Intervening with healthcare workers’ hand hygiene compliance, knowledge, and perception in a limited-resource hospital in Indonesia: a randomized controlled trial study

The study was performed in Dr. Saiful Anwar hospital, a 902-bed tertiary care hospital, in Malang, Indonesia. In this hospital, there are four classes of care, including VIP (very important person), class I, II and III related to the room and care facilities. In this study, four departments including pediatrics, surgery, internal medicine, and obstetrics-gynecology (obst-gyn) were involved with characteristics as presented in Table 1. The alcohol-based hand rub that is used in the hospital is produced by the hospital pharmacist according to the WHO formulation II⁶. A hand rub container was attached to the footboard of each bed and next to each entrance door.

The Dr. Saiful Anwar hospital has an infection prevention control team that consists of eight infection prevention control nurses (IPCN), each representing a specific ward (internal medicine, surgery, obst-gyn, pediatrics, intensive care unit, VIP unit, emergency unit, and operation room unit). These nurses work part time as an infection control practitioner and part time as a nurse providing patient care in the wards. The IPCN coordinate a larger team of 48 infection prevention control-linked nurses (IPCLN) who are selected among senior nurses from the different wards. IPCN and IPCLN were recruited based on Pedoman Pencegahan dan Pengendalian Infeksi di Rumah Sakit dan Fasilitas Pelayanan Kesehatan Lainnya (Guideline of Infection Prevention and Control for Hospitals and other Healthcare Services) published by Ministry of Health of the Republic of Indonesia, 2008. Before the start of the study and partly during the study period, the hospital was preparing for a national hospital accreditation. Therefore, the hand hygiene procedure, according to the existing guideline, had been introduced to HCW by the IPCN and IPCLN in collaboration with the hospital accreditation team. In addition, posters presenting the hand hygiene procedures had been posted in the workplaces. Nevertheless, observations of the hand hygiene compliance had not been conducted by the infection prevention control team until the present study started.

The design of the study was a pilot cluster randomized controlled trial, with a total duration of 24 weeks. The study was divided into three phases: pre-intervention (May to June 2014; 8 weeks), intervention (July to August 2014; 8 weeks), and post-intervention (September to October 2014; 8 weeks). The interventions consisted of three different educational programs: (1) active presentations; (2) role model training; (3) a combination of active presentations and role model training. By drawing lots, the four departments were randomly assigned to either one of the three educational interventions or to no intervention (Table 1). Active presentations to the HCW were held on at least three different occasions per ward to ensure that all HCW could participate and focused on the threat of HAIs and hand hygiene procedures [6]. In the intervention with role model training, IPCLN, as role models, received training about the hand hygiene educational program focusing on hand hygiene training techniques, including active presentations, discussions, practicing the hand hygiene procedure and the observation method. The theoretical part of HAIs and their prevention through high hand hygiene compliance was also presented to IPCLN. Therefore, they were able to motivate other HCW to better adhere to the hand hygiene procedures in the ward. The combination of active presentations and role model training was executed separately from the other interventions.

The main outcome and secondary outcome of the study was the hand hygiene compliance among HCW, including doctors, nurses, and students (either nursing students or medical students), and knowledge-perception regarding HAIs and hand hygiene among HCW obtained by a survey in the pre-intervention phase compared to the post-intervention phase, respectively. The direct observation method was applied to establish hand hygiene compliance rates, because this is considered the gold standard [13]. The observations were carried out several times a week during differing time slots, but not during the weekend. Every moment of observation lasted about 30 to 60 min. The outcomes of these observations were presented as percentages of compliance representing the fraction of the number of times when hand hygiene should have taken place correctly, and the number of times it had actually taken place correctly. The hand hygiene compliance observation sheet as well as knowledge and perception questionnaires were based on the WHO tools [6]. The knowledge survey consisted of three single item and three multiple item (i.e., more than one answer) questions on the following topics: transmission of microorganisms, source of HAIs, and hand hygiene indications. A correct answer was awarded with one point, with a maximum score of 12 points for 12 correct answers. A wrong answer led to one score deduction for multiple item questions, and a score of zero for a wrong answer to a single item question. The perception survey consisted of 12 yes/no questions, 13 of a 4-Likert-items scale questions (the last two points of the scale were considered as positive perception), and 3 open-ended questions, and included: intention to adhere to hand hygiene, risk of cross-transmission and HAIs related to non-compliance, social norms concerning hand hygiene, and hand hygiene methods, indications, importance, promotion, and compliance barriers. In addition, the three open-ended questions concerned the perception of HCW on the risk of patients acquiring HAIs, the hand hygiene compliance rate that should be achieved, and self-reporting of the hand hygiene compliance level.

