A twenty-four-hour observational study of hand hygiene compliance among health-care workers in Debre Berhan referral hospital, Ethiopia
Kolola and Gezahegn Antimicrobial Resistance and Infection Control
A twenty-four-hour observational study of hand hygiene compliance among health- care workers in Debre Berhan referral hospital, Ethiopia
Tufa Kolola 0
Takele Gezahegn 0
0 Department of public health, Debre Berhan University , P.O.Box 445, Debre Berhan , Ethiopia
Background: Hand hygiene (HH) is recognized as the single most effective strategy for preventing health care-associated infections. In developing countries, data on hand hygiene compliance is available only for few health-care facilities. This study aimed to assess hand hygiene compliance among health-care workers in Debre Berhan referral hospital, Ethiopia. Methods: This study employed the WHO hand hygiene observation method. Direct observation of the health care workers (HCWs) was conducted using an observation record form in five different wards. Trained and validated observers watched HCWs while they had direct contact with patients or their surroundings, and the observers then recorded all possible hand hygiene opportunities and hand hygiene actions. Observation was conducted over a 24 h period to minimize selection bias. More than 200 opportunities per ward were observed according to WHO recommendation, except in neonatal intensive care unit. HH compliance was calculated by dividing the number of times hand hygiene was performed by the total number of opportunities for hand hygiene. A 95% confidence interval (CI) was computed for compliance with the exact binomial method. Results: A total of 917 hand hygiene opportunities were observed during the study. Overall HH compliance was 22. 0% (95% CI: 19.4-24.9). HH compliance was similar across all professional categories and did not vary by shift. Levels of compliance were lower before patient contact (2.4%; 95% CI: 0.9-5.3), before an aseptic procedure (3.6%; 95% CI: 1.6-7.6) and after contact with patient surroundings (3.3%; 95% CI: 1.2-7.9), whereas better levels of compliance were found after body fluid exposure (75.8%; 95% CI: 68.0-82.3) and after patient contact (42.8%; 95% CI: 35.2-50.7). Conclusion: HH compliance of HCWs was found to be low in Debre Berhan referral hospital. Compliance with indications that protect patients from infection was lower than that protect the HCWs. The findings of this study indicate that HH compliance needs further improvement.
Hand hygiene compliance; Direct observation method; Health-care worker; Debre Berhan; World health organization
Health care-associated infections (HAIs) are a major
threat to patient safety worldwide [
]. Such infections
spread between patients in the health-care settings by
various means, mainly via the hands of health-care
workers (HCWs) [
Hand hygiene (HH) is the single most effective
strategy for preventing HAIs [
]. Hand hygiene is
defined as either rubbing the hands with an
alcoholbased handrub or handwashing with soap and water
]. WHO has launched a multimodal hand hygiene
improvement strategy to optimize hand hygiene in
health care settings [
]. This strategy is now
recommended as the most reliable and evidence-based
method for ensuring sustainable hand hygiene
improvement around the world [
compliance with hand hygiene during routine patient
care is an integral part of this strategy. HH
compliance is measured in a variety of ways. These include:
direct observation, handrub consumption, and survey
]. Direct observation of HCWs using
WHO’s hand hygiene observation tool is currently
recognized as the gold standard for hand hygiene
monitoring in the sequence of care [
6, 10, 17
World Health Organization has endorsed “My five
moments for hand hygiene” approach, the moments
when hand hygiene is required, to effectively interrupt
the spread of HAIs [
]. This approach encourages
HCWs to clean their hands, i.e., (1) before patient
contact, (2) before an aseptic procedure, (3) after body fluid
exposure, (4) after patient contact and (5) after contact
with patient surroundings [
]. The World Health
Organization (WHO) has defined these moments as
hand hygiene opportunities (HHOs) to which HCWs
should comply with [
]. Hand hygiene opportunity
exists whenever one of the indications for hand hygiene
occurs. Each opportunity corresponds to hand hygiene
In developing countries with high burden of
healthcare-associated infections, improving HCWs
compliance with hand hygiene during routine patient care is
urgently needed for the patient safety [
the clear benefits of hand hygiene practices in
healthcare settings, compliance remains an issue in
developing countries . In Ethiopia, data on hand hygiene
compliance is available only for few health-care
]. In Debre Berhan referral hospital, HCWs
compliance to the WHO’s five moments for hand
hygiene was not investigated so far. This study aimed to
assess hand hygiene compliance among health-care
workers in Debre Berhan referral hospital through
direct observation of the WHO’s five moments. The
result of this study provides insights about hand hygiene
compliance level of health care providers.
