Abstract
Background
Healthcare-associated infections caused by poor hand hygiene (HH) practices can affect both the care seekers and the health care providers (HCPs) while providing primary health care. No study has been conducted on the compliance of HH practices among the primary level HCPs in Bangladesh.
Objective
The study aimed to assess the compliance rates of HH and its determinant factors among Community Health Care Providers (CHCPs) in Community Clinics (CC).
Methods
A cross-sectional study was conducted from September 2019 to February 2020 among 150 randomly selected CHCPs with functional HH facilities in Patuakhali district, Bangladesh. Structured interviews and observation tools were used to collect data.
Results
Good HH compliance among CHCPs was found to be 16.7% (95% CI: 11.3–21.3). Out of all 1218 possible HH opportunities, only 255 (20.9%) resulted in any HH action. Presence of 70% alcohol-based hand sanitiser at the point of care (aOR: 6.4, 95% CI: 1.1–38.3), HH training (aOR: 4.6, 95% CI: 1.1–18.9), displayed visual cues (aOR: 4.4, 95% CI: 1.1–17.7), knowledge about HH (aOR: 3.8, 95% CI: 1.1–13.6) and number of HH opportunities (aOR: 0.6, 95% CI: 0.4–0.8) were factors associated with HH compliance.
Discussion
Overall HH compliance among CHCPs was relatively low. It was recommended to implement multimodal HH improvement strategies, including a continuous training program, supply of alcohol-based hand rub, reminder, provision of five moments of HH in the training modules and feedback on HH performance.
Keywords: Hand hygiene, Community Health Care Provider, primary health care providers, Community Clinic, Bangladesh
Introduction
Healthcare-associated infections (HCAIs) refer to ‘an infection acquired by patients as a result of health procedures carried out and which can also affect the health of professionals during their practice’ (WHO, 2009). Every year, HCAIs affect millions of patients globally, and the prevalence of overall HCAIs ranged from 8.5 to 15.5 per 100 patients. Furthermore, low and middle-income countries (LMICs) have a three times higher prevalence of HCAIs than developed countries (Allegranzi et al., 2011). The estimated prevalence of HCAIs is 25 percent among patients and 27 percent among healthcare providers (HCPs) in Bangladesh (icddr, b, 2011).
The HCPs are the most common means of transmission of HCAIs in health facility settings. Around 50 percent of HCAIs are caused by the hands of HCPs (Martín-Madrazo et al., 2009). Thus, hand hygiene (HH) is believed to be the best cost-efficient and empirical measure to prevent the spread of HCAIs from tertiary healthcare facilities to primary healthcare centres (Garner and Favero, 1986; Kelcíkova et al., 2012). However, HCPs around the globe have low compliance with HH, and the average adherence to HH was 38.7 percent of the opportunities (WHO, 2009). In Bangladesh, HCPs in hospital settings are less likely to wash their hands before and after patient handling. In Bangladesh, HCPs and family caregivers comply with HH in only 9 percent and 3 percent of the opportunities, respectively, indicating poor compliance with HH practices among HCPs (Horng et al., 2016).
There is limited research that has been done on HH practices among HCPs, especially in LMICs (Makeham et al., 2008; WHO, 2012). However, the existing studies suggest that lack of HH knowledge, training on HH and scarcity of evidence about the impact of HH on the spread of HCAIs rates were considered potential factors influencing adherence to HH practices (Engdaw et al., 2019; Weeks, 1999). It was also evident that increasing the number of accessible handwashing points does not improve HH compliance among HCPs (Whitby and McLaws, 2004). One of the other reasons could be the variation of HH behaviour among HCPs within the same unit or institution (Pittet et al., 1999; Whitby and McLaws, 2004). Therefore, it is assumed that personal features might play a significant role in regulating HH behaviour. World Health Organization (WHO) considered this cognitive determinant of HH behaviour as one of the unsolved issues for research to promote HH in health care settings and suggested that researchers, scientists and clinical investigators should address it (WHO, 2009).
