) acquired HAI. Out of every 10 affected patients, one patient dies of HAI. Due to the COVID-19 pandemic, from the month of January 2020 to the month of May 2021, approximately 80,00 to 1,80,000 health care workers were affected and it had resulted in 115,500 deaths.¹

Good hand hygiene practices can prevent the HAIs by cleaning hands at the correct time and in the correct way. The most efficient approach for improvement of these practices is the multimodal hand hygiene improvement strategy by WHO. Nearly 50% of the avoidable infections acquired during healthcare can be prevented by adopting the required practices for hand hygiene and economically the cost of implementation can also be reduced 16 times.² Since there are enough studies assessing the knowledge related to hand hygiene practices, this study particularly aimed to assess the compliance to the practices related to hand hygiene and the barriers and difficulties in implementing the same.

Materials and Methods

Written informed consent was obtained from the participants. The data collection was carried out using convenience sampling method for recruitment. Medical undergraduate students who were currently doing their internship in a tertiary care hospital were recruited for the study and interviews were conducted with eleven students during the month of April to June 2022. An interview guide in a structured format was used (Table 1) and venue was fixed prior. Assurance was given regarding anonymity of the data collected from the participants and an interview guide in a structured format was used; however the duration was not fixed. Permission was obtained from the Institutional Ethical Committee before conducting the study and the whole interview was audio recorded after obtaining consent from the participants and fully transcribed.

Statistical data analysis

The audio recording was fully transcribed and was classified into codes, which were then categorized under different categories and then into different themes, after consensus of all the researchers by using Atlas Ti software.

Results

In the present study, interview was conducted for eleven participants, out of which six were males and five were females (Figure 1). The mean age was 23.7±1.08 years. Interviews were conducted for an average of 15 minutes (range: 11–17 min).

Motivation for hand hygiene practices Majority of the participants felt the personal safety, the safety of their loved ones and safety of the patient as the main motivation for hand hygiene. [“Everyone of us …like doctors other health workers… family members, patients will be safe if we follow ….good hand hygiene.”]

Factors influencing hand hygiene behaviour (Figure 2)

[“ The hygiene aspects for example… in any ward….are under the control of nurses ..nursing department… so we can follow it properly…”]

[“I feel patients… feel…. safe seeing us follow proper hand hygiene …”]

The negative influence reported was some careless attitude of junior staff.

Reasons for non-compliance (Figure 3)

[“Like in 2019, before…. the pandemic….we did not follow …any strict hand hygiene ….so accepting ….and following it immediately is like little difficult…”]

[“High patient load …so much of rush…overcrowding… so we will not have time…we are likely to forget it.”]

[“Using like sanitiser, handwash again and again… can kill normal flora of skin…that can cause fungal infections…it will also cause dryness, soreness of skin…”]

[“The handwashing facilities and hand sanitiser.… is like kept in inconvenient places…price was also very high during the first and second wave times…”]

Adjusting to the “new normal” - COVID pandemic

[“Initially only in like…operation theatres…strict handwashing ..using of hand rub…was practiced….”]  

[“Before the COVID-19 pandemic, hand hygiene practices were not followed ..but now it is done..…but now it is done ... ”].

[“ Actually this COVID pandemic has given us a lesson…”]

Information education communication and supervision

The respondents suggested few improvements like practical demonstration and a role model person in wards which can further improve the compliance along with hospital feedback from patients, media contributions and reminders for hand hygiene.

[“For example, in any big shopping malls, metro….. when you enter security asks you to wash hands and enter …but in hospital I feel it is …not like that strict reminder….”]

Discussion

The present study results suggest that the best practices that can be adapted are role modelling, hospital protocols, reminders, supervision for increasing compliance to hand hygiene. Based on the study conducted by Feather et al., only 8.5% of study participants after patient contact had cleaned their hands. In a study conducted for assessing the hand washing behaviour among 187 undergraduate medical students pursuing their final year, it was reported that hand washing improved to 18.3% after displaying a hand wash sign.³ According to the study conducted by Kaur et al., an efficient method to teach students was the use of ultraviolet hand inspection cabinet for which students rated >90%.⁴ The main barriers that needs to be eliminated are time constraints, overload of patients, skin irritation and less availability of alcohol based hand rub in appropriate places. The dryness and irritation can be prevented by moisturising cream.⁵ Compliance to hand hygiene has increased in post-pandemic period when compared to pre-pandemic period.

Limitations

This study can be interpreted keeping in mind the following limitations. This study was conducted in a single tertiary care hospital. Participants were not recruited by systematic sampling method, so there may be a selection bias and thus the results cannot be generalized to the whole population.

Conclusion

As per the results obtained in the study, the hand hygiene compliance has increased compared to pre-pandemic period. The positive influences for hand hygiene compliance were staff nurses being role models emphasizing the importance, role of academic physicians, reminders, posters etc. The negative influences were time constraint, increased patient workload, unavailability or inconvenient placement of hand sanitizers and handwashing facilities.

Conflicts of Interest

None