Text Box:  
ORIGINAL ARTICLE

 

Pak J Med Res

Vol. 45, No. 4, 2006.

 

Knowledge, Attitude and Practice Patterns of Handwashing in Major Public Sector Hospitals of Karachi

 

Masood Hussain Rao

PMRC Research Center, Dow Medical College, Karachi

 

ABSTRACT

 

Aims: To determine the knowledge, attitude, and practice pattern of hand washing in medical professionals of some public sector hospitals and determine the variations in different groups and also check the availability of hand washing facilities at these sites.

Methods: A questionnaire based study was conducted at 10 wards and 10 OPD’s of six major public sector hospitals of Karachi. From each unit, 5 staff members (2 doctors 3 paramedics) were selected A precoded proforma was used to collect the information.

Results: A total of 386 individuals were interviewed and rest could not be accessed due to non availability. Of the total only 68.8% had sufficient knowledge about the benefits of hand washing while the facility was available at only 16.8% (16/96) units. Although 59% of those interviewed said that they were adopting the practice of hand washing but when observed only 8.9% doctors and staff were practicing it. Majority (62.7%) used the toilet soap for hand washing which they purchased themselves. Only 33.4% individuals thought that soap and water were adequate for disinfection whereas others (66.6%) did not think so. Attitude of 48.7% doctors and 66.2% paramedical staff was positive for adopting the hand washing practices provided the facility was available to them. Main reason for not washing hands was non availability of the facility and heavy rush of patients.

Conclusion: To prevent nosocomial infection, the hospital management should provide hand-washing facilities at all sites where patients are examined. Seniors should make sure that they adhere to this practice and also keep a check on their juniors. Health education should be provided regularly through print and visual media and workshops.

 

Key word:        Handwashing.

 

INTRODUCTION

 

Hand washing can prevent potentially fatal infections spreading from patient to patient and from patient to health care workers. Careful hand washing or use of antiseptic after examination of each patient is one of the important measures for preventing the spread of pathogens in the hospitals. Although a number of studies have been done on this issue internationally, but scanty work has been done locally. About one and a half century ago, Dr Semmelweis1, 2, demonstrated that routine hand washing prevents the spread of disease and reduces hospital-acquired infections by half thus saving precious resources. Transmission of the microorganisms from the health care personnel has been found to be the main source of cross infection in Hospitals, which can be, prevented by hand washing3. According to a US study, viruses and bacteria spreading from hospitals infect about 2 million patients each year and kill about 90 000 patients4. According to a study2, health care workers often wash their hands for an average of only 8.5 to 9.5 seconds whereas a minimum of 10 seconds is recommended.

It is a general practice in our society that medical personnel frequently skip hand washing between patients, because either the hand washing facility is not available or the procedure is not felt important or is time consuming. In developing countries like Pakistan where financial resources are limited and there is shortage of beds and doctors (1517 persons per bed and one doctor for 1466 persons)5, we cannot afford to exhaust our limited resources on hospital-acquired infections. It is therefore essential to adopt some measures to reduce the infection rate.  The  present  study was done to study the knowledge, attitude, and practice pattern  of  hand  washing  in  various  groups  of  public sector  medical  professionals  of  Karachi  and  see  if  any difference  in  knowledge,  attitude,  and  practice occurs in different levels of health care workers and also simultaneously check the assess and availability of hand washing facilities in these hospitals.

 

 

SUBJECTS AND METHODS

 

The study was conducted at six major public sector hospitals of Karachi where thousands of patients come from all over the city including some from interior of Sindh and Baluchistan provinces. The Ethical Review Board of Dow University of Health Sciences, Karachi approved the project. A written consent was obtained from the Director/Medical Superintendent of the hospital before starting the study and a written conse

