Knowledge of hand hygiene and use of alcohol-based hand rub among interns in a Nigerian Tertiary Health Facility

Ifeoma J Ogugua; Kingsley I Achigbu; Denning M Chukwumam; Chioma A Ejim; Eunice O Enabulele; Chioma F Friday-Edeh; Hope O Nwoga; Ernest O Nwazor; Johnson S Mafuka; Somtochukwu R Akunne

doi:10.4103/ijmh.IJMH_67_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 28 | Issue : 2 | Page : 127-133

Knowledge of hand hygiene and use of alcohol-based hand rub among interns in a Nigerian Tertiary Health Facility

Ifeoma J Ogugua¹, Kingsley I Achigbu², Denning M Chukwumam³, Chioma A Ejim⁴, Eunice O Enabulele⁴, Chioma F Friday-Edeh⁴, Hope O Nwoga⁵, Ernest O Nwazor⁶, Johnson S Mafuka⁶, Somtochukwu R Akunne⁷
¹ Department of Community Medicine, Federal Medical Centre, Owerri, Imo State, Nigeria
² Department of Paediatrics, Federal Medical Centre, Owerri, Imo State, Nigeria
³ Department of Orthopaedic Surgery, Federal Medical Centre, Owerri, Imo State, Nigeria
⁴ Department of Community Medicine, University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu, Nigeria
⁵ Department of Community Medicine, Enugu State University Teaching Hospital, Enugu, Nigeria
⁶ Department of Internal Medicine, Federal Medical Centre, Owerri, Imo State, Nigeria
⁷ Department of Paediatrics, Lagos University Teaching Hospital, Lagos, Nigeria

Date of Submission	21-Oct-2022
Date of Decision	20-Nov-2022
Date of Acceptance	24-Jan-2023
Date of Web Publication	21-Mar-2023

Correspondence Address:
Ifeoma J Ogugua
Department of Community Medicine, Federal Medical Centre, Owerri, Imo State
Nigeria

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmh.IJMH_67_22

Abstract

Background: Healthcare-associated infections and antimicrobial resistance are both largely prevented through hand hygiene. There are still gaps in hand hygiene knowledge and routine use of alcohol-based hand rub among healthcare workers. Objectives: This study assessed the knowledge of hand hygiene and the use of alcohol-based hand rub among interns at the University of Nigeria Teaching Hospital, Enugu State, Nigeria. Materials and Methods: A cross-sectional study was conducted among 230 interns using a structured WHO hand hygiene knowledge questionnaire. A two-stage sampling technique was employed. Descriptive and inferential statistics were carried out and p-value was set at ≤ 0.05. Results: Two respondents (0.9%) had good knowledge of hand hygiene while slightly more than half (117/230, 50.9%) had moderate knowledge. Also 50.9% (n = 117) used alcohol-based hand rub. Majority of the respondents, 140 (60.9%) had attended training in hand hygiene. Sex was significantly associated with the knowledge of hand hygiene (p=0.03) as male respondents had a higher proportion of good knowledge while having received training on hand hygiene was significantly associated with routine use of hand hygiene (p=0.004). Conclusions: Since only very few of the interns had overall good knowledge of hand hygiene, targeted structured training on hand hygiene and infection prevention and control practices to improve the knowledge of such healthcare workers is highly recommended.

Keywords: Alcohol-based hand rub, hand hygiene, interns, knowledge

How to cite this article:
Ogugua IJ, Achigbu KI, Chukwumam DM, Ejim CA, Enabulele EO, Friday-Edeh CF, Nwoga HO, Nwazor EO, Mafuka JS, Akunne SR. Knowledge of hand hygiene and use of alcohol-based hand rub among interns in a Nigerian Tertiary Health Facility. Int J Med Health Dev 2023;28:127-33

How to cite this URL:
Ogugua IJ, Achigbu KI, Chukwumam DM, Ejim CA, Enabulele EO, Friday-Edeh CF, Nwoga HO, Nwazor EO, Mafuka JS, Akunne SR. Knowledge of hand hygiene and use of alcohol-based hand rub among interns in a Nigerian Tertiary Health Facility. Int J Med Health Dev [serial online] 2023 [cited 2023 May 28];28:127-33. Available from: https://www.ijmhdev.com/text.asp?2023/28/2/127/372156

