International Journal of Science and Research (IJSR)

ISSN (Online): 2319-7064

Index Copernicus Value (2013): 6.14 | Impact Factor (2015): 6.391

A Study to Assess Hand Hygiene Knowledge and

Practices among Health Care Workers in a Teaching
Hospital in Ghana
Immanuel Amissah, BSc, MD1, Soziema Salia2, MBChB, Joshua Panyin Craymah, MSc3
1,2,3
Department of Internal Medicine & Therapeutics,University of Cape Coast School of Medical Sciences, Cape Coast, Ghana

Abstract: Background: Despite widespread evidence that proper hand hygiene practices is the simplest and most-effective intervention
to reduce transmission of hospital-acquired infections, healthcare workers adherence to proper hand hygiene practices remains poor.
This study was to 1) assess the knowledge of proper hand hygiene among health care workers according to WHO guidelines, 2) to assess
hand hygiene practices among healthcare workers at the hospital, 3)to assess any correlations between knowledge of hand hygiene and
professional type; and department of health care provider and 4) to assess factors that hinder proper hand hygiene practices. Methods:
The study was conducted at the Cape Coast Teaching Hospital from January, 2016 through April, 2016. A total of 130 healthcare
workers participated in the study. A cross-sectional survey was conducted using a self-administered questionnaire based on the hand
hygiene guidelines by the World Health Organization (WHO). Results: Majority of the respondents (51.2%) knowledge on hand hygiene
was fair.Compliance to proper hand hygiene practices was hampered by heavy patient load (33.5%), forgetfulness (23.6%), inadequate
water (21.9%),lack of clean towels (15.1%), absence of air dryer (14.0%).The techniques commonly used for hand hygiene reported were
the use of cold running water (27.3%), use of alcohol-based hand rub (22.9%). Only 18 (5.3%) used warm running water.Hand drying
technique used included: use of common towels (30.3%),use of personnel handkerchiefs (21.5%), allowing hands to dry on their own
(19.3%), use of disposable towels (10.9%).Also there was a statistically significant correlation between healthcare workers professional
status and knowledge on hand hygiene (p=0.005). Conclusion: This study showed that knowledge in hand hygiene practices was found
to be fair, with heavy patient load, forgetfulness and unavailability of water and lack of clean towels being the major contributing factors
hampering proper hand hygiene practices. Also low patronage for alcohol-based hand rubs was found. A hospital-wide awareness
program aiming at healthcare workers and adoption of alcohol-based hand rubs at the point of care can help improve compliance to
hand hygiene.