As per protocol interviews were conducted from 10 wards and 10 out patient departments (OPD) of the same units. These included 2 units of Medicine and Surgery and one each of ENT, Eye, Dermatology, Gynecology, Pediatrics and Casualty/Intensive Care Unit (ICU). From each department (ward or OPD), 5 staff members were selected on the basis of availability and they were interviewed. The staff included two doctors (one senior and one junior) and three paramedics (one head/staff nurse, one nurse/student nurse and one dispenser /dresser/ trainee technicians). The Principal Investigator visited each hospital three times a week and interviewed these personnel using a pre coded, pre tested questionnaire. Besides the interview, an observational questionnaire was also filled to see the actual availability of the facility and practices of the staff. Out of 120 units to be studied, only 96 were studied and a total of 386 questionnaires were filled from 6 major public sector hospitals. The reason for shortfall of the targeted interviews was that all OPD units/wards were not available at some hospitals whereas nursing staff was also not available at few places especially in the OPD’s. For the assessment of general cleanliness of the unit or ward i.e. dusting condition, cow web cleaning, proper dustbin near the staff and patient’s bed with covers, proper ventilation and proper drainage facility were considered as good .If some of these facilities were missing, they were considered as adequate and if most of them missing, it was considered as bad.

 

RESULTS

 

The data of 386 individuals was collected from 6 major public sector hospitals of the city. Of the total, 191 were doctors and 195 were staff members. (Table 1 A & 1B)

 

Table 1A:  Category v/s hospital position of staff interviewed for the project.

 

Name of hospital

Category

Total

Senior doctor

Junior doctor

Head/

Staff nurse

Nurse

Dispenser/Dresser/

Student nurse/Technicians

 

Sindh.Government Hospital,

Liaquatabad (SGHL)

16

16

9

4

6

51

National Institute of Child Health (NICH)

11

10

9

8

8

46

Jinnah Postgraduate Medical Centre (JPMC)

18

18

12

13

16

77

Civil Hospital Karachi (CHK)

20

20

14

15

16

85

Sindh Government Qatar Hospital (SGQH)

15

15

9

11

10

60

Layari General Hospital (LGH)

16

16

12

10

13

67

Total

96

95

65

61

69

386

 

Table 1B:  Wards/OPD v/s hospital position of staff interviewed for the project.

 

Name of Hospital

OPD

Wards

Total

Doctors

Paramedical staff

Doctors

Paramedical staff

Sindh.Government Hospital,

Liaquatabad (SGHL)

18

5

14

14

51

National Institute of Child Health (NICH)

11

10

10

15

46

Jinnah Postgraduate Medical Centre (JPMC)

18

15

18

26

77

Civil Hospital Karachi (CHK)

20

15

20

30

85

Sindh Government Qatar Hospital (SGQH)

18

12

12

18

60

Layari General Hospital (LGH)

18

15

14

20

67

Total

103

72

88

123

386

 

 

According to the assessment of knowledge, majority (68.8%) of the health care providers had the knowledge about the benefits of hand washing, while the remaining 31.2 % did not think that hand washing was mandatory after examination of every patient. (Table 2)

 

Table 2:   Knowledge about benefits of Handwashing.

 

 

Doctors

(191)

%

Paramedical Staff (195)

%

Total

(386)

%

 

 

 

 

 

 

 

Do you think that hand washing reduces the chances of transfer of micro-organisms from one patient to another

191

100.0

195

100.0

386

100.0

Do you think that hand washing reduces the chances of development of general infection in the hospital

190

99.5

195

100.0

385

99.7

Do you think that proper hand washing reduces the duration of stay of patients in the hospital

139

72.8

106

54.4

245

63.4

Do you think that due to proper hand washing, the hospital cost of medicines per patient reduces?

117

61.3

57

29.2

174

45.1

Do you think that it helps to reduce rush in the hospital?

29

15.2

14

7.2

43

11.1

Do you think that it helps in improvement of health environment in the hospital?

175

91.6

171

87.7

346

89.6

Any other (specify)

50

26.2

73

37.4

123

31.9

What time do you think is suitable for hand wash in hospital?

a) Only before starting the examination

b) Only after examination of some serious patient

c) After examination of every patient

 

 

3

59

129

 

 

1.6

30.9

67.5

 

 

8

50

137

 

 

4.1

25.6

70.3

 

 

11

109

266

 

 

 

2.9

28.2

68.8

 

 

When inquired whether these health care providers were also practicing hand washing after examination of every patient, overall 59% (228/386) stated that they were practicing it including 40% doctors (91/228) and 60% (137/228) paramedical staff. Of the 191doctors 91(48%) and of the 195 paramedical staff 137(70%) said that they were practicing hand washing. Most of the doctors and paramedical staff (62.7%) were using toilet soap for hand washing, which was bought by them, though 33.4% did not think that hand washing with toilet soap was sufficient to prevent infection. (Table 3)

 

Table 3:    Practice pattern of handwashing.  (Only yes reply tabulated below)

 

Practice pattern

Doctors

(191) Yes

%

Paramedical staff (195) Yes

%

Total

(386) Yes

%

 

 

 

 

 

 

 

Do you adopt it after examination of every patient?

