KNOWLEDGE OF HAND HYGIENE AND COMPLIANCE AMONG CLINICIANS- AT A LEVEL SIX HOSPITAL IN KENYA: A CROSS SECTIONAL STUDY

Background: Healthcare-associated infection (HCAI) is a significant cause of morbidity and mortality among hospitalized patients, Compliance with hand hygiene (HH) recommendations is the simplest and most effective measure in preventing this infection. These infections are a cause of 37,000 deaths in Europe and 100,000 deaths in the United States annually. Thus, prevention of their spread is of utmost importance. Aim/Objectives: The study sought to determine the knowledge and compliance of hand hygiene among clinicians in a level six hospital in Kenya. Methods: A cross-sectional study was conducted among 140 clinicians using a multistage sampling technique. Data were collected with a set of self-administered, modified WHO questionnaire and analyzed using IBM and SPSS version 25 statistical package Results: A total of 140 respondents, (121 nurses and 19 doctors) participated in the study, of which 93 were females. Compliance to hand-disinfection was found to 65% (n=19) for doctors and 64% (n=121) for nurses. The mean age of respondents was 35.2±9.3 years, and majority of them were between 31-40years (50%). The male to female ratio was 1.9: 2004). An Australian audit data on hand hygiene reported average compliance rates for doctors and nurses were 66% and 83% respectively (Hand hygiene Australia, 2013). Furthermore a study done in Nigeria revealed that doctors significantly more possibly than nursestowashhands before patient contact. The greatest inspiration for hand washing was fear of contracting diseases whereas lack of soap, water andforgetfulness were the major hindrances to hand washing compliance.(Ekwere , 2013) was obtained from the management of MTRH and a verbal consent was obtained from the nurse manager in charge of various directorates. The study was conducted in the units. There were no threat of potential risk since no drugs or chemicals was administered. The participants benefited from the study since interventions from improvement were put in place. The privacy and confidentiality was ensured during data collection process since the information was kept by the principal investigator and anonymity of participants was assured. The participation of participantswasvoluntary and verbal informed consent wassought before interviewing them and maintaining anonymity to participants. The nature and purpose of the study will be explained to the respondents during data collection.


Introduction
Hand washing refers to the act of washing hands with an un-medicated detergent and water to remove dirt andtransient flora to prevent cross-infection whereas hand hygiene an antiseptic agent is added to the detergent. (Pittet, 2017).Hand hygiene has been singled out as the most effective measure for preventing healthcareassociated infections. (Ogugu, 2015).However, despite the simplicity and compliance of hand hygiene practices by HCWs, remainsunacceptably low below 50% in most healthcare settings. (Hillier, 2020). This has been supported by AbouZakithat very low hand hygiene compliance rate and in-sufficiency has exhibited from both developed and developing countries. (Abou et al., 2020).
The most important moment for preventing cross transmission of infections before touching a patient is through practicing hand hygiene. (Hillier, 2020).A study performed in India revealed hand hygiene compliance rate ranged from 26%-80%and recommended need for the development of strategies to improve hand hygiene. (Rynga et al., 2017).Consequently, another study done by Ahmed on hand hygiene non-compliance among intensive care health workers comprising of physicians and nurses working in ICU, medical wards, HDU, cardiac care unit, peadriatic unit showed that hand hygiene non-compliance was observed at 41% giving a compliance rate of 59%. (Mahfouz et al. 2013).
Majority of HCAI are thought to be transmitted by handsofHCWs. So assessment of knowledge, attitude and practices of hand hygiene among HCWs is paramount. (Khaled, 2011).An observational study done in Japanese Teaching Hospitals on hand hygiene adherence/compliance internal medicine wards, intensive care unit, surgery and emergency department indicated a hand hygiene adherence rate of 19% generally with 15% among physicians and 23% among nurses. Ranges of adherence were 11%-31% between units. (Sakihama et al., 2016). Contrary, a study done in Ghanaian teaching hospital using an infection prevention check-list based on WHO Guidelines on hand hygiene practices documented low care-related hand hygiene compliance rates among doctors and nurses which ranged 9.2% to 57% and 9.6% to 54% respectively. The compliance was higher when risk was perceived to be higher with intensive care unit showing the highest level of compliance among health care workers. Facilities like hand hygiene like alcohol hand rub were found to be deficient. (Amissah et al., 2016).
A research done in Nigeria by Braomoh and Udeabor reported high hygiene compliance among HCWs, hand washing before patient contactwas 60% and after patient contact was at 97%. Before interacting with patients example clerking and routine nursing procedures 76% of HCWs never washed their hands, while 9.3% always washed their hands. Meanwhile before performing simple procedures like cannulation, wound dressing and glucose check, 69.7% health workers never wash their hands while 13.6% always washed their hands.(Alex-Hart & Opara, 2011). In addition to this, a study done by Gilbert revealed that nurses were more likely to appreciate and put into practice the five moments for hand hygiene that doctors who often abstained from these chances asserting that more pressing essential obligations. (Gilbert, 2014).
A study done by Ndegwa (2014) to assess hand hygienepractices in threeKenyan hospitals revealed a baseline adherence rate of 28%, with ICU having the highest compliance rates while surgical and pediatrics units had the lowest rates. Consequently another study done katama in Kenya on hand hygiene among health care workers at a referral hospital showed hand hygiene adherence rate at 30.8% .(Ndegwa& Amb, 2014).
A study done on knowledge of nurses in Canada portrayed that nurses had good level of knowledge, but the knowledge enhancement was realized through holding educational classes and coursesin cases where a breach was recognized. (Sharif et al., 2015).A research done in a tertiary hospital in Nigeria depicted good knowledge to hand washing which was higher after patient contact than before. Startlingly, hand drying practices were meager which customarily risked the comparatively good hand washing practices.Demanding work program in between patient care wassingled out as a probable limitation to hand washing.(Ekwere , 2013).
World Health Organization (2011) highlights numerous factors associated with poor adherence to standardized hand hygiene practices among HCWs. Consequently, a study done by Pittet 2006, showed casual attitude among HCWs towards bio-safety enhancing poor compliance among others. ( Pittet, 2006). Similar studies were also cited by Jang, who observed that despite the doctors influential positions in hospitals, their attitudes and practices towards hand hygiene disproportionately influence practices of other HCWs (Pittet et al