Keywords: Knowledge, hand hygiene, healthcare workers, Cape Coast, Ghana

1. Introduction
Organisms that cause nosocomial infections are
Hand hygiene has become a major issue in health care mostcommonly transmitted by the hands of healthcare
settings due to the high incidence of Health care associated workers(Kusachi et al., 2006).Hand hygiene practices may
infections (HCAIs), also known as nosocomial infections. also vary among professional groups(Rao MH,2006;Pittet et
Despite widespread evidence that hand hygiene is the al.,2004; Suchitra& Devi, 2007).However, most relevant
simplest and most cost-effective intervention to reduce studies agree that type and availability of facilities have a
transmission of hospital-acquired infections (Pittet et al., significant effect on hand hygiene ( Samuel et al.,2005;
2000; Trick et al.,2007; Girou et al., 2006; Ho et al., 2012; Boyce JM,2000).
Grayson et al., 2008; Grayson et al., 2011; Biddle et
al.,2009), physicians' adherence to hand-hygiene practices Formal written guidelines on hand hygiene practices in
remains consistently poor (Pittet et al.,2000; Danchaivijtr et hospitals have been developed by the Centers for Disease
al., 2005; Harris et al.,2000; Patarakul et al.,2005). Notable Control and Prevention (CDC) and World Health
factors for poor compliance include hand irritation(Akyol Organization (WHO). According to the World Health
AD, 2007), inaccessibility or shortage of hand-washing Organization(WHO,2005) the indications for hand hygiene
equipments, dense working conditions,(Akyol AD ,2007;Sax can be merged into five (5) moments during health care
et al.,2005; Pittet et al.,2004) and poor knowledge( delivery. Adequate knowledge and recognition of these
Danchaivijtr et al., 2005; Sax et al.,2005). moments are the pillars for effective hand hygiene.
Therefore, it is possible to prevent health care associated
Health-care associated infections continue to pose aserious infections by cross‑transmission via hands if health care
threat of increasing mortality and morbidity among providers promptly identify these moments and comply with
hospitalized patients and World Health Organization hand hygiene actions. These five moments that call for the
reportsthat at anytime, over 1.4 million people world- wide use of hand hygiene include the moment before touching a
sufferfrom infections acquired in health-care settings patient, before performing aseptic and clean procedures,
(WHO,2005).In developed countries, HCAIs have been after being at risk of exposure to body fluids, after touching
reported to affect 5%-15% of hospitalized patients and 9%- a patient, and after touching patient surroundings.
37% of those admitted to intensive care units (Vincent
JL,2003), while in developing countries where reliable data Hospital-acquired infection rates are also known to be
on HCAIs are limited, prevalence rates have been estimated highest in teaching hospitals (Samuel et al., 2005). In Ghana,
to be between 14.8% and 19.1%(Gosling et al.,2003; Faria et a cross-sectional observational study at the Komfo Anokye
al.,2007; Kallel et al.,2005; Jroundi et al.,2007). Teaching Hospital in Kumasi byOwusu-Oforiet al (2010)
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ISSN (Online): 2319-7064
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indicated that the most commonly identified barriers to hand reach doctors, while the laboratory was also visited during
hygiene by health workers were limited resources and lack the morning, afternoon and evening shift. Potential
of knowledge on appropriate times to perform hand washing respondents were given questionnaires to be returned
or rubbing. A study conducted in 2009, at the Neonatal through a designated colleague.
Intensive Care Unit (NICU) of the Department of Child
Health in the Korle-Bu Teaching Hospital, Ghana by Asare Data collection
et al(2009) indicated that hand hygiene compliance of A structured,self-administered questionnaire with both open-
physicians and nurses in that unit was low.Another study in ended and close-ended questions were used to collect data.
Ghana by Yawson and Hesse (2013) showed that care- The questionnaire had three sections: section one wason the
related hand hygiene (HH) compliance of doctors and nurses personal data and work history of each participant; section
was low and basic HH resources were deficient in all 15 two assess the knowledge of participants on hand hygiene;
service centres that were studied. In that sttdy, care-related and section three assess the hand hygiene practices among
HH compliance among doctors ranged from 9.2% to 57% participants and the facilities available for hand hygiene in
and 9.6% to 54% among nurses and HH compliance was the hospital and the factors influencing hand hygiene
higher when risk was perceived to be higher (i.e., in the practice in the hospital. Knowledge was assessed using the
emergency and wound dressing/treatment rooms and labour WHO’s hand hygiene questionnaire for health care workers.
wards). In that same study, facilities for HH, particularly This proforma of 25 questions includes multiple choice and
alcohol hand rub and liquid soap dispensers were shown to ‘yes’ or ‘no’ questions.The knowledge of hand hygiene was
be deficient. No such studies has been conducted at the scored as follows: each correct response was given one (1)
Cape Coast teaching hospital, Ghana. Therefore, the aim of point and each wrong response given a score zero (0). The
this study was to assess Hand Hygiene Knowledge and maximum score will be 25 marks. The total score for each
practices among health care providers at the Cape Coast respondent was expressed as a percentage of the maximum
teaching hospital,Ghana.The objectives of the study was to score. Respondents were then categorized into those with
1)assess the knowledge of proper hand hygiene among poor knowledge (<50%), fair knowledge (50-69.9%) and
health care workers according to WHO guidelines, 2)to good knowledge (>70%). Hand hygiene practice was
assess hand hygiene practices among healthcare workers at assessed by another self-structured questionnaire consisting
the hospital, 3) to assess any correlations between of 13 questions.
knowledge of proper hand hygiene and professional