Introduction

Nosocomial infections also referred to as healthcare-associated infections (HAI), are infections that were not present at the time of admission but were acquired during the process of receiving health care and those that affect employees due to occupational exposure.^[1] Healthcare-associated infections and antimicrobial resistance (AMR) are both largely prevented through hand hygiene (HH).^[2] Hand hygiene can be defined as any action of hygienic hand antisepsis to reduce transient microbial flora. HH is generally performed by hand-rubbing with an alcohol-based formulation or handwashing with plain or antimicrobial soap and water.^[3] HH is also an important measure for preventing the spread of infectious diseases, including diarrhoeal diseases and respiratory illnesses, such as coronavirus disease 2019 (COVID-19).^[4] Studies done in Nigeria have shown the prevalence of HAI to be between the 2.6%-14.3%.^[5],[6],[7]

HAI has been documented to result in prolonged hospital stay, disability, increased resistance to antimicrobials, increased cost for patients, and their families, higher rate of mortality, and increased financial burden on the healthcare system.^[1],[2] Defective hand cleansing (e.g. use of an insufficient amount of hand hygiene product and/or insufficient duration of hand hygiene action) leads to poor hand decontamination.^[2] Therefore, a microbial transfer is likely to occur when healthcare workers fail to clean their hands during the sequence of care of a single patient and/or between patients’ contact. Hence, there is the likelihood of developing a HAI from a healthcare worker (HCW) who has increased levels of hand contamination, especially in facilities that do not adhere to hand hygiene best practices.^[2] The World Health Organization (WHO) guidelines recommend that hand hygiene be maintained through the use of alcohol-based hand rub (ABHR), except when the hands are visibly soiled or dirty, because the ABHR is much faster and more effective, and skin can tolerate it better than hand washing.^[2] Also, by improving hand hygiene, the infection prevention and control systems in the fight against Ebola Virus Disease (EVD) and other viral haemorrhagic fevers are strengthened.^[8] A study done in Southeast Nigeria noted that the introduction of an ABHR was an important factor, which might have significantly contributed to the high rate of HH compliance as it relates to WHO’s 5 moments for hand hygiene.^[9] Therefore, to achieve acceptable standards of hand hygiene compliance, the provision and promotion of the proper use of hand decontamination agents such as ABHR should be encouraged.^[10] Performing hand hygiene is simple, and encouraging healthcare facilities to adopt the “My 5 Moments for Hand Hygiene” approach, will significantly raise awareness and understanding of the importance of hand hygiene.^[2]

There are still gaps in the knowledge regarding HH among HCWs,^[11] and the lack of knowledge of guidelines for hand hygiene, lack of recognition of hand hygiene opportunities during patient care, and lack of awareness of the risk of cross-transmission of pathogens were documented as barriers to good hand hygiene practices.^[12],[13] In Nigeria, postgraduates in the field of Medical, dental, and health sciences undergo a compulsory 1-year internship programme/training in approved healthcare facilities where they are meant to learn and gain clinical skills and expertise in their respective fields. This one-year period serves as initial close contact with the patients for most of them and so the knowledge and practice of HH are paramount to enable them to know the necessary precautions to prevent themselves from getting infected and infecting their patients.

Therefore, this study assessed hand hygiene knowledge and use of ABHR and identified predictors of HH knowledge and ABHR use among interns in a tertiary health facility. Findings from this study might assist the hospital management in implementing appropriate measures for improved knowledge and practice of HH among interns.

Materials and Methods

Study setting

The study was conducted at the University of Nigeria Teaching Hospital (UNTH) Ituku/Ozalla, Enugu State, Nigeria. Enugu State is located in the South-East geopolitical zone of Nigeria and has 17 Local Government Areas (LGAs) with Enugu Metropolitan city as the capital. UNTH Ituku/Ozalla is one of the public tertiary health facilities in Enugu state that offers internship programmes in all the medical and allied medical fields.

Study design and population

This was a hospital-based cross-sectional study of 230 selected healthcare workers that were employed for internship training at the tertiary healthcare facility.

Sample size technique

The minimum sample size required for the study was determined using the formula for descriptive cross-sectional study (n = z²p (1-p)/d²).^[14] Where n is the minimum sample size, z, is the standard normal deviate corresponding to a confidence interval of 95%, d is the margin of error at a 95% confidence interval (5%), and p, is the proportion of healthcare workers with good knowledge of HH in a tertiary healthcare facility in Southwest Nigeria (83%).^[15] After adjusting for 10% non-response, the minimum sample size (respondents) was 237.

