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Year : 2018  |  Volume : 15  |  Issue : 2  |  Page : 109-113

Hand hygiene practice among healthcare workers in a public hospital in North-Western Nigeria

Department of Paediatrics, Bayero University, Kano, Nigeria

Date of Web Publication14-Sep-2018

Correspondence Address:
Dr. Garba D Gwarzo
Department of Paediatrics, Bayero University, Kano
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njbcs.njbcs_40_17

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Background: Hospital-acquired infection is still a major cause of morbidity and mortality in hospitals. Compliance with hand hygiene by healthcare workers is an important preventive measure. However, many healthcare workers do not wash their hands properly or not at all. This cross-sectional study was conducted to assess the practice of hand washing among healthcare workers in a tertiary hospital in Nigeria. Patients and Methods: Healthcare workers were randomly selected and were asked, using a questionnaire, regarding hand hygiene in their working places. Results: A total of 173 healthcare workers who had contact with patients participated in the study. They included doctors, nurses, physiotherapists, laboratory scientists, and technicians. Majority (54.3%) of them were males and 60.1% worked in a health facility for 5 years or less. All participants practiced hand washing at work but only 127 (73.4%) washed their hands correctly. Contact with body fluids was the major (87.3%) reason for washing hands. Soap and water only were used by 58.4% and hands were air dried by 45.1%. The main constraint to hand hygiene was lack of alcohol hand rub, soap, and water. Knowledge of hand washing was from multiple sources. Conclusion: Compliance with hand hygiene was good. Alcohol hand rub, water, and soap should always be available.

Keywords: Hand hygiene, hand washing, healthcare workers, Kano, Nigeria

How to cite this article:
Gwarzo GD. Hand hygiene practice among healthcare workers in a public hospital in North-Western Nigeria. Niger J Basic Clin Sci 2018;15:109-13

How to cite this URL:
Gwarzo GD. Hand hygiene practice among healthcare workers in a public hospital in North-Western Nigeria. Niger J Basic Clin Sci [serial online] 2018 [cited 2022 Oct 3];15:109-13. Available from: https://www.njbcs.net/text.asp?2018/15/2/109/241158

  Introduction Top

Hospital-acquired infections contribute significantly to morbidity and mortality of patients in hospital settings. Infections acquired through poor hand hygiene among health care workers (HCWs) caring for these patients has been documented to be among the major causes of such infections.[1],[2]

According to the Centre for disease control (CDC), healthcare workers must institute standard hand washing procedures before attending to each patient.[3] Unfortunately, compliance with this point-of-care standard has been low in many parts of the world including Nigeria.[4],[5],[6]

There are differences in the practice of hand washing among various HCWs while on duty,[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19] despite recommendations by the World Health Organization (WHO). The WHO recommends routine use of alcohol-based hand rubs before or after contact with patients, after contact with body fluids, and before performing invasive procedure on patients.[8] It also recommends the use of soap and water when hands are visibly dirty or soiled or when alcohol-based hand rubs are not available.

In Switzerland, Pitet et al.[9] found poor hand hygiene among doctors compared with nurses even after intervention, and soap and water were commonly used. Similarly, Kingstone et al.[10] reported nonavailability and poor acceptability of alcohol-based hand rub among the major barrier to its use among Irish doctors, and as of 2015, only 86% of the doctors studied were compliant with hand hygiene. In Italy, Chittaro et al. found a very low (less than 30%) overall compliance rate among HCWs following the introduction of alcohol-based hand rubs.[19]

In southern Nigeria, Bello et al. found that more than two-thirds of healthcare providers in a teaching hospital had good hand washing practices, and nurses had higher handwashing frequency than other healthcare providers.[7] Similarly, in another south Nigerian study, Alice et al. found that compliance with standard precaution was the highest among doctors working in a tertiary hospital whereas nurses had the highest compliance with hand hygiene.[16] Similar results were found by Ekwere and Okafor.[18] In northeastern Nigeria, only 13% of the HCWs studied had adequate knowledge of universal precautions.[20] There is a paucity of studies on hand hygiene among HCWs in the northwestern part of Nigeria.