type;department of health care provider, 4)to assess factors Ethical Clearance
that hinder proper hand hygiene practices.
Ethical clearance was sought from the University of Cape
2. Methodology Coast Institutional review board (UCCIRB/CHAS/2015/37).
Approval was also sought from management of the Cape
Setting Coast Teaching hospital. Written informed consent was
The study was conducted between January 2016 through obtained from participants and confidentiality was ensured
April 2016 at the Cape Coast Teaching Hospital of Ghana. throughout the study.
The Cape Coast teachinghospital is a tertiary health facility
that provides a wide range of specialist services to the Data analysis
people in the Central region of Ghana as well as those in the Data obtained from the study wasanalyzed using the SPSS
neighboring region. software version 20. Each completed questionnaire
waschecked visually for completeness before fed to the
Study Population computer.Descriptive statistics was used to calculate
Healthcare workers included in the study were: house- percentages for each of the responses given. Chi-square test
officers, medical officers, resident doctors, specialist/ was used to compare the percentage of correct responses
consultants, nurses, ward assistants, midwives, among health care providers,and department. A P value less
physiotherapist, anesthetists, x-ray technologist and than 0.05 was considered significant.
laboratory scientists who works at the hospital at the time of
the study. All the health care providers working at the 3. Results
hospital at the time of the study were eligible for
participation in the study. Those health care providers who 3.1 Characteristics of Respondents’
were on leave during the data collection period were
excluded. A total of 130 healthcare workers filled out the
questionnaire, the majority of which 54 (41.9%) were
Study design nurses, 21 (16.3%) were houseofficers,13 (10.1%)were
The research design wasa cross sectional descriptive study.. midwives and 10 (7.8%) were medical officers. Majority
(66.4%) were within the 20-29 age-group and 62.3% were
Sampling method females and 37.7% were males. Majority of the respondents’
Cluster sampling technique was used to recruit participants. were from the following departments: emergency (18),
Each ward in the hospital was visited thrice a week during Paediatrics (18), OPD (18), Obstetrics (15), laboratory (11).
the morning, afternoon and evening shift to distribute Majority (65.9%) had 1-5 years of working experience and
questionnaires to the health care workers on duty at that more than half of the respondents’ (77.3%) have had training
particular shift after obtaining informed consent. in hand hygiene.
Departmental Clinical meetings were also used as clusters to
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 International Journal of Science and Research (IJSR)
ISSN (Online): 2319-7064
Index Copernicus Value (2013): 6.14 | Impact Factor (2015): 6.391
3.2 Knowledge on Hand Hygiene by Respondents’ 3.4 Association between respondents’ Professional status,
their department and their hand hygiene knowledge
Table 2 and 3 demonstrates knowledge on hand hygiene by score.
respondents’ using the WHO hand hygiene questionnaire for
healthcare workers. Only 10 (8.7%) of the respondents’ From table 6, the professional status of the healthcare
knew that the minimal time needed for alcohol-based hand worker was significantly associated with hand hygiene
rub to kill germs should be at least 20s. Majority of the knowledge score (P= 0.005), but not correlated to their
respondents’ knew that hand hygiene should be performed departments (P=0.390).
before touching a patient (87.7%) and after touching a
patient (89.4%) respectively. Table 1: Socio-demographic characteristics of respondents’
Characteristics Frequency (N) Percent (%)
Also majority (86.6%) knew that hand rubbing is not more Age
effective against germs than handwashing. Less than half of 20-29 73 56.2
the respondents’ were aware of the hand hygiene method 30-39 36 27.7
needed before giving an injection (39.4%) and after making 40-49 17 13.1
a patient’s bed (20.5%). Majority (>80%) were aware that 50-59 2 1.5
the following should be avoided as is associated with 60+ 2 1.5
increased likelihood of colonisation of hands with harmful Gender
germs: wearing jewellery, damaged skin and artificial Male 49 37.7
fingernails.The overall knowledge score computed showed Female 81 62.3
that 29.5% of the respondents had poor knowledge, 51.2% Professional status
had fair knowledge and 19.3% had good knowledge. Nurses 54 41.9
House officer 21 16.3
3.3 Self-reported hand hygiene practices by Midwife 13 10.1
Respondents’ Medical officer 10 7.8
Specialist/Consultant 3 2.3
Table 4 and 5 shows hand hygiene practices reported by Lab Scientist 9 7.0
respondents’. Less than half (31.1%) does not believe that Ward Assistant 6 4.7
infection prevention notices reminds them of hand hygiene. Physiotherapist 4 3.1
Anaesthetist 2 1.6
Also about 32.2% believes that wearing gloves sometimes
Other 7 5.4
reduces the need for hand hygiene. Majority of the
Departments
respondents (>70%) always washes hands after defecating,
Internal medicine 3 2.3
before and after meals.Top four (4) factors influencing hand
Surgery 12 9.2
hygiene practices included: inadequate water (21.9%); lack
ICU 5 3.8
of clean towels (15.1%); lack of air dryer (14.0%) and
Mixed Medical/Surgical 10 7.7
absence of detergent (13.0%). Top three (3) reasons for not
Emergency 18 13.8
practicing hand hygiene included: heavy patient load Obstetrics 15 11.5
(33.5%); forgetfulness (23.6%) and lack of time (17.9%). Paediatrics 18 13.8
Laboratory 11 8.5
Techniques commonly used by respondents’ for hand Outpatient Department 18 13.8
hygiene are the use of cold running water (27.3%), use of Others 20 15.4
alcohol-based hand rub (22.9%). Only 18 (5.3%) were using Years of working experience
warm running water. Hand drying technique used included: 1-5 years 85 65.9
use of common towels (30.3%);use of personnel 6-10 years 27 20.9
handkerchiefs 50 (21.5%); allow hands to dry on their own >10 years 17 13.2
46 (19.3%), use of disposable towels 25 (10.9%). Training on hand hygiene
Yes 99 77.3
No 29 22.7