Sampling technique

A two-stage sampling technique was used in selecting the respondents. UNTH was conveniently selected out of the two public tertiary healthcare facilities that offer internship training in Enugu. Three out of the six departments that offer internship training in UNTH were selected by simple random sampling using the balloting method. Proportionate allocation to size was used to determine the number of interns to be recruited from each of the selected departments (the number of interns in each of the selected departments was gotten from the personnel unit of the hospital). Then, respondents who gave consent were recruited consecutively until the sample size was achieved.

Data collection

Data were collected between February and March 2019 using a self-administered semi-structured questionnaire. The questionnaire was based on the WHO “Knowledge Questionnaire for Health Care Workers.”^[16] and it contained questions on the participant’s age, gender, profession, formal training in HH, and 25 multiple choices “yes” or “no” questions to assess HH knowledge. For HH knowledge scoring, each correct answer was scored “1” while each wrong answer was scored “zero”. Overall scores were expressed in percentage and categorized using Bloom’s cut-off point into good (80–100% score), moderate (60–79%), and poor if the score was less than 60%

For the practice of HH, a single item “yes” or “no” question was used to assess the proportion of HCWs that use ABHR routinely during work. The research assistants were trained for two days on the objectives of the study, data collection tool, and ethical issues. The principal investigator checked the collected data for completeness, accuracy, and clarity.

Data analysis

Data were analyzed using the IBM Statistical Package for Social Sciences (SPSS) version 23. Quantitative variables were summarized using means and standard deviation while categorical variables were summarized using frequencies and percentages. The Chi-square test of independent association was used to test for a relationship between categorical variables. \The level of significance was set at p ≤0.05.

Ethical consideration

Ethical approval was obtained from the Health Research and Ethics Committee of the University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu State, Nigeria (application reference no: NHREC/05/01/2008B-FWA00002458-IRB00002323). Written informed consent was obtained from all the respondents. Confidentiality and voluntary participation were assured.

Results

Socio-demographic characteristics of respondents

A total of 237 questionnaires were distributed however, 230 completed questionnaires were returned yielding a response rate of 97%. The majority of the respondents were aged less than 30 years and their mean age (±standard deviation) was 26.91 (± 3.3 years). The majority of the respondents 153 (66.5%) were female, and regarding their profession, a higher proportion, 100 (43.5%) were medical interns [Table 1].

Table 1: Socio-demographic characteristics of interns in UNTH Enugu Nigeria, 2019

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Respondent’s knowledge of hand hygiene

More than half of the interns 123 (53.5%) knew that contaminated hands were the main route of cross-transmission between patients in a healthcare facility while only 63 (27.4%) knew that germs were already present on or within the patient were the most frequent source of germs responsible for healthcare-associated infections. The majority of the respondents 183 (79.6%), and 176 (76.5%) answered correctly that HH actions before touching a patient and before a clean/aseptic procedure respectively prevent transmission of germs to the patient. On the other hand, the majority 198 (86.1%) of interns knew that HH action immediately after the risk of body fluid exposure prevents transmission of germs to the healthcare worker while only 63 (27.4%) knew that HH action after exposure to a patient’s immediate surroundings prevents germs transmission to the HCW. Only 67 (29.1) respondents knew that 20 seconds was the minimum time needed for an alcohol-based hand rub to kill most germs on the hands.

Overall, only 2 (0.9%) of the respondents had a good knowledge of HH, half 115 (50.0%) had moderate knowledge and 113 (49.1%) of the respondents had poor knowledge [Table 2].

Table 2: Knowledge of hand hygiene among interns in UNTH, Enugu Nigeria, 2019 (n=230)

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Association between socio-demographic variables and hand hygiene knowledge among the respondents

In bivariate analysis, there was a significant association between sex and overall knowledge of HH (p=0.03). Male respondents had a higher proportion of good and moderate knowledge than female respondents [Table 3].

Table 3: Factors associated with knowledge of hand hygiene among interns in UNTH, Enugu Nigeria, 2019

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Factors associated with routine use of ABHR among the respondents

Having received training on hand hygiene was significantly associated with the routine use of hand hygiene (p=0.004) [Table 4].

Table 4: Factors associated with use of ABHR among interns in UNTH, Enugu Nigeria 2019

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Considering the use of alcohol hand-based rub, half of the respondents 117 (50.9%) used ABHR routinely at work while 113 (49.1%) do not use it routinely [Figure 1].

Figure 1: Proportion of respondents who use ABHR routinely at work

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Majority of the respondents 140 (60.9%) had received formal training on hand hygiene [Figure 2].