When the HCW were providing patient care in the wards and filling out the surveys, two observers concurrently recorded their clothing regarding jewelry on the arms or fingers, long sleeves, and nail polish.

The study was approved by the medical ethics committee (No 129/EC/KEPK-JK/05/2012). Informed consent was not obtained, since it involved little risk of harm for the participants and the study was regarded as a hospital infection control program. Anonymity of HCW was guaranteed in the knowledge and perception survey.

The overall compliance to hand hygiene with confidence intervals (95%CI) was calculated using the standard normal distribution. To assess differences in compliance and each of the WHO five moments of hand hygiene at the different departments between pre- and post-intervention, the Pearson Chi-Square statistic or the Fisher’s exact test was used when applicable. If the compliance in pre- and post-intervention at the departments with intervention (i.e., pediatrics, surgery and internal medicine) was significantly different from the department without intervention (i.e., obst-gyn), the Pearson Chi-Square statistic was used followed by the Mantel-Haenszel statistic. In addition, knowledge and perception improvement were analyzed using the independent T-test and the Chi-Square test, respectively. Backward multiple logistic regression analysis was performed to determine factors associated with hand hygiene compliance and included department, class, room type, nurse-to-patient ratio, moment of hand hygiene, and HCWs’ professions before and after intervention. A P value of < 0.05 was considered statistically significant and all analyses were performed using IBM SPSS version 21 (SPSS Inc., Chicago, IL, USA).

During the study period, 2,766 potential hand hygiene opportunities were observed at the 4 participating departments. The overall compliance to hand hygiene was 19.5% (95%CI: 18.0 to 20.9). After intervention, the hand hygiene compliance rate increased both in the departments with intervention (i.e., pediatrics, internal medicine, and surgery) and in the department without intervention (i.e., obst-gyn) from 16.1% to 27.1% and from 10.1% to 20.5%, respectively. Departments pediatrics, internal medicine and obst-gyn improved significantly when comparing pre-intervention to post-intervention (P < 0.001). However, the intervention did not significantly improve hand hygiene compliance in the surgery department (P = 0.05). When considering the different types of HCW, hand hygiene compliance of doctors and nurses improved significantly post-intervention (P < 0.001), but not among students (P = 0.840). For the 538 opportunities with good hand hygiene compliance, it was observed that HCW used hand rub at 379 (70.6%) opportunities, whereas at 159 (29.6%) opportunities they washed their hands. We did not find a significant increase in the use of hand rub in the departments with intervention (Table 2). For the 2,228 opportunities with non-compliance, we found that HCW used hand rub while wearing gloves (GA) at 74 (3.3%) opportunities, wore gloves when it was not necessary at 157 (7.0%) opportunities, and did not perform hand hygiene at all at 1,997 (89.6%) opportunities. When comparing pre-intervention and post-intervention phases, the nurses who did not perform hand hygiene at all and wore gloves when it was not necessary decreased significantly (P = 0.024 and P = 0.046, respectively), however their use of hand rub while wearing gloves increased (P < 0.001). Similarly, the students who wore gloves when it was not necessary decreased but the use of hand rub while wearing gloves increased significantly (P < 0.001) (Table 3). With regard to clothing among nurses in the pre-intervention phase, 17% of the nurses wore jewelry, 31% of the nurses had long sleeves and 33% wore both jewelry and had long sleeves. Thus, a total of 81% did not wear appropriate clothing.