Introduction
This chapter presented the design and methods that were used to collect the relevant data for this research. The data was analyzed so as to answer the research questions. This was included in the research design, description of the target population, sample size and sampling technique procedures that were applied, research instruments and their administration on the participants, data collection methods, data analysis procedures and ethical considerations

Research Design
The study adopted descriptive and observational cross-sectional study design. The study design was considered appropriate for this study for several reasons. First, it attempted to collect data from members of a population in order to determine their current knowledge with respect to one or more variables. Secondly, it wasan appropriate way of eliciting the most complete response from a sample of individuals presumed to have experienced the phenomena of interest. Besides, it collected information from a large number of respondents and relies on the individual self-report of their knowledge.

Study Setting
The study will be carried out at Moi Teaching and Referral Hospital (MTRH), alevel six Hospital situated along Nandi Road in Uasin-Gishu County, Kenya. The Hospital has 1000 bed capacity, and a staff of about 2000providing preventive, curative and rehabilitative services and the hospital also serves as a teaching hospital to various institutions notably MTRH, Moi University, University of Eastern Baraton, Kenya Medical Training college among others.

Study Population
The study population comprised of all Nurses and Doctors working in internal medicine unit comprising of CCU, Emergency Unit, general female ward and general male ward. Surgery unit in ICU, the directorate of reproductive unit comprised of nurses and physicians in labour ward. The nurses and doctors included medical doctors and registered nursing officers.

Sample Size Determination
The The following formula was used to determine the sample size as recommended by Fisher et al (1983); n = z 2 pq d 2 Where: n -Desired sample size z 2 -Standard normal deviate at the required confidence interval p-The proportion in the target population estimated to have the characteristic being measured q=1-p d-Marginal error (degree of confidence) Hence; n = (1.96) 2 x0.5x0. 5 (0.05) 2 = 384 Since the population was less than 10,000 the following formula was used nf = n 1+ n N  Sampling Procedure Stratified random sampling wasapplied to select participants for the survey. Consent was sought from the hospital administration prior to carrying out the observational study and or directly from the Nurses and Doctors.
Observations were carried out without the knowledge of the Nurses and medical doctors on the specifics of the study to minimize bias. A record was kept by the researchers of the number of times each Nurse or medical Doctor has been observed so as to avoid over/under observations. After the observational study, the Nurses and Doctors willing to participate in the study were given questionnaires to fill after obtaining both verbal and written consent from them.

Inclusion and Exclusion Criteria Inclusion Criteria
All nurses and medical doctors working inthedirectorateof internal medicine (CCU, Emergency department, and general medical wards). Surgery directorate (ICU) Reproductive directorate (Labour ward) All nurses and medical doctors who were willing to participate were included in the study

Exclusion Criteria
On study leave and annual leave during the study period.