Community clinics (CCs) were initiated by the Ministry of Health and Family Welfare in Bangladesh (MoHFW) to bring primary healthcare to the community doorstep. Each CC is staffed with a Community Health Care Provider (CHCP) to deliver primary health cares, including management of fever, infectious diseases, minor injuries, asthma, conditions with eye and teeth, vaccination, antenatal and post-natal care, child delivery and essential neonatal cares (MoHFW, 2016). HCAIs can affect both the care seekers and the health of professionals during the procedure of this primary healthcare (WHO, 2012).
HH has been acknowledged as an essential measure to prevent and control infectious diseases in primary healthcare settings (WHO, 2012). In Bangladesh, various studies have reported HH practices among HCPs in secondary and tertiary healthcare facilities (Ara et al., 2019; Horng et al., 2016), but no study has examined HH practices’ compliance among HCPs in primary healthcare facilities. Such a detailed understanding of HH practice and its behavioural drivers among CHCPs is essential for developing water, sanitation and hygiene (WASH) interventions in CCs to reduce the risk of HCAI. Therefore, the study aimed to assess the compliance rates of HH and its determinant factors among CHCPs in CCs.
Methods
Study design, study area, and participant
A cross-sectional study was conducted from September 2019 to February 2020 among CHCPs in CCs. The study was carried out in the Patuakhali district, which is located in the coastal region of Bangladesh. Inclusion criteria: All the CHCPs who had functional HH facilities (having both soap and water or 70 percent alcohol-based hand sanitiser) in their CCs were included in this study. Exclusion criteria: We excluded CHCPs who were not available in their CCs and did not give consent for observation at the time of data collection.
Sampling
According to the MoHFW facility registry database (MoHFW, 2019), Patuakhali district has a total of 215 numbers of CCs. The sample size was calculated using the EPI INFO stat calc tool by single population proportion formula assuming the population size 215, 50 percent proportion value (since there is no previous study), and 5 percent marginal error, a standard Z score of 1.96 corresponding to 95 percent confidence interval (CI), and 5 percent of nonresponse rate. The required sample size was calculated as 146. However, 150 CHCPs participated in this study.
Data collection tools
First, we conducted an environmental scan of the CC and observed the availability and type of handwashing settings, presence of water and soap, 70% alcohol-based hand sanitiser, visual cues and visibility of HH point from the point of care. Each CHCP was observed for about 2 h (average) to collect data about compliance to HH. One CHCP was observed in a single round of observation. Participants were informed that the primary objective was to observe their daily practices and healthcare-related activities in CC settings. Events of HH opportunities and whether or not CHCPs washed their hands with soap at those opportunities were recorded in an observation checklist. Events of HH opportunities included WHO recommended ‘my five moments for HH’: before touching a patient (moment-1), before a clean/aseptic procedure (moment-2), after body fluid exposure risk (moment-3), after touching a patient (moment-4) and after touching a patients’ surroundings (moment-5) (WHO, 2009).
After each observation session, we interviewed the same participant using a Bengali version of a structured questionnaire adapted from different literature (Abdella et al., 2014; Engdaw et al., 2019). Questions relating to socio-demographic (gender, age, religion, marital status and year of experience), HH knowledge (five moments of HH), attitude (positive and negative), WASH funding, institutional promotion for HH, HH practice all time and HH training were included in the questionnaire.
Informed consent was obtained from the participants before the data collection. Two days of training was given to the data collectors on the data collection methods, tools, ethics and how to interact with respondents. The data collectors were graduate students in environmental sanitation.
Operational definitions
Good HH compliance
CHCPs scored equal to or above 50 percent of the observational checklists (Abdella et al., 2014).
Poor hand hygiene compliance
CHCPs scored less than 50 percent of the observational checklists (Abdella et al., 2014).
Good HH knowledge
CHCPs who scored equal to or above 50 percent of the knowledge questions regarding WHO recommended six steps and five moments of HH (WHO, 2009).
Poor HH knowledge
CHCPs who scored less than 50 percent of the knowledge questions regarding WHO recommended six steps and five moments of HH (WHO, 2009).
Data analysis
The obtained data were rechecked for completeness and consistency. Data were analysed in IBM SPSS Windows version 24. Descriptive statistics were carried out for the socio-demographic characteristics and availability of HH facilities. Bivariate and multivariate logistic regressions were performed by computing Crude Odds Ratio (OR), and adjusted Odds Ratio (aOR) with 95% CI to evaluate significantly associated variables with HH compliance by backward logistic regression variable selection method. All the covariates from Tables 1 and 2 were included in the primary model to run backward logistic regression. p-value of ≤.05 was considered statistically significant.