91/191

47.6

137/195

70.3

228/386

59.1

What type of detergent you use

a) Only water

b) Beauty soap

c)Antibacterial solution

d) Antibacterial soap

e) Antibacterial tissue

f) Sprit swab

g) Gloves

h) Sprit Swab +gloves

 

11

121

51

4

1

2

0

1

 

5.8

63.4

26.7

2.1

0.5

1.0

0.0

0.5

 

3

121

63

1

0

6

1

0

 

1.5

63.4

32.3

0.5

0.0

3.1

0.5

0.0

 

14

242

114

5

1

8

1

1

 

3.6

62.7*

29.5

1.3

0.3

2.1

0.3

0.3

Do you think what you are going to use is sufficient to protect yourself and other patients from infection

55

28.8

74

37.9

129

33.4

 

 

 

 

 

 

 

*Significantly higher

 

When inquired about the facilities available for hand washing, majority (83.2%) said that these facilities were not available, while 17% doctors and paramedical staff said that it is available. The details of the facilities which were not available was; no water at 56% sites, detergent was missing at 76 % sites and there was no washbasin at 40% sites. (Table 4).

 

 

Table 4:   Facilities available for handwashing.

 

FACILITIES

Doctors

(191)

Paramedical staff (195)

Total

(386)

Yes

No

Yes

No

Yes

No

Whether all the required facilities available at your department

26

(13.6%)

 

165

(86.4%)

39

(20.0%)

156

(80.0%)

65

(16.8%)

321

(83.2%)

What type of facilities are not available

a) Washbasin

b) Water

c) Detergent

d) Any other

i) Nothing is available

ii) Gloves

iii) Towel

iv) Dryer

v) Tissue

vi) Antiseptic solution

vii) Strong detergent

viii) Drainage

ix) Mics

 

76

117

151

 

96

40

22

15

4

21

8

3

37

 

%

39.8

61.3

79.1

 

50.3

20.9

11.5

7.9

2.1

11.0

4.2

1.6

19.4

 

 

79

100

143

 

119

31

21

17

2

19

4

4

9

 

%

40.5

51.3

73.3

 

61.0

15.9

10.8

8.7

1.0

9.7

2.1

2.1

4.6

 

155

217

294

 

215

71

43

32

6

40

12

7

46

%

40.2

56.2

76.2

 

55.7

18.4

11.1

8.3

1.6

10.4

3.1

1.8

11.9

 

To assess the attitude of these health care providers, they were asked that if all the hand washing facilities are provided to them in their ward near to their working place, would they then adopt hand-washing practice properly. Only 48.7 % doctors and 66.2% paramedical staff said that they would adopt hand washing if these facilities were provided to them while the rest still were not willing to hand wash. The reasons for not adopting hand-washing practice were lack of time reported by 32.4%; heavy rush of patients by 34.7%, non-conducive atmosphere by 28.8% and 6.5% reported that seniors did not allow them to leave for hand washing during the rounds. (Table 5)

 

Table 5:  Attitude regarding handwashing.

 

Attitude

Doctors

(191)

Paramedical staff

(195)

Total

(386)

Yes

No

Yes

No

Yes

No

If all the required facilities provided, do you adopt the hand washing techniques properly after every patient.

93

(48.7%)

98

(51.3%)

129

(66.2%)

66

(33.8%)

222

(57.5%)

164

(42.5%)

Reasons for not adaptation of hand washing techniques.

a) Having no time for it

b) Due to heavy rush of patients

c) Seniors did not allow

d) Suitable atmosphere is not available

e) Any other

i) Health education

ii) Not interested

iii) Facilities not available

iv) Due to rush

 

Yes

 

74

79

11

72

 

1

0

1

1

%

 

38.7

41.4

5.8

37.7

 

0.5

0.0

0.5

0.5

Yes

 

51

55

14

39

 

1

1

0

0

 

%

 

26.2

28.2

7.2

20.0

 

0.5

0.5

0.0

0.0

Yes

 

125

134

25

111

 

2

1

1

1

%

 

32.4

34.7

6.5

28.8

 

0.5

0.3

0.3

0.3

 

When asked as to how to improve the situation, majority (69.2%) said that water and detergent should be provided along with health education through workshops, which should be run regularly. (Table 6)

 

Table 6:  Comments on how to improve the situation.