Observations of Hand Hygiene
Waiver of consent was obtained from IREC to assist in the observational study of this project to avoid change of behavior in a forum of both nurses and doctors within the unit that there was an ongoing study. Observation checklist was used to assess the hand hygiene practices as per WHO standards (Appendix V).
Nurses and doctors in direct conduct with patientswereobserved randomly for 10-20 minutes at pre-specified times on the week-day until hand hygiene an opportunity occurs or the nurses and doctors who left the room. An opportunityfor hand hygiene was defined as the occurrence of any of the five indications for hand hygiene recommended by the WHO during the observed care sequences; that is-Before patient contact, before a clean/aseptic procedure, after patient contact, after risk of body fluid exposure and after contact with patient"s surroundings. At certain instances more than one nurse or doctor was observed during these sessions depending on the density of activities. Hand hygiene action was then observed for the different opportunities and these included: hand washing with soap and water or use of alcohol based hand rub (ABHR).Hand hygiene actions was defined as either hand washing with soap and water or hand rubbing with alcohol-based hand rub and these were recorded on the observation card separately for each nurse and doctor. During each session availability of soap, free flowing water and ABHR was noted Data collection will take approximately three months and a record of those observed were kept strictly confidential.

Questionnaires
Questionnaire: After the participants" consents he/she was assigned with a participant study code (to protect the participant"s identity) The participant was requested to complete the questionnaire. The questionnaire consists of bio-data that was filled and 19 multiple choice question test (appendix IV).
The self-administered questionnaires were given to the nurse and doctor observed earlier to assess their knowledge and perceptions regarding HCAIs and importance of hygiene. They were counterchecked on collection for completion.

Validity
The researcher will use WHO-standardized hand hygiene knowledge survey instrument with scoring guide and ward hand hygiene facilities survey whose content validities will be established at the design stage.

Reliability
The researcher selected a pilot group of 10 clinicians from various departments at the Uasin-Gishu district Hospital who did not participate in the main study to test the reliability of the research instruments (appendix I and II).

Data Analysis and Presentation
The raw data entries from both observation and questionnaires was edited to detect errors and omissions and to correct errors where possible. After all data was collected, cleaning and coding preceded entry done in SPSS software. Descriptive statistics such as means, frequencies, and percentages was computed. Paired t-test analysis was carried out on selected variables to test for significance between expectation and perception. Frequency and percentage was used to identify the least and most scored dimension. Results were presented in form of tables, pie charts and bar graphs.
To determine hand hygiene practices among HCWs compliance to hand hygiene was calculated as Compliance (%) = Performed actions * 100

Study Frame
The study was done for a period of 3 months starting from July , August and September and there after stated in the table below: Ethical Considerations A number of measures will be put in place to ensure that the rights of participants were not violated. These measures include; permission to carry out the study was obtained from the management of MTRH and a verbal consent was obtained from the nurse manager in charge of various directorates. The study was conducted in the units. There were no threat of potential risk since no drugs or chemicals was administered. The participants benefited from the study since interventions from improvement were put in place. The privacy and confidentiality was ensured during data collection process since the information was kept by the principal investigator and anonymity of participants was assured. The participation of participantswasvoluntary and verbal informed consent wassought before interviewing them and maintaining anonymity to participants. The nature and purpose of the study will be explained to the respondents during data collection.

Study Implications
Proper hand hygiene is the most important, simplest and least expensive means of reducing prevalence of health associated infections and spread of antimicrobial resistance. Most studies have shown that adherence to hand hygiene has significantly reduced the rate to acquired pathogens on hands and HAIs in a hospital.

Chapter Four: Study Findings Descriptive Findings Socio-Demographic Characteristics
The study, which attractedtotal of 140 participants (46 male and 93 female).Of these, 19 participants were doctors (10 male and 9 female) and 121 were nurses (36 male and 84 female). Majority of the particpants (70%) were aged between 30-50. Only 3% (n=4) of the particpantswereaged above 50 years. Whereas majority of the respondents were above 30 years, most of them (56%; n=75) had worked in the facility for under 6 years.
Fourtyseven (43) of these were male and 93 were female. This included 19 Doctors and 121 Nurses who were working in the following wards; Emergency, Intensive Care Unit (ICU), Umoja, Amani, CCU and Labor ward. Medical wards or intensive care units (ICUs). The rest of the Demographic information is summarized in Table 1 below. Seventeen (n=17; 85%) doctors had worked at the facility for less than 6 years with 63% (n=13) having worked at the facility for less than 3 years. The study noted that only one doctor had worked at the facility for more than a year. Forty six respondents (n=58) had at least a bachelors degree. Majority of the respondents (n=80; 57%) had either a diploma or higher diploma and all were nurses. Majority of the doctors (n=16; 84%) had a bachelors degree whereas 32% of the nurses had at least a bachelors degree.