A cross-sectional study was conducted in Debre Berhan
referral hospital using the WHO hand hygiene
observation method. Debre Berhan referral hospital is located in
North Shoa Zone of Amhara Region which is about
130 km away from Addis Ababa to Dessie. Currently,
this hospital serves as a referral centre for a population
of North Shoa Zone of Amhara region and for other
population from the neighbouring regions. The hospital
has a total of 307 HCWs: 38 physicians, 153 nurses, 26
midwives, 7 anaesthetists, 31 laboratory technicians, 2
physiotherapists, 4 dentists, 6 radiographers, 4
optometrists and 36 pharmacists. In addition, 48 medical interns
were affiliated to this hospital during data collection.
This study was conducted from May 2 to 9, 2017 in the
selected wards (Medical, Surgical, Paediatric, Obstetrics
and gynecology, and Neonatal intensive care unit) of the
hospital. All HCWs, including medical interns, having
direct contact with patients or their surroundings in the
selected wards were observed.
Data were collected using standardized WHO’s hand
hygiene observation tool for direct observation (Additional
file 1). Before conducting observation sessions, observers
were trained in accordance with the WHO’s hand
hygiene observation method [
]. Thereafter, observers
were validated by one of the authors based on Sax
et al.’s [
] recommendation. In the first case, each
observer engaged in an observation session during a patient
care situation. Each observer completed the observation
form separately while observing the same HCW and the
same care sequence. Results were then compared and
discordant notifications were discussed. This process
was repeated until concordance is reached in terms of
the number of hand hygiene opportunities and hand
hygiene actions that occurred [
In brief, three nurses directly watched 261 HCWs
having direct contact with patients or their
surroundings, and recorded all possible HHOs and HHAs.
Observation was conducted over a 24 h period in each
ward to minimize selection bias. The HCWs were
unaware of being observed to minimize “Hawthorne effect”.
Each HCW was observed for a maximum of four HHOs
during the observed care sequence. More than 200
opportunities per ward were observed according to WHO
], except in neonatal intensive care unit
(NICU). Few opportunities were observed in NICU due to
the small number of HCWs working in this unit.
Data analysis was done using Epi Info 7 and SPSS version
21. Data set underlying the findings is available within the
supplementary information files (Additional file 2).
Overall compliance was calculated by dividing the
number of times hand hygiene was performed by the
total number of opportunities for hand hygiene. We
also estimated HH compliance by professional
categories, and “my five moments for hand hygiene”. A 95%
confidence interval (CI) was computed for compliance
with the exact binomial method. Overlapping 95%
confidence intervals were interpreted as not being
Hand hygiene compliance
A total of 917 opportunities for hand hygiene were
observed during the study. The overall HH compliance was
22.0% (95% CI: 19.4–24.9). HH compliance was 20.6%
(95% CI:16.2–25.9) for doctors, 22.9% (95% CI:19.2–27.0)
for nurses, 21.2% (95% CI:13.9–30.8) for midwives, and
23.2% (95% CI: 13.4–36.7) for other HCWs. HH
compliance was slightly higher in the neonatal intensive care unit
(NICU) and paediatric ward compared to other wards.
HH compliance varied according to the five moments for
hand hygiene. Levels of compliance were lower before
patient contact (2.4%%; 95% CI: 0.9–5.3), before an aseptic
procedure (3.6%; 95% CI: 1.6–7.6) and after contact with
patient surroundings (3.3%; 95% CI: 1.2–7.9). Better levels
of compliance were found after body fluid exposure
(75.8%; 95% CI: 68.0–82.3) and after patient contact
(42.8%; 95% CI: 35.2–50.7) (Table 1).
Hand rubbing was performed in 95, (47.0%; 95% CI:
40.2–53.9), out of the 202 hand hygiene actions. Hand
rubbing was frequently performed, (55.8%; 95% CI: 45.7–
65.5), after patient contact while handwashing with soap
and water was more frequent, (76.6%; 95% CI: 67.9–83.9),
after body fluid exposure compared with other indications
Hand hygiene resources
In this study, sink to patient beds ratio was 1:4.9, and soap
was available to 36.4% of the sinks. Alcohol-based
handrub was available for 16.8% (18/107) of the patient beds.