Table 1.
Socio-demographic characteristics of the CHCPs in CCs, Patuakhali Bangladesh, 2020 (n = 150).
| Variable | Frequency | % (95% CI) | |
|---|---|---|---|
| Gender | Male | 93 | 62.0 (54.7–70.1) |
| Female | 57 | 38.0 (29.9–45.3) | |
| Age | 25–29 year | 36 | 24.0 (17.7–30.7) |
| 30–34 year | 64 | 42.7 (34.7–50.0) | |
| ≥35 year | 50 | 33.3 (24.7–40.9) | |
| Religion | Muslim | 122 | 81.3 (75.2–88.0) |
| Hindu | 23 | 15.3 (9.2–20.7) | |
| Christian | 5 | 3.3 (0.0–6.1) | |
| Marital status | Single | 25 | 16.7 (11.3–22.0) |
| Married | 125 | 83.3 (78.0–88.7) | |
| Experience as health care worker | 0–4 year | 1 | 0.7 (0.0–2.0) |
| 5–9 year | 133 | 88.7 (83.2–92.8) | |
| 10–14 year | 16 | 10.7 (6.5–16.7) | |
CI: Confidence Interval.
Table 2.
Variables related to HH compliance of CHCPs in CCs, Patuakhali Bangladesh (n = 150).
| Total sample | Good HH compliance | Poor HH compliance | |||||
|---|---|---|---|---|---|---|---|
| Variables | Frequency | % (95% CI) | Frequency | % (95% CI) | Frequency | % (95% CI) | |
| Type of handwashing settings a | Tubewell | 95 | 63.3 (56.7–70.7) | 20 | 21.1 (13.5–29.5) | 75 | 78.9 (70.5–86.5) |
| Sink | 41 | 27.3 (21.7–34.7) | 4 | 9.8 (2.4–22.0) | 37 | 90.2 (78.0–97.6) | |
| Bucket | 14 | 9.3 (4.5–14.8) | 1 | 7.1 (0.0–22.9) | 13 | 92.9 (77.1–100) | |
| Availability of water and soap | Yes | 64 | 42.7 (33.7–50.7) | 20 | 31.3 (21.9–42.5) | 44 | 68.8 (57.5–78.1) |
| No | 86 | 57.3 (49.3–66.3) | 5 | 5.8 (0.9–11.6) | 81 | 94.2 (88.4–99.1) | |
| Presence of 70% alcohol-based hand sanitiser a | Yes | 54 | 36.0 (29.9–43.5) | 20 | 37.0 (22.2–48.5) | 34 | 63.0 (51.5–77.8) |
| No | 96 | 64.0 (56.5–70.1) | 5 | 5.2 (1.0–9.6) | 91 | 94.8 (90.4–99.0) | |
| Displayed visual cues a | Yes | 33 | 22.0 (16.0–28.1) | 16 | 48.5 (32.1–64.3) | 17 | 51.5 (35.7–67.9) |
| No | 117 | 78.0 (71.9–84.0) | 9 | 7.7 (4.3–12.8) | 108 | 92.3 (87.2–95.7) | |
| Promotion for HH by the institution | Yes | 46 | 30.7 (23.3–38.0) | 13 | 28.3 (17.4–41.7) | 33 | 71.7 (58.3–82.6) |
| No | 104 | 69.3 (62.0–76.7) | 12 | 11.5 (6.5–19.2) | 92 | 88.5 (80.8–93.5) | |
| Received training on HH | Yes | 57 | 38.0 (30.7–45.6) | 15 | 26.3 (15.4–38.6) | 42 | 73.7 (61.4–84.6) |
| No | 93 | 62.0 (54.4–69.3) | 10 | 10.8 (4.3–17.4) | 83 | 89.2 (82.6–95.7) | |
| Attitude towards HH | Positive | 54 | 36.0 (29.2–42.9) | 16 | 29.6 (18.1–42.6) | 38 | 70.4 (57.4–81.9) |
| Negative | 96 | 64.0 (57.1–70.8) | 9 | 9.4 (4.0–15.8) | 87 | 90.6 (84.2–96.0) | |
| Handwashing point is visible from the point of care a | Yes | 60 | 40.0 (32.7–47.3) | 18 | 30.0 (17.7–41.7) | 42 | 70.0 (58.3–82.3) |
| No | 90 | 60.0 (52.7–67.3) | 7 | 7.8 (3.3–13.3) | 83 | 92.2 (86.7–96.7) | |