Knowledge Characteristics
In assessing respondent knowledge on hand hygiene practices, the study reviewed posed four questions to all cadres. The responces were as illustrated in the table below The study further sought to dissegrate the level of knowledge based on the respondent"s cadre and findings were as documented in the table below.

Practice Factors
From the study findings, a total of 23practice questions driven from 6 thematic areas were answered. Responses were categorized as pass or fail to denote right and wrong responses to the questions. The highest scored question got an average 96% whereas the lowest scored question got an average 23% with only 17 nurses (14%) and 2 Doctors(11%) scoring it right. The average score of passes for both nurses and doctors was 64% and 65% respectively bringing a total average score of 64.5%.
Whereas majority (64%) of the respondents demonstrated good hand hygiene practices, the study noted that most of the respondents lacked requisite knowledge in; the use of alcohol swabs, the hand hygiene method required in specific situations, and the hand hygiene actions that would prevent transmission of HCAI-causing germs both to the healthcare worker and the patients. As demonstrated in the table below, majority (n=96; 68.6%) of the respondents did not know the minimal time needed for alcohol-based hand rub to kill most germs on a users" hand. Similarly, majority (n=121; 86.4%) of the respondents could not identify the best hand hygiene method required in after making patients bed and before giving an injection (n=72; 51.8%). The study also noted that the majority of respondents could not tell whether hand washing and hand rubbing are recommended to be performed in sequence (n=96; 69.1%). On hand hygiene actions that prevent transmission of HCAI-causing germs to both the patient and the healthcare worker; majority of the respondents (n=94; 69.6%) did not know the hand hygiene actions to perform after exposure to the immediate surrounding of the patient and an even bigger proportion (n=104; 78.2%) did not know the hand hygiene actions to perform immediately before a clean/ascetic procedure (See table below).  Hand Hygiene On-site Observation by Professional cadre Before Managing Patients From the observation, more nurses were observed using hand rub and hand wash before touching a patient than the Physicians. However, Physicians who missed and those who used gloves were more compared to nurses.

Before Aseptic Procedure
Almost half (58%) of physicians were observed using gloves before aseptic procedure than their counterparts (40%).Those who missed was almost the same,5% and 4% by physicians and nurses respectively. For the hand wash and hand rub, more nurses were observed using than physicians, 44 %( Hand wash) and 12% (hand rub) by nurses, 32 %( hand wash) and 5 %( hand rub) by physicians

After Body Fluid Exposure
From the observation, majority wash their hands after body fluid exposure. This was shown by 79% (Physicians) and 71% (Nurses). However, none of the Physicians used a hand rub on the same. The rest of the information is summarized in figure 9 below;

Physician Nurse
After Touching the Patient From survey findings, the most observed hand hygiene practice "after touching a patient" was Hand rub whereby 63% and 43% of the Physicians and nurses were observed respectively. The least observed hand hygiene indication was the use of gloves "after touching a patient" where 4% of the nurses were observed using and none of the physicians was (0%) observed. The information is summarized in the figure 10 below; Figure 5:-After touching the patient.

After Patient Surrounding
Most of the Physicians (68%) were not observed using any hand hygiene "after Patient surrounding as compared to 30% nurses who also missed. However, none of the physicians (0%) used gloves "after Patient Surrounding" and the other hand hygiene summary observed is shown in the figure 11 below;

Conclusion:-
Based on this study, majority of the study participants were knowledgeable and the hand hygiene practice was good, nurses being more knowledgeable than Doctors.
There is an improved hand hygiene compliance compared to previous studies, hand driers, towels and sporadic supply of soap are some of the factors affecting effective hand hygiene practices in the study area

Recommendation:-
There is need to improving the knowledge and practice of HCWs on hand washing. Equal and consistent Supply of hand hygiene materials and infrastructure like soap, water, dryer, disposable hand towel, sinks and sanitizers will increase ease of access and compliance to hand hygiene practices in the hospital.
To improve staff knowledge there is need to promote continuous education and use of posters and pictures to act as constant reminders and guidelines on hand hygiene.
A more scientific study is recommended to establish the effectiveness of soap and sanitizers in relation to specific bugs and flora.

Data Availability
The data used to support the findings of this study are available for provision upon request. References:-