The provision of healthcare worldwide is
always associated with a potential range of safety problems. Yet, despite
advances in healthcare systems, patients remain vulnerable to unintentional
harm in hospitals. One of the most significant, current discussions in
healthcare delivery in hospitals is healthcare associated infection (HAI),
sometimes called hospital acquired infection or nosocomial infection, which is
defined as ‘an infection acquired in hospital by a patient who was admitted for
a reason other than that infection (1). An infection occurring in a patient in
a hospital or other health care facility in whom the infection was not present
or incubating at the time of admission. This includes infection acquired in the
hospital but appearing after discharge and also occupational infections among
staff of the facility'(2). HAI is the one of the most frequent adverse event in
health care delivery system worldwide (3).
The various modalities of treatment in
clinics beginning from physical examination of the patient to the dispensing of
prescriptions and medicines, there is a very high chance of physical contact
between HCW and the patient through hands.
Contact transmission is the most important
and frequent mode of transmission in healthcare settings. Organisms are
transferred through direct contact between an infected patient and a
susceptible worker. Patient organisms can be transiently transferred to the
intact skin of HCW (not causing infection) and then transferred to a
susceptible patient who develops infection from that organism (4). Hospital
acquired infections spreading through the hands of health care workers is
mostly due to poor hand hygiene of the health care providers.
Hand hygiene is an important healthcare
issue globally and is a single most cost-effective and practical measure to reduce
the incidence of healthcare associated infection and the spread of
antimicrobial resistance across all settings – from advanced health care
systems to primary healthcare centers (5).
Health care workers (HCWs) are involved in
direct or indirect patient care needs to be concerned about hand hygiene.
Regular hand washing, particularly before and after certain procedures is necessary
to prevent spread of infection. Adequate hand hygiene among hospital personal
could prevent an estimated 15 to 30% of the HAIs (3,6).
According to WHO, hand hygiene performance
varies according to work intensity and several other factors; in observational
studies conducted in hospitals, HCWs cleaned their hands on average from 5 to
as many as 42 times per shift and 1.7-15.2 times per hour (6).
Health care workers put themselves and
their patients at risk when they fail to observe routine hand hygiene
practices. Despite the relative simplicity of this procedure, compliance with
hand hygiene among health care providers is as low as 40% (5).
There are certain factors which predispose
poor compliance to hand hygiene among health care workers. Possible factors
concerned to settings are limited resources like inadequate environmental
hygienic conditions, insufficient equipment, understaffing, overcrowding, poor
knowledge and ignorance about application of basic infection control measures and
absence of local and National guidelines and policies.
Likewise, hand hygiene is also influenced
by many factors w.r.t HCWs such as hand hygiene action or lack of compliance, perception
and knowledge of the transmission risk and of the impact of HAI, social
pressure, HCW’s conviction of their self-efficacy, the evaluation of perceived
benefits against the existing barrier and the intention to perform hand hygiene
Yet, despite the momentum for hand
hygiene, some HCWs are still presenting with low compliance because they
perceive it as not their problem, that it is something to do with infection
control staff and they have to deal with it. Furthermore, Nazarko (2009)
indicates that nurses often fail to practice hand hygiene because they are busy
and they feel hand hygiene takes up precious time. In addition, nurses often
perceive that gloves can be used as an alternative to hand hygiene (8).
To address the issue of poor compliance
with hand hygiene, continuous efforts are being made to identify effective and
sustainable strategies. One of such efforts is the introduction of an evidence
based concept of “My five moments for hand hygiene” by World Health
Organization. These five moments that call for the use of hand hygiene include
the moment before touching a patient, before performing aseptic and clean
procedures, after being at risk of exposure to body fluids, after touching a
patient, and after touching patient surroundings (9). This concept has been
aptly used to improve understanding, training, monitoring, and reporting hand
hygiene among healthcare workers in spite of the fact that some recent research
has recommended more cautious approach in the universal adoption of this
Health professionals are aware that health
care associated infection has an impact on patient outcome as well as the
simplicity of hand hygiene, but studies continue to report unacceptably low
hand washing compliance rates amongst health workers (5).
The complexity of the current situation in
regard to hand hygiene and the myriad of factors discussed above affecting the
same, necessitates a comprehensive evaluation of the existing trends of knowledge, attitude and compliance
of healthcare workers to hand hygiene in the
Indian setting more holistically and to shed light on potential targets
for framing of exhaustive guidelines on the National front.
In light of above
scenario, the present study has been designed to evaluate the knowledge,
attitudes, perception and compliance towards hand hygiene, focusing on the
factors acting as barrier to optimum adoption of hand hygiene and highlighting the
present scenario in the Tertiary Care Hospital in Uttarakhand, India.