This study investigated compliance with hand hygiene guidelines and barriers to standard hand hygiene practice among healthcare workers practicing at the reference hospital in Kano, Nigeria.

  Patients and Methods Top

This was a cross-sectional study conducted at the Murtala Mohammed Specialist hospital, a reference hospital in Kano, northwestern Nigeria, from August to November 2017. This large public hospital caters to a majority of over 10 million inhabitants of Kano state. It has various specialty departments including Medicine, Surgery, Paediatrics, Obstetrics and Gynaecology, Ophthalmology, Laboratory services, and Physiotherapy. Ethical clearance to conduct the research was obtained from the hospital's management board.

HCWs who came in direct contact with patients in their routine works in the hospital were included in the study. These HCWs included medical doctors, nurses, physiotherapist, laboratory scientists, laboratory technicians, community health workers, and community health extension workers (CHEWs). Participants were selected using simple random sampling method from the list of staff. Each of those selected gave informed consent at the time of enrolment in the study. Questionnaire was distributed to and filled by the selected HCWs. Biodata and data on the knowledge and practices of standard hand washing at work station was obtained.

The data were entered in Microsoft Excel 2016 computer software and analyzed using Statistical Package for Social Sciences (SPSS) version 16. Tables and charts were used to present the results. A P value of less than 0.05 was considered statistically significant.

  Results Top

One hundred and seventy-three health workers participated in the study. There were 94 (54.3%) males and the remaining were females. Medical doctors constituted 61 (35.3%) of the respondents. One hundred and four (60.1%) of the 173 respondents were working in the healthcare facility for 5 years or less. The demographic characteristics of the respondents are shown in [Table 1].
Table 1: Demographic characteristics of 173 healthcare workers

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All of the 173 respondents practiced hand washing in their place of work. [Table 2] shows various reasons why the respondents washed their hands at the workplace. Only 25 (14.5%) washed their hands on arrival at their work place, whereas 126 (72.8%) washed hands while going home after day's work. The most common (87.3%) reason for washing hands among respondents was after contact with patient's body fluid.
Table 2: Practice of hand washing among 173 healthcare workers

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Majority of the respondents knew how to wash their hands correctly, as shown in [Table 2]. One hundred and twenty-seven (73.4%) always followed correct sequence in hand washing. However, only 64 (37.0%) washed their hands for at least 20 s.

Lack of water and soap were the major constraints against washing hands among HCWs in their place of work, as shown in [Table 2]. Lack of knowledge of how to wash hands was reported as a constraint by only 13 (7.5%).

The respondents used various things to clean or wash their hands at their work lace. These included soap and water, chlorhexidine solution, and alcohol-based hand wash, as shown in [Table 3]. Soap and water was used by 101 (58.4%) of the respondents whereas 24 (13.9%) used water only.
Table 3: Items used in washing and drying hands by 173 respondents

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Free air drying was the preferred method of hand drying after washing, as seen in 78 (45.1%) of the participants [Table 3].

One hundred and thirty (75.1%) of the 173 respondents were trained on washing hands. Many of them learnt from multiple sources. Majority (82.1%) of 173 workers learnt it in school, as shown in [Figure 1]. Forty-three (24.9%) had no training on hand washing from anybody or from anywhere.
Figure 1: Sources of knowledge of proper hand washing among 173 Healthcare Workers

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Significantly (P = 0.0008) more doctors had training on how to wash their hands from somebody than other healthcare workers. Age, gender, and length of practice were not significantly associated with prior training on hand washing, as shown in [Table 4].
Table 4: Demographic features of workers who had formal training on hand hygiene and who did not have

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Logistic regression analysis shows that profession was significantly associated with learning how to wash hands correctly by the healthcare workers [Table 5].
Table 5: Logistic regression of learning how to wash hands versus health workers' profession, gender, age group, and years of practice

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  Discussion Top

All the 173 (100%) participants practiced hand washing while working in the hospital. This shows very high awareness and practice of hand washing in the hospital. Similarly, in larger studies, prevalence of hand washing by medical staff was high.[11],[12],[13],[14]