| Knowledge about HH | Yes | 79 | 52.7 (44.4–61.5) | 19 | 24.1 (13.9–35.4) | 60 | 75.9 (64.6–86.1) |
| No | 71 | 47.3 (38.5–55.6) | 6 | 8.5 (2.8–15.5) | 65 | 91.5 (84.5–97.2) | |
| Frequently keep hand hygiene | Yes | 116 | 77.3 (69.3–83.5) | 25 | 21.6 (13.6–29.3) | 91 | 78.4 (70.7–86.4) |
| No | 34 | 22.7 (16.5–30.7) | 0 | 0 | 34 | 100 (100–100) | |
| Receive enough fund for HH facilities | Yes | 46 | 30.7 (23.3–37.3) | 16 | 34.8 (19.6–50.4) | 30 | 65.2 (49.6–80.4) |
| No | 104 | 69.3 (62.7–76.7) | 9 | 8.7 (3.8–15.4) | 95 | 91.3 (84.6–96.2) | |
| Number of HH moments appeared a (mean ± SD) | 8.1 ± 2.6 | 6.7 ± 1.7 | 8.4 ± 2.6 | ||||
| HH moments turned into practice a (mean ± SD) | 1.7 ± 1.6 | 3.8 ± 1.0 | 1.3 ± 1.4 | ||||
aData were obtained by observational method.
SD: Standard Deviation.
Results
Socio-demographic characteristics of study participants
Of the 150 participants, 93 (62.0%) were male and 57 (38%) were female. The majority (n = 64, 42.7%) of the study participants were aged between 30 and 34 years. Participants’ mean year (±SD) of experience as an HCP was 8.3 ± 1.3 (Table 1).
Compliance with hand hygiene among community health care providers
Our observation suggests that only 25 (16.7%) (95% confidence interval [CI]: 11.3–21.3) CHCPs showed good compliance to HH. A total of 1218 HH opportunities appeared, while only 255 (20.9%) resulted in any HH action. Among all the moments that turned into HH practice, compliance rates were found higher at moment-3: after body fluid exposure risk (n = 117, 45.9%) and moment-4: after touching a patient (n = 68, 26.7%) (Figure 1).
Figure 1.
Moment when CHCPs were observed to comply with hand hygiene in Community Clinics in Patuakhali, Bangladesh (n = 150).
Of the participants, 57 (38%) CHCPs were trained on HH, and around half 79 (52.7%) of the respondents had knowledge about HH steps and moments. However, a positive attitude towards the HH was found in only 54 participants (36%). The presence of 70% alcohol-based hand sanitiser at the point of care was observed in around one-third of facilities. About 60 (40%) CCs were observed having handwashing locations from the point of care (Table 2).
Factors associated with hand hygiene compliance
Multivariate logistic regression analysis showed that the number of HH opportunities was inversely correlated with HH compliance (adjusted odds ratio [aOR]: 0.6, 95% CI: 0.4–0.8, p ≤ .01). Besides, presence of 70% alcohol-based hand sanitiser at the point of care (aOR: 6.4, 95% CI: 1.1–38.3, p ≤ .05), training on HH (aOR: 4.6, 95% CI: 1.1–18.9, p ≤ .05), displayed visual cues (aOR: 4.4, 95% CI: 1.1–17.7, p ≤ .05) and knowledge about HH (aOR: 3.8, 95% CI: 1.1–13.6, p ≤ .05) were factors associated with HH compliance (Table 3).
Table 3.
