Knowledge, attitude and perceived barriers of doctors towards hand hygiene in a govt. tertiary care hospital

Introduction: Health-care Providers hands become progressively colonized by germs and potential pathogen during patient care. Absence of hand hygiene practices by health care providers possesses high risk to patient’s safety. Hand hygiene practices either by Hand rub by disinfectant or hand washing by Soap & Water is very important for preventing Health Care Associated Infections (HCAIs). Objective: Assessment of Knowledge, Attitude & Perceived Barriers among doctors towards practice of Hand Hygiene during patient care. Materials and Methods: Cross sectional observation study carried among 36 doctors working in 8 indoor departments of a Govt. Tertiary care Hospital. Semi Structured Questionnaires was used for data collection. Data Entry was done in MS excel and was analysed in SPSS software. Categorical Variables was expressed in frequency and Percentage. Result was extrapolated on Graph and Table. Result: 53% Doctors do not have knowledge about “5 moments of hand hygiene”. 92% Doctors realised the importance of practice of Hand hygiene as in prevention of transmission of infection. 61% Doctors realised that forgetfulness’ leads to omission of practice of hand hygiene. Perceived Barriers to practice Hand Hygiene identified were increased workload, lack of water, sinks, hand rubs and antiseptic solutions in the practice area. Conclusion: The study identifies the knowledge gap still exist among Doctors regarding Hand hygiene and although Doctors have good attitude towards hand hygiene, Perceived barriers which are rectifiable prevents them from practicing hand hygiene everywhere and all the time.


Introduction
Hand hygiene Practices prevents transmission of Health Care Associated Infections (HCAIs) among patients as well as health care providers at health care delivery points. Various factors have been identified for noncompliance to hand hygiene practices and Lack of knowledge among health care providers was found to be most important factor responsible for poor compliance towards hand hygiene practices. 1 Most shocking finding identified is that compliance towards hand hygiene practices was found to be worst before conducting high risk procedure. 2,3 Comparing various Professional cadre of health care provider, compliance for hand washing was found to be maximum among nurses, least among doctors. 4 Although numerous studies have shown that hand hygiene decreases the transmission of potential pathogens or antimicrobial-resistant organisms, there is no sustained improvements towards practice of hand hygiene recommendations and adherence to proper hand washing technique among health care providers. 5 Perceived Barriers towards hand hygiene practices were found to be low education, high work load, lack of human resource, lack of facilities, working in critical care units, lack of encouragement and role model among senior staff along with absence of any guidelines of practice of hand hygiene as set by the institution. 6 Various studies have showed that health care facilities where training sessions were held to improve hand hygiene practices has resulted in sustained improvement in compliance. [7][8][9] Performance Indicator of health care staff by direct observation is also found to be additional factor contributing to hand hygiene practice. 10 Direct observation of hand hygiene practice is still considered superior as it shows compliance with all 5 moments of Hand Hygiene. 11,12 This study assess the Knowledge, Attitude and Perceived barrier towards practicing hand hygiene among Doctors and provide the information for intervention needed to improve compliance and adherence to hand hygiene practice among health care providers and further reduction in Health Care Associated Infections.  Knowledge of doctors about transmission of infection was analysed and it was found that 33% doctors believe that after exposure to the immediate surroundings of a patient there is no role of hand hygiene in prevention of transmission of infection to patients. Knowledge about Increased likelihood of colonisation of hands with harmful germs was assessed and it was shocking to find that that 31% doctors believes that wearing jewellery, 25% doctors believes that damaged skin, 22% doctors believes that artificial fingernail and 67% believed that Regular Use of hand cream do not increase likelihood of colonisation of hand with harmful germs as shown in Table 2. Assessment of the knowledge about the method of choice of hand hygiene was done and it was found that majority of doctors have knowledge about hand rub and hand washing but there were very few doctors who still have misconception, that situations like after visible exposure to blood (2), after removal of examination gloves (2), after emptying bed pan (1), before giving an injection (2) and before palpation of abdomen (4) do not require hand hygiene practices as shown in Graph 1. 69% Doctors belives that although hand rub is more rapid method for hand hygine practice, it is the hand washing(58%) which is more superior to hand hygiene and majority(72%) also belived that they should be performed in sequence( as shown in graph 3). Perceived barriers about practice of Hand Hygiene was assessed (as shown in graph 5) among and 64% Doctors expressed that workload acts as barrier to practice Hand Hygiene. 53% Doctors mentioned that Lack of time at the workplace acts as barrier to practice correct hand hygiene methods.     16 Knowledge of doctors about transmission of infection was analysed and it was found that 33% doctors believes that after exposure to the immediate surroundings of a patient there is no role of hand hygiene in prevention of transmission of infection to patients.28 % believes that immediately before a clean/aseptic procedure there is no role of hand hygiene in prevention of transmission of germs to the health care worker 31% believed wearing jwelaring, 25% believes that damaged skin, 22% believes artificial fingernail and 67% believes that Regular Use of hand cream do not increase likelihood of colonisation of hand. Contrast to this a study done by W.E Trick 5 have shown that 40% of the nurses harboured the gram negative bacilli, Acinetobacter spp. on the skin under the rings and some of them carried the same organism under their rings for months.

Objectives
In the present study, 36% of Doctors believed that 1 minute of time is required to kill germs by usage of alcohol based hand rub and only 22% were able to mention it correctly (20 seconds). 69% Doctors belives that although hand rub is more rapid method for hand hygine practice, it is the hand washing (58%) which is more superior to hand hygiene and majority (72%) also belived that they should be performed in sequence .69% of Doctors believed that Infection prevention notice board plays a vital role in reminding about hand hygiene practices, 50% of Doctors also believed that infection prevention team also promotes practice of hand hygiene. Among participants 55% doctors believed that frequency that is required for hand hygiene makes it difficult to practice it. 81% Doctors also admitted that it is difficult to practice hand hygiene during emergency.
Perceived barriers about practice of hand hygiene was assessed among 36 Doctors who participated in the study and findings indicted that Workload (64%), Lack of time (53%), Location and Shortage of Sinks (69%) Lack of Encouragement (69%), Lack of water(56%), Lack of Hand Rub(78%)Lack of soap(58%) are major barrier to practice of hand hygiene in health care setting. Previous studies showed increase in compliance with the availability of hand rub solutions at the bedside of the patient. 16 These barriers can be corrected with extra efforts and will definitely lead to decline in HCAI in the country. The best way to improve hand washing compliance based on the finding of this study was motivation, training and education of health care workers followed by availability of alcohol based hand rubs which is similar to a study by JB Suchitra 4 which listed that Barriers to practice hand hygiene were lack of education, high work load, understaffing, working in critical care units, lack of encouragement, lack of role model among senior staff & lack of knowledge of guidelines set by the institution.

Conclusion
The study identifies the knowledge gap still exist among Doctors regarding Hand hygiene and although Doctors have good attitude towards hand hygiene, perceived barriers which are rectifiable prevents them from practicing hand hygiene everywhere and all the time. The best way to improve hand washing compliance based on the finding of this study was motivation, training and education of health care workers followed by availability of alcohol based hand rubs. These barriers are rectifiable at the level of the hospital and there can be huge increment in hand hygiene practice in the hospital among health care providers.

Source of funding
None.