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Paper ID: ART2016631 DOI: 10.21275/ART2016631 303
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Table 2: Knowledge of Hand Hygiene Among Respondents’
No. of subjects
Percent
Knowledge on hand hygiene practices (correct responses in brackets) with correct
(%)
response
1.Which of the following is the main route of cross transmission of potentially harmful germs between patients in a health-care
facility?
(Health-care workers hands when not clean) 69 56.1
2.What is the most frequent source of germs responsible for health care- associated infections?
(Germs already present on or within patient) 34 27.4
Which of the following hand hygiene actions prevent transmission of germs to the patient?
3.Before touching a patient (Yes) 100 87.7
4.Immediately after risk of body fluid exposure (Yes) 84 83.2
5.Immediately before a clean/aseptic procedure (No) 93 91.2
6.After exposure to the immediate surroundings of a patient (Yes) 75 78.1
Which of the following hand hygiene actions prevents transmission of germs to the healthcare worker?
7.After touching a patient (Yes) 101 89.4
8.Immediately after risk of body fluid exposure (Yes) 88 88.9
9.Immediately before a clean/aseptic procedure (No) 30 31.3
10.After exposure to the immediate surroundings of a patient (Yes) 75 78.1
Which of the following statements on alcohol-based hand rub and handwashingwith soap and water are true
11.Hand washing is more rapid for hand cleansing than hand washing (True) 59 50.9
12.Hand rubbing causes skin dryness more than hand washing (false) 35 29.7
13.Hand rubbing is more effective against germs than hand washing (false) 97 86.6
14.Hand washing and hand rubbing are recommended to be performed in sequence (false) 37 30.8
15.What is the minimal time needed for alcohol-based hand rub to kill most germs on your hands?
(20 seconds) 10 8.7
Which type of hand hygiene method is required in the following situations?
16.Before palpation of the abdomen (rubbing) 65 52.4
17.Before giving an injection (rubbing) 50 39.4
18.After emptying a bedpan (washing) 123 96.9
19.After removing examination gloves (rubbing/washing 128 99
20.After making a patients bed (rubbing) 26 20.5
21.After visible exposure to blood (washing) 120 94.5
Which of the following should be avoided, as associated with increased likelihood of colonisation of hands with harmful germs?
22.Wearing jewellery (Yes) 104 84.6
23.Damaged skin (Yes) 101 84.9
24.Artificial fingernails (Yes) 120 96.8
25.Regular use of a hand cream (No) 77 64.7