However, among those who washed their hands, 73.4% always followed the right sequence but only 37.0% rubbed their hands for at least 20 s. It is good that a majority of the staff knew and followed the correct sequence of washing hands. However, it appeared that not enough time was spent by the staff in washing hands. This may be due to a large number of patients to deal with by relatively few staff in a short period. Wetzker et al.[13] reported a similar rate of hand washing (overall median 73%) in a large survey conducted in hospitals in Germany. On the other hand, some researchers reported low hand washing compliance. In Switzerland, for example, Scheithauer et al.[14] found a mean compliance of 42.39%, which was attributed to high workload among health workers.

Hand hygiene following contact with the surrounding (hospital environment) was very low. Only 14.5% of the respondents always washed their hands on arrival at their working place in the hospital before actual contact with patient. Randle et al.[15] also observed the lowest hand hygiene compliance following contact with hospital surrounding compared with following contact with patients.

In contrast, 72.8% of them washed their hands after the day's work before leaving the hospital. While at work, contact with patient's body fluid was the most common reason (87.3%) for always washing hands. This is comparable with the findings of Kingston et al.[10] in 2015 in Ireland where 86% and 91% of the physicians surveyed washed their hands before and after contact with patients, respectively. A high rate of hand washing after exposure to body fluids was observed by Lebovic et al. in Canada.[12]

WHO-recommended alcohol-based hand rub formulations have better antimicrobial property than soap and water or chlorhexidine.[8] Appropriate washing liquids were not always used by the respondents. The most commonly used hand cleaning agent among the respondents was soap and water. Close to one-quarter (24.3%) of the participants had never used alcohol-based hand rubs to clean their hands in the hospital, whereas almost two-thirds (65.4%) either always or sometimes used water only to clean their hands while at work. This may be because they were not available or the staff were not using them. This is similar to what was found in Ireland where only 39% of the physicians almost always used alcohol-based hand rub to clean their hands due to dermatological issues, poor acceptance, or lack of alcohol-based hand rub in the facilities.[10]

After washing hands, the participants mostly dried their hands in the air. Hot air machine had never been used by 84.4% of them because it was not available or there was no electricity to operate the machine.

One-third of the respondents had training on hand washing, mostly from multiple sources. Many of them had the training while in school. Other opportunities for training included special training sessions at working places, observing a senior washing hands, and reading about washing hand. This shows that the participants had many opportunities for training on hand washing which they utilized.

More doctors significantly (P = 0.001) had trainings on hand washing than other health workers who had direct contact with patients. This may be due to more robust training of medical doctors while in school. In Edo state, Nigeria, Alice et al. found a similar pattern where medical doctors and nurses had better knowledge of standard practices including hand washing than other health workers. Number of years on the job did not, however, significantly affect the chance of training on hand washing.

Many constraints to hand washing existed in the hospital. The main constraints identified by the respondents were lack of water and/or lack of soap, as well as lack of alcohol hand rub. Provision of these hand sanitizers is important because basic hand hygiene is very important in preventing transmission of infection from one patient to another and from patient to health workers. A systemic review study found that compliance with hand hygiene was better with introduction of alcohol hand rubs.[17]

Other constraints identified included not knowing how to wash hands, no place provided for washing hands, no time to wash hands while at work, and not remembering to wash hands while at work. Not having enough time for washing hands may be a result of high workload experienced by staff in many hospitals in developing countries such as Nigeria. Previous research conducted in Switzerland showed an inverse relationship between hand hygiene compliance and workload.

  Conclusions Top

Awareness of hand hygiene among the hospital staff surveyed was high and compliance with hand hygiene was good. The main constraint to hand hygiene was unavailability of alcohol hand rub, soap, and water.

Financial support and sponsorship


Conflicts of Interest

There are no conflicts of interest.