Bivariate and multivariate regression analysis of factors associated with HH compliance among CHCPs in CCs, Patuakhali Bangladesh (n = 150).
| Variables | Crude ORs (CI) | p-value | Adjusted ORs (CI) | p-value | |
|---|---|---|---|---|---|
| Displayed visual cues | Yes | 11.3 (4.3–29.6) | <.001 | 4.4 (1.1–17.7) | ≤.05 |
| No | 1 | — | 1 | — | |
| Presence of 70% alcohol-based hand sanitiser | Yes | 10.7 (3.7–30.8) | <.001 | 6.4 (1.1–38.3) | ≤.05 |
| No | 1 | — | 1 | — | |
| Promotion for HH by the institution | Yes | 3.0 (1.3–7.3) | .01 | 1.1 (0.3–4.2) | .90 |
| No | 1 | — | 1 | — | |
| Received training on HH | Yes | 3.0 (1.2–7.2) | .01 | 4.6 (1.1–18.9) | ≤.05 |
| No | 1 | — | 1 | — | |
| Attitude towards HH | Yes | 4.1 (1.7–10.0) | .002 | 1 (0.2–4.6) | .92 |
| No | 1 | — | 1 | — | |
| Handwashing point is visible | Yes | 5.1 (2.0–13.1) | .001 | 1.2 (0.2–6.3) | .83 |
| No | 1 | — | 1 | — | |
| Knowledge about HH | Yes | 3.4 (1.3–9.2) | .01 | 3.8 (1.1–13.6) | ≤.05 |
| No | 1 | — | 1 | — | |
| Number of HH moments appeared | 0.7 (0.5–.9) | .003 | 0.6 (0.4–0.8) | ≤.01 | |
OR: Odds ratio; CI: Confidence interval. The bold areas are the variables that were found significant in the analysis. It was bolded so that the reader could identify the significant variables.
Discussion
The present study demonstrates an alarming picture of compliance to HH among primary level HCPs in Bangladesh. The overall prevalence of good compliance with HH among CHCPs was only 16.7 percent (n = 25). The present study was in accordance with findings of a study carried out in primary health care settings in Ethiopia, which showed that the overall HH compliance was 14.9 percent (Engdaw et al., 2019). However, this finding was lower than studies conducted in Nigeria: 31 percent (Onyedibe et al., 2020), Kuwait: 33.4 percent (Al-Wazzan et al., 2011), India: 43.4 percent (Harbarth et al., 2001) and higher than a study conducted in Ghana: 12 percent (Owusu-Ofori et al., 2010). The variance could be because of different research sites, types of HCPs, methodology, sample size, availability of HH resources and awareness about HH.
Only 20.9 percent (255 out of 1218) of all possible HH opportunities resulted in any HH action in this study. This result is slightly above the National Hygiene Baseline Survey 2014, showing that only 9 percent of the total HH opportunities turned into HH performance among HCPs in Bangladesh (Horng et al., 2016). Contributing factors to such a poor rate of HH performance among HCPs in Bangladesh might be the inadequate refresher training on HH, minor budget for maintenance of HH infrastructures and lack of HH supplies (Horng et al., 2016; WHO, 2018).
The number of HH moments was inversely correlated with HH compliance. The present study found that HH compliance decreased by 40 percent among the CHCPs with an increase of a HH moment. This finding coherent with research conducted by Hugonnet et al. (2002) showed that a higher number of HH moments contribute to less compliance with HH among HCPs. The present study also found that HCPs who had 70% alcohol-based hand sanitiser were 6.4 times more likely to comply with HH practice than those who did not have 70% alcohol-based hand sanitiser. This result is concordant with other studies carried out in Bangladesh (Horng et al., 2016), Mali (Allegranzi et al., 2010), Taiwan (Chen et al., 2011) and Brazil (Santana et al., 2007). Workload and inaccessible handwashing resources at the point of care might be reasons for non-compliance to HH. Thus, alcohol-based hand sanitiser might make the HH practice more convenient and comfortable for the HCPs. Increasing the supply of alcohol-based hand sanitiser may lead to more compliance with HH, although HH compliance does not necessarily improve by building accessible handwashing infrastructures (Whitby and McLaws, 2004). Therefore, applying alcohol-based hand sanitiser is a reasonable alternative to resolve HH non-compliance, especially in healthcare facilities in LMICs overcrowded with patients and having limited HH resources.