Table 3: Overall Knowledge Score On Hand Hygiene by Respondents’

Knowledge Frequency Percent (%)
Good (>70%) 25 19.3
Fair (50-69.9%) 66 51.2
Poor (<50%) 38 29.5

Table 4: Self-reported Practices of Hand Hygiene by Respondents’

Always Most of the time Sometimes Never Total
Variable
n (%) n (%) n (%) n (%) N
I miss out hand hygiene because I forget 0(0.0) 8(6.5) 64(52.0) 51(41.5) 123
Hand hygiene makes it difficult to carry it out 2(1.7) 15(12.4) 51(42.1) 53(43.8) 121
Infection prevention notices reminds us of hand hygiene 20(16.4) 20(16.4) 44(36.1) 38(31.1) 122
Have more important things to do than hand hygiene 1(0.8) 9(7.4) 31(25.4) 81(66.4) 122
Wearing gloves reduces the need for hand hygiene 3(2.5) 11(9.1) 39(32.2) 68(56.2) 121
Emergencies makes hand hygiene difficult 6(5.0) 23(19.0) 62(51.2) 30(24.8) 121
Washing hands after defecating 108(88.5) 6(4.9) 5(4.1) 3(2.3) 122
Hand washing before meals 108(88.5) 8(6.6) 4(3.3) 2(1.6) 122
Hand washing after meals 94(76.4) 10(8.1) 16(13.0) 3(2.4) 123