  References Top

Garner JS, Simmons BP. Guideline for isolation precautions in hospitals. Infect Control 1983;4:245-325.  Back to cited text no. 1
Larson EA. Causal link between hand washing and risk of infection. Examination of the evidence. Infect Control 1988;9:28-36.  Back to cited text no. 2
Centers for Disease Control. CDC. Guideline for hand washing and hospital environmental control. Infect Control 1986;7:231-43.  Back to cited text no. 3
Pittet D, Mouronga P, Perneger TV. Compliance with hand washing in a teaching hospital. Ann Intern Med 1999;130:126-30.  Back to cited text no. 4
Lankford MG, Zembower TR, Trick WE, Hacek DM, Noskin GA, Peterson LR. Influence of role model and hospital design on hand hygiene of health care workers. Emerg Infect Dis 2003;9:217-23.  Back to cited text no. 5
Onyeonoro U, Ukegbu A, Emelumadu O, Kanu O. Hand washing practices among health care providers in a tertiary hospital in South East Nigeria. J Epidemiol Comm Health 2011;65:470-1.  Back to cited text no. 6
Bello S, Emmanuel EE, Enembe FO, Olabisi AO. Hand washing practice among health care providers in a teaching in Southern Nigeria. Int J Infect Control 2013;9:32-4.  Back to cited text no. 7
World Health Organization. Guideline: WHO Guidelines on Hand Hygiene in Health Care. First Global Patient Safety Challenge Clean Care is Safer Care. Geneva: WHO; 2009. p. 30-156.  Back to cited text no. 8
Pitet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, Perneger T. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000;356:1307-12.  Back to cited text no. 9
Kingston LM, Slevin BL, O'Connell NH, Dunne CP. Attitudes and practices of Irish hospital-based physicians towards hand hygiene and hand rubbing using alcohol-based hand rub: A comparison between 2007 and 2015. J Hosp Infect 2017;97:17-25.  Back to cited text no. 10
Kowitt B, Jefferson J, Mermel, L. Factors Associated with Hand Hygiene Compliance at a Tertiary Care Teaching Hospital. Infect Control Hosp Epid 2013;34:1146-52.  Back to cited text no. 11
Lebovic G, Siddiqui N, Muller MP. Predictors of hand hygiene compliance in the era of alcohol-based hand rinse. J Hosp Infection 2013;83:276-83.  Back to cited text no. 12
Wetzker W, Bunte-Schönberger K, Walter J, Pilarski G, Gastmeier P. Compliance with hand hygiene: Reference data from the national hand hygiene campaign in Germany. J Hosp Infect 2016;92:328-31.  Back to cited text no. 13
Scheithauer S, Batzer B, Dangel M, Passweg J, Widmer A. Workload even affects hand hygiene in a highly trained and well-staffed setting: A prospective 365/7/24 observational study. J Hosp Infect 2017;97:11-6.  Back to cited text no. 14
Randle J, Arthur A, Vaughan N. Twenty-four-hour observational study of hospital hand hygiene compliance. J Hosp Infect 2010;76:252-5.  Back to cited text no. 15
Alice T, Akhere A, Ikponwonsa O, Ehidiamhen G. Knowledge and practice of infection control among health workers in a tertiary hospital in Edo state, Nigeria. Direct Res J Health Pharmacol 2013;1:20-7.  Back to cited text no. 16
Erasmus V, Daha T, Brug H, Richardus J. Systematic Review of Studies on Compliance with Hand Hygiene Guidelines in Hospital Care. Infect Control Hosp Epid 2010;31:283-94.  Back to cited text no. 17
Ekwere TA, Okafor IP. Hand hygiene knowledge and practices among healthcare providers in a tertiary hospital, South West Nigeria. Int J Infect Control 2013;9:i4.  Back to cited text no. 18
Chittaro M, Calligaris L, Farneti F, Faruzzo A, Panariti M, Brusaferro S. Healthcare Workers' Compliance with Hand Hygiene after the Introduction of an Alcohol-Based Handrub. Int J Infect Control 2009;5:i1.  Back to cited text no. 19
Abdulraheem IS, Amodu MO, Saka MJ, Bolarinwa OA, Uthman MMB. Knowledge, Awareness and Compliance with Standard Precautions among Health Workers in North Eastern Nigeria. J Community Med Health Educ 2012;2:131.  Back to cited text no. 20


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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