Figure 2: Proportion of respondents who received formal training in hand hygiene

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Discussion

Gaps in knowledge and practice of hand hygiene among HCWs can affect the implementation of infection prevention and control practices in the hospital setting and its attendant consequences. In this study, we assessed hand hygiene knowledge, use of ABHR, and the associated factors among interns in a Nigeria tertiary healthcare facility. The present study revealed gaps in the knowledge regarding HH among the early career HCWS as only a few of the respondents had overall good HH knowledge. Our finding, though lower was somewhat comparable to findings from similar studies done in Northcentral Nigeria and Ghana where only 16% and 19.3% respectively had good knowledge of hand hygiene.^[17],[18] However, findings from studies done in different regions in Nigeria, Southeast (80.3%),^[19] Southwest 83%,^[15] 98.95%,^[20] and Northern Nigeria 91.7%^[21] were disproportionately higher than our finding. The high proportion of good knowledge of HH noted in some of these studies might be due to the training of HCWs in school and the public campaign on hand hygiene in the country as a result of the current Ebola virus disease and recurrent epidemics of viral heamorrhagic fever disease.^[20] Though the HH sensitization was done across the country, the lower level of knowledge reported in our study might be due to nonchalant attitudes by the respondents.

The differences could also be because the respondents in the other studies were fully employed healthcare workers and therefore the longer duration of work experience could have exposed them to opportunities to attend various seminars and training on infection control.^[15] This was unlike the respondents in our study who were fresh graduates from different training centres in the country and so might have gained little or no knowledge on HH. As a high knowledge score has been linked with good practice of hand hygiene,^[22] thus, the low level of HH knowledge in our study is a cause for concern as it might affect the HH practice of the interns and could lead to a higher incidence of nosocomial infection for the HCWs and their patients. In this study, only sex was significantly associated with the knowledge of HH among the respondents. Male respondents had a higher proportion of good and moderate knowledge of HH than female respondents. This is in contrast with a study conducted in Saudi Arabia which revealed that female healthcare workers have comparatively better knowledge of hand hygiene than male healthcare workers.^[23] This might be because in our study a higher proportion of male respondents had received training on HH compared to the female respondents.

Similar to a study done in Ghana, no association was found between having received formal HH training and the respondents’ knowledge of HH.^[24] This could reflect the quality of the training received by the respondents or the training received was not practiced. There is therefore the need for regular training and retraining which might help improve their knowledge.

Concerning HH practice, our study revealed that half of the respondents used ABHR routinely. This was lower than what was obtained in studies done in Southwest Nigeria where 62.7% of the HCWs used ABHR routinely for HH.^[20] The variation might be due to the high knowledge of HH noted in the other study unlike in our current study. Another study conducted in Southeast Nigeria found that the majority (67.5%) of the HCWs practice HH by hand rubbing using sanitizers as opposed to hand washing.^[9] Therefore, in developing countries such as ours, to promote patient safety, the timely provision and promotion of ABHR in hospitals can help prevent and reduce the number of HAIs and transmission of infection from patients to HCWs as running water is not always available.^[20],[25]

Our study also revealed that having received formal training on HH was significantly associated with the use ABHR. Studies conducted in Ethiopia and Saudi Arabia also noted that receiving formal HH training was a predictor of good HH practices among HCWs.^[23],[26] Therefore, the importance of regular training on HH should be encouraged as it will build the capacity HCWs on HH practice and compliance. The use of the WHO multi-dimensional strategy for training has been suggested as an effective way to improve HH compliance among HCWs.^[27] It comprises; access to HH products, training/education based on the “My 5 Moments for Hand Hygiene” approach, the correct procedures for hand rubbing and handwashing, evaluation and feedback, providing reminders in the workplace and institutional safety climate by active participation at both the institution and individual levels.^[28] Therefore, this should be adopted and implemented by all health institutions.

Study limitations

The study was conducted in one state in Nigeria, therefore, the findings are not representative of the entire interns in Nigeria. Also, since it is a cross-sectional study, it will be difficult to establish a true cause and effect relationship.

Conclusion

This study highlights a gap in overall knowledge of hand hygiene among interns. Therefore, targeted structured training programmes on hand hygiene and infection prevention and control practices to improve the knowledge of such healthcare workers are highly recommended.

Ethical consideration

Ethical approval was obtained from the Health Research and Ethics Committee of the University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu State, Nigeria. Written informed consent was obtained from all the respondents. Confidentiality and voluntary participation were ensured.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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