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Paper ID: ART2016631 DOI: 10.21275/ART2016631 304
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ISSN (Online): 2319-7064
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Table 5: Hand Hygiene Practices by Respondents’ (61.1) (22.2)
Variable Frequency Percent Outpatient Dept. 3 (16.7) 8 7 18
(n) (%) (44.4) (38.9)
Factors influencing hand hygiene practices Obstetrics 5 (33.3) 6 4 15
Inadequate water 86 21.9 (40.0) (26.7)
Absence of detergent 51 13.0 Others 1 (7.7) 10 2 13
Unavailability of sinks 25 6.4 (76.9) (15.4)
Sink leakage 31 7.9 Surgery 3 (25.0) 8 1 (8.3) 12
Sink too far 32 8.2 (66.7)
Lack of clean towels 59 15.1 Laboratory 0 (0.0) 6 5 11
Lack of hand lotion 45 11.5 (54.5) (45.5)
Lack of air dryer 55 14.0 Mixed 2 (20.0) 4 4 10
Others 8 2.0 Medical/Surgical (40.0) (40.0)
Reasons for not practicing hand hygiene ICU 2 (40.0) 3 0 (0.0) 5
Lack of time 38 17.9 (60.0)
Forgetfulness 50 23.6 Internal 1 (33.3) 2 0 (0.0) 3
Heavy patient load 71 33.5 medicine (66.7)
Non conducive atmosphere 31 14.6
Not knowledgeable in hand washing 17 8.0 4. Discussion
Others 5 2.4
Techniques commonly used for hand hygiene With the aim to reduce healthcare associated infections and
Use of warm running water 18 5.3 the spread of antimicrobial resistance, the WHO launched
Use of cold running water 93 27.3
Global Patient Safety Challenge in October 2005 Under the
Use of soapy water in a basin 14 4.1
Slogan of ‘Clean Care is Safer Care’. Our study aim to fulfill
Rubbing soap on wet hands for 20mins 69 20.2
before rinsing the aforementioned statement by providing useful insights
Use of alcohol-based hand rub 78 22.9 into the prevailing practices of hand hygiene and major
Personal hand sanitizer 69 20.2 barriers to proper hand hygiene practices.
Hand drying technique frequently used
Allow hands to dry on their own 46 19.3 A total of 130 healthcare workers participated in the study
Use of common towels 72 30.3 with majority of them as nurses (41.9%) and house-officers
Use of disposable paper towels 25 10.9 21 (16.3%), and majority were females (62.3%).Though
Use of personal handkerchiefs 50 21.0 majority of the respondents’(77.3%) have had training in
Use of air dryer 34 14.3 hand hygiene, more than half of them (51.2%) had fair
None 10 4.2 knowledge in hand hygiene practices. This finding is
consistent with other studies which shows low level
Table 6: Association between Respondents’ Professional knowledge in hand hygiene among healthcare workers
status, Departments and their hand hygiene knowledge score (Pittet et al., 2000; Danchaivijtr et al., 2005; Harris et al.,
Good Fair Poor Total Chi- 2000). But majority of the respondents’ knew that hand
P-
(>70%) (50- (<50%) Sample square hygiene should be performed before touching a patient
Variable 2 value
69.9%) (X ) (87.7%) and after touching a patient (89.4%) which is
n (%) n (%) n (%) N
consistent to findings in other studies (Pittet et al.,2004).
Professional
status
Nurses 6 (11.1) 27 21 54 37.609 0.005 Also majority (86.6%) knew that hand rubbing is not more
(50.0) (38.9) effective against germs than handwashing. Less than half of
House officer 5 (23.8) 13 3 21 the respondents’ were aware of the hand hygiene method
(61.9) (14.3) needed before giving an injection (39.4%) and after making
Midwife 3 (23.1) 5 5 13 a patient’s bed (20.5%). Majority (>80%) were aware that
(38.5) (38.5) the following should be avoided as is associated with
Medical officer 6 (60.0) 4 0 (0.0) 10 increased likelihood of colonisation of hands with harmful
(40.0) germs: wearing jewellery, damaged skin and artificial
Lab Scientist 0 (0.0) 5 4 9 fingernails.
(55.6) (44.4)
Others 0 (0.0) 5 2 7
In our study,less than half (31.1%) does not believe that
(71.4) (28.6)
infection prevention notices reminds them of hand hygiene.
Ward Assistant 0 (0.0) 3 3 6
(50.0) (50.0) Also about 32.2% believes that wearing gloves sometimes
Physiotherapist 2 (50.0) 2 0 (0.0) 4 reduces the need for hand hygiene. Majority of the
(50.0) respondents (>70%) always washes hands after defecating,
Specialist/ 1 (33.3) 2 0 (0.0) 3 before and after meals. The top four (4) factors influencing
Consultant (66.7) hand hygiene practices included: inadequate water (21.9%);
Anaesthetist 2 (100) 0 (0.0) 0 (0.0) 2 lack of clean towels (15.1%); lack of air dryer (14.0%) and
Departments absence of detergent (13.0%) and the top three (3) reasons
Emergency 4 (22.2) 7 7 18 18.454 0.390 for not practicing hand hygiene included: heavy patient load
(38.9) (38.9) (33.5%); forgetfulness (23.6%) and lack of time
Paediatrics 3 (16.7) 11 4 18 (17.9%).This findings explaining the low compliance in
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ISSN (Online): 2319-7064
Index Copernicus Value (2013): 6.14 | Impact Factor (2015): 6.391
proper hand hygiene practices is consistent with other [6] Harris AD, Samore MH, Nafziger R, DiRasorio K,
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ISSN (Online): 2319-7064
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