This study captured hand hygiene compliance of HCWs
over a 24 h period. Overall hand hygiene compliance
was low (22%). HH compliance was low across all
professional categories and similar by shift. In line with
our study, HH compliance was found low in previous
14, 22, 24
]. In low-income and middle-income
countries, HH compliance was averaged 22·4% before
multimodal intervention [
]. Hand hygiene
compliance was much lower in the present study compared to
post- multimodal intervention studies from India (82%)
], Kuwait (61.4%) [
], and Colombia (77%) [
The possible reason for low compliance in our study
might be due to the WHO’s multimodal HH
improvement strategy which was not implemented. For
instance, HH resources were deficient at the point of
patient care. There were no visual reminders for hand
hygiene at work place. Similarly, there was lack of HH
monitoring and provision of performance feedback to
HCWs. Studies have demonstrated that
implementation of a multimodal strategy is globally accepted as
best approach to achieve HH compliance in
healthcare settings [
11, 27, 28
Hand hygiene compliance was inconsistent by the five
indications for hand hygiene which might be another
reason for low compliance. Lower levels of compliance
were witnessed for indications before patient contact,
before an aseptic procedure and after contact with
patient surroundings. By contrast, compliance with hand
hygiene was relatively higher after body fluid exposure
followed by after patient contact. This suggests that
HCWs more likely to perform HH for the indications
that protect themselves from microbial contamination
and infection rather than that protect patients.
Selfprotection tendency of HCWs has been identified in
multiple studies [
11, 25, 29–31
Hand rubbing is recommended as the gold standard
for hand hygiene according to the “my five moments
for hand hygiene” in clinical situations [
Particularly in resource-constrained settings, the use of alcohol
based hand rubs is a practical solution to overcome
constraints because they can be distributed individually
to staff for pocket carriage and placed at the point of
]. In contrary to findings from other studies
11, 12, 32
], the present study revealed that hand
rubbing was not the preferred means for hand hygiene.
One reason could be that alcohol based hand rub was
deficient at the point of care and was obstacle to
performing HH according to recommendation. Ensuring
availability of alcohol-based hand rubs at the point of
patient care is a key factor for hand hygiene
improvement in previous studies [
30, 33, 34
The strength of this study is that observation was done
over a 24 h to minimize selection bias. In addition to
this, the HCWs were unaware of being observed to
minimize “Hawthorne effect”. This study was not free of
limitations. This study solely employed direct
observation method. As a result, did not address why HH
compliance was found to be low. The cross-sectional results
of this study might not be representative of HH
compliance throughout the year. This study conducted in a
single hospital, and hence the generalizability of our results
to other settings might be limited.
This study showed that HH compliance of HCWs was
found to be low. Indications that are high risk to the
patient have lower compliance. This suggests that the
need of HH compliance improvement strategy is
evident. Implementing WHO’s multimodal strategy is
crucial to improve HH compliance of HCWs. Access to
HH resources should be emphasised as an integral part
of HH improvement strategy.
Additional file 1: Hand hygiene compliance observation form. (DOC 407 kb)
Additional file 2: Hand hygiene compliance data set. (SAV 71 kb)
CI: Confidence interval; HAI: Health-care associated infection; HCW: Health
care worker; HH: Hand hygiene; HHA: Hand hygiene action; HHO: Hand
hygiene opportunity; HR: Hand rubbing; HW: Hand washing; NICU: Neonatal
intensive care unit; OB/GYN: Obstetrics and gynecology; PSG: Patient safety
goal; WHO: World Health Organization
Availability of data and materials
All data generated or analysed during this study are included in this
manuscript and its supplementary information files.
TK: conception of the idea, study design, facilitation of data collection,
data analysis, drafting the manuscript. TG: study design, facilitation of
data collection, revising the manuscript. Both authors read and approved
the final manuscript.
Ethics approval and consent to participate
This study was approved by the Ethics Review Committee of College of
Health Sciences, Debre Berhan University. HCWs were not identified during
observation sessions for confidentiality reasons. The need for consent to
participate was waived as no data from any individual person was collected
in this study.
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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