The study identified that HH compliance was 4.6 times more among trained HCPs on HH than those who were not trained. It is consistent with what has been found in previous studies conducted in Bangladesh (Ara et al., 2019), Taiwan (Huang and Wu, 2008), Brazil (Santana et al., 2007) and India (Suchitra and Devi, 2007) which reported that training on HH increases HH compliance among HCPs. Research conducted in a teaching hospital in Ethiopia found a significant association with HH compliance at the baseline and follow-up period after training. It could be because HH training has a beneficial influence on developing awareness, attitudes and practices of HH compliance among HCPs. Therefore, this indicates the importance of a continuous HH training program for the CHCPs to reduce the HCAIs in CCs.
The present study also found a positive association between good compliance and HH knowledge. Those with good HH knowledge had 3.8 times more compliance with HH than those with poor HH Knowledge. This result ties nicely with previous studies in Kuwait (Al-Wazzan et al., 2011) and Ethiopia (Engdaw et al., 2019) which reported the significant relationship between HH knowledge and good compliance HH. The possible explanation might be that knowledge on HH makes HCPs more aware of the merits and demerits of HH compliance, mode of HCAIs transmission and its prevention and help HCPs comply with recommended HH practices. Perhaps, the training program may increase HH and, in turn, potentially reduce HCAIs in the CCs.
The odds of having good compliance with HH were 4.4 times higher among CHCPs who had visual HH cues than those who did not have visual HH cues displayed at their CCs. It is in line with research conducted in the Netherlands (Arntz et al., 2016) and United States (Wiles et al., 2015) which reported that HH cues increase compliance with HH. The HH visual cues act as a reminder and instruct the HCPs to maintain HH in healthcare settings. Thus it triggers compliance to HH (Nevo et al., 2010).
Our study has some definite limitations. Firstly, the causality association between the explanatory and outcome variable could not be defined due to the cross-sectional design. Secondly, we did not measure the duration of HH. Thirdly, the presence of observers may affect the participants’ performance, which might also be the case in the current study.
Conclusion
Overall HH compliance among CHCPs in CCs in Patuakhali, Bangladesh, was relatively low. Besides, the presence of 70% alcohol-based hand sanitiser at the point of care, training on HH, displayed visual cues, knowledge about HH and the number of HH opportunities were factors associated with compliance to HH among CHCPs. Based on the findings of this study, it was recommended to implement multimodal HH improvement strategies, including a continuous training program, supply of alcohol-based hand rub, reminder, provision of five moments of HH in the training modules and feedback on HH performance.
Acknowledgements
We are grateful to all the participants of this study for their time and invaluable information. We extend our gratitude to Community Based Health Care (CBHC), Ministry of Health and Family Welfare (MoHFW), Patuakhali Science and Technology University (PSTU), and WaterAid Bangladesh for their tremendous support to conduct the research work and comments to enrich the report. We want to thank Md. Fakrul Alam Hasib and Md. Rashed Imam, MS student of PSTU, for their support to obtain the data from the field. We especially thank WaterAid Bangladesh for providing financial aid to conduct the study.
Footnotes
Author contributions: Conceptualization: Md Hafizur Rahman.Methodology: Md Hafizur Rahman, Md. Nazmul Hassan, Nurullah Awal.Formal analysis and investigation: Md Hafizur Rahman, Md. Nazmul Hassan, Md Shafiqul Islam Khan, Md Hasanuzzaman.Writing - original draft preparation: Md Hafizur Rahman.Writing - review and editing: Md. Nazmul Hassan, Md Hasanuzzaman, Nurullah Awal.Funding acquisition: Nurullah Awal.Resources: Nurullah Awal.Supervision: Md. Nazmul Hassan, Md Shafiqul Islam Khan, Md Hasanuzzaman.
Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: WaterAid Bangladesh provided funding support for this study under a research fellowship grant titled “Young Researcher Fellowship-2019.”
Ethics approval: Informed consent was obtained from all participants. This study was performed as per the ethical standards outlined in the 1964 Declaration of Helsinki and its later amendments. Research Ethical Committee (REC) of the Department of Environmental Sanitation, Patuakhali Science and Technology University, Bangladesh (approval no.:16/11/2019:05) reviewed the protocol and approved this study.
ORCID iD
Md Hafizur Rahman https://orcid.org/0000-0002-2742-049X
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