 

Comments

Doctors

(191)

Paramedical staff (195)

Total

(386)

No.

%

No.

%

No.

%

Facilities provided like filter water better detergent

Health education provided/attitude or motivation development /counseling

Number of doctors/paramedical staff increases

Hygiene condition of the hospital should be made better

Repeated reminder

Proper management should be developed

Senior should practice and guide the juniors

Sterilization of all equipment should be made

Strict supervision/watch over staff/administration watch over supply and utilization

Through poster display

Supply should be smooth/permanent

Media campaign

Mics (workshops/ventilation /patients awareness through practicing by the doctors /corruption stop /funds utilized properly /self determination/proper place /collective efforts / appriciation/essy accessible/ dry system/ water provided /working conditions improved etc=35

 

143

115

 

14

13

15

8

12

8

7

 

7

7

6

35

74.9

60.2

 

7.3

6.8

7.8

4.2

6.3

4.2

3.6

 

3.6

3.6

3.1

18.3

124

81

 

14

8

2

8

3

4

5

 

4

1

1

9

63.6

41.5

 

7.2

4.1

1.0

4.1

1.5

2.1

2.6

 

2.1

0.5

0.5

4.6

267

196

 

28

21

17

16

15

12

12

 

11

8

7

44

69.2*

50.8*

 

7.3

5.4

4.4

4.1

3.9

3.1

3.1

 

2.8

2.1

1.8

11.4

 

 

A part from questionnaire based interviews, physical verification of the facilities and the practices of the health care providers were also assessed. It was noticed that 61% units did not have a washbasin near the doctor’s or staff rooms. At 66% places water and at 68% places detergent were not available. Similarly gloves were not available at 71% units. At some places these facilities were available only to the senior doctors where as junior doctors and other staff was not allowed to use it. Only 8.9 % doctors and staff were found practicing hand washing. General cleanliness of the wards/OPDs was recorded as bad or very bad at 23% units and adequate in 50.6% units while only 26% units were labeled as good in general cleanliness.

 

DISCUSSION

 

The present study shows that basic facilities for hand washing were not available at majority of the public sector teaching Hospitals in Karachi due to which even those who have knowledge about the importance of the hand washing are unable to practice it. Only 16.8% doctors and paramedical staff said that hand-washing facilities are available at their place of duty. In a study8, electronic monitoring  and voice prompts improved  hand washing and decreased nosocomial infection.

According to the present study, if proper hand washing facilities were provided at public sector hospitals, a better  result could be obtained.

However according to a study6, it was proved that accessibility to wash basin does not improve the compliance of hand washing. In another study7-10,  in the private hospitals where administrative support for the hand-washing program was significantly greater, hand washing compliance was significantly higher. In another study11, there was no significant difference in hospital staff in any phase of the study in hand washing practices. The study showed that constant motivation through movies, brochures, and posters, transiently increased the frequency of hand washing among the house staff of a tertiary care facility. In a study12, conducted in Canada, it was concluded that nurses adjusted their hand washing rates according with the risk level of each visit. In another study13 conducted in Australia, the rate of hand washing was increased from12.4% to 54.6% after induction of written advice for five weeks. In the present study it was suggested by the participants that motivation through media, conferences, and posters could help to change the situation. According to our study, overall 59.5% staff said that they were practicing hand washing but during physical verification, only 8.9% staff was doing so. Comparing our results with the Indian study14, a lapse in hand washing was observed in 41% cases and they concluded that nothing other than an individual’s commitment is likely to prevent hospital acquired infection.

In order to reduce nosocomial infection, the hand washing practices in health care providers need to be emphasized but before that facilities for hand washing be introduced. Water filters and hand washing detergents may be installed at all places where patients are examined. Apart from the hospital administration drug companies and philanthropic support can be used to install and maintain these facilities

It is suggested that such type of study should be done at a large scale in all public sector and some private sector dispensaries of the Sindh Province especially in rural areas, to see if difference exists between rural and urban behavoiur and between public and private sector. Such a study shall also provide basic information regarding infrastructure available for hand washing at different levels.

 

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