Based on the five moments of hand hygiene recommended by the WHO, the highest compliance was to moment 4 (27.4%) (i.e., after touching a patient). The lowest compliance was to moment 5 (12.2%) (i.e., after touching patient surroundings). Table 4 shows compliance considering the five moments pre-intervention and post-intervention at the four participating departments.

Independent of phase (i.e., pre-intervention and post-intervention), we observed a statistically significant difference between compliance at departments obst-gyn and surgery (P < 0.001), and between obst-gyn and pediatrics (P < 0.001). When adding phase as a confounding factor, the relationships remained significant (P = 0.001 and P < 0.001, respectively). Independent of phase (i.e., pre-intervention and post-intervention), we did not observe a statistically significant difference between compliance at departments obst-gyn and internal medicine (P = 0.207). When adding phase as confounding factor, the relationship remained non-significant (P = 0.069).

Multivariate analysis showed that when comparing the pre- and post-intervention phase, the pediatric and surgery department was significantly associated with hand hygiene compliance improvement among HCW (odds ratio [OR] 4.078 and 1.963; 95%CI 1.513-10.994 and 1.178-3.270, respectively). Other factors associated with the hand hygiene compliance at the different departments were general adult room (OR 1.710; 95%CI 1.002-2.918), class III room facilities (OR 1.993; 95%CI 1.168-3.400), WHO moment of before touching a patient and after touching a patient (OR 1.442; 95%CI 1.057-1.968 and OR 2.333; 95%CI 1.850-2.943, respectively). Professional categories being either a doctor or a nurse was also associated with hand hygiene compliance improvement in the post-intervention phase (OR 1.366; 95%CI 1.012-1.843 or OR 1.279; 95%CI 1.019-1.604) (Table 5).

A total of 284 HCW participated in the knowledge and perception survey regarding hand hygiene and HAIs in the pre- (total n = 196; internal medicine, 56; surgery, 33; obst-gyn, 47, and pediatrics, 60) and post-intervention phase (total n = 88; internal medicine, 33; surgery, 18; obst-gyn, 15; pediatrics, 22). Overall, the average score was 5.8 (SD = 2.1), the median score was 6 and the mode score was 7/12, whereas the minimum and maximum score were 1/12 and 11/12, respectively. After interventions, the average of knowledge score improved from 5.6 (SD = 2.1) to 6.2 (SD = 1.9) (P < 0.05). We classified the knowledge score to be low level (0-5) and high level (6-12) and noted a significant increase in the proportion of high level scores in the pediatrics department (P < 0.05) after the intervention. There was not a significant change identified in other departments (Table 2). Also, we did not find a significant increase in the proportion of high level scores among doctors, nurses, and students in the four departments. The results of the perception survey on intention to adhere to hand hygiene, risk of cross-transmission and HAIs related to non-compliance, social norms concerning hand hygiene, hand hygiene indications, methods and promotion are presented in Table 6. In the departments with intervention, positive perception was demonstrated by 69.1 to 98.7% of HCW in the pre-intervention phase and 67.1 to 98.6% of HCW in the post-intervention phase to all perception items. The survey in the department without an intervention showed that 63.8% to 100% of HCW in the pre-intervention phase and 80 to 100% of HCW in the post-intervention phase answered with positive response. There was no significant improvement of the hand hygiene perception before and after the interventions. However, “strong smell of hand-alcohol” as a reason not to perform hand hygiene increased significantly in the departments with intervention. The perception of HCW in the departments with intervention regarding the average percentage of hospitalized patients who will develop a HAI increased significantly from 49.7 to 58.6% (P < 0.05) in the post-intervention phase. In addition, the self-reporting of hand hygiene compliance rate decreased from 85.5% to 75.1% (P < 0.001). We did not find any significant difference in the perception survey in the department without intervention between pre- and post-intervention (Table 6).