Table of Contents  
Year : 2022  |  Volume : 30  |  Issue : 3  |  Page : 110-115

Perception of Hand Hygiene Practice among Eye Care Workers in Onitsha, Nigeria

Center for Eye Health Research and Training, Nnamdi Azikiwe University, Awka, Anambra State; Guinness Eye Centre, Onitsha, Anambra State, Nigeria

Date of Submission28-Jun-2022
Date of Decision31-Aug-2022
Date of Acceptance09-Oct-2022
Date of Web Publication09-Dec-2022

Correspondence Address:
Dr. Adaora A Onyiaorah
Department of Ophthalmology, Nnamdi Azikiwe University, Awka Anambra State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njo.njo_13_22

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Objectives: To determine the perception of hand hygiene practice by eye care workers of a tertiary hospital in Nigeria. Methods: This was a cross-sectional study of eye health workers at a tertiary hospital in Nigeria using the WHO Hand Hygiene Perception questionnaire to obtain information on different aspects of hand hygiene perception. Responses were graded as good (≥75%); moderate (50–74%); poor (<50%). Information obtained was analyzed. Results: Fifty-three eye care workers comprising 11 (20.8%) males and 42 (79.2%) females with age range 28 to 68 years; mean of 43.8 ± 9.0 years. Average work experience was 18.5 ± 9.6 years. Nurses and doctors constituted 47 (88.7%) participants. Mean overall perception score was 36.2 ± 9.0 (or 61.4%). Hand hygiene practice perception was good in 11 (20.7%), moderate in 32 (60.4%), and poor in 10 (18.9%) participants. Doctors had significantly higher mean score (39.7 ± 8.0) than nurses (33.5 ± 8.0) (P = 0.04). Fifty-one (96.2%) had soap and water at the service point but these were not always available all the time to 40 (75.5%) participants. Alcohol-based hand sanitizer was unavailable to 41 (77.4%); 13 (24.5%) participants had posters of hand washing at their service points. Fifty (94.3%) participants would want hospital management to lend greater support to hand hygiene practice. Conclusions: Hand hygiene practice perception was only moderate among the participants. Institutional support via frequent training and reminders on hand hygiene, and steady water and soap supply at service points would help to improve hand hygiene perception and practice among eye care workers.

Keywords: Eye health workers, hand hygiene, perception

How to cite this article:
Uba-Obiano CU, Onyiaorah AA, Akudinobi CU, Okpala NE, Ezenwa AC, Nwosu SN. Perception of Hand Hygiene Practice among Eye Care Workers in Onitsha, Nigeria. Niger J Ophthalmol 2022;30:110-5

How to cite this URL:
Uba-Obiano CU, Onyiaorah AA, Akudinobi CU, Okpala NE, Ezenwa AC, Nwosu SN. Perception of Hand Hygiene Practice among Eye Care Workers in Onitsha, Nigeria. Niger J Ophthalmol [serial online] 2022 [cited 2023 Mar 22];30:110-5. Available from:

  Introduction Top

Health care associated infections (HCAI) are an important cause of morbidity and mortality in the healthcare setting. The World Health Organisation (WHO) reported that one in 10 patients who received care in the hospital acquire an infection.[1] Hand hygiene measures including washing hands with soap and water and use of alcohol-based hand sanitizer have been found to be effective in the control and prevention of infections in healthcare facilities.[2] It is therefore not surprising that the WHO recommended hand hygiene for control of health care associated infections.[3]

Eye care workers’ hands have been identified as a source of healthcare associated infections in ophthalmic practice.[4],[5] Hand hygiene is therefore critical in controlling healthcare-associated infections in eye care setting.

Perception of hand hygiene has been shown to have a strong correlation with self-reported hand hygiene performance.[6],[7] Changes in perception influence adherence to hand hygiene practices.[6],[7] This means that good perception will drive compliance with hand hygiene.

Hand hygiene perception has been reported among different health care workers in various settings and specialties with many showing moderate to good perception.[8],[9],[10],[11],[12],[13] Hand hygiene rates have been found to vary between units or specialties even within the same health institution.[14],[15]

Perception of hand hygiene among ophthalmic care givers had not been widely documented. This study therefore aimed to determine the perception about hand hygiene practices among eye care workers of a tertiary hospital in Nigeria. Information obtained will be invaluable in reorientation and training of eye care workers on recommended hand hygiene practices.

  Materials and Methods Top

The study was conducted in accordance with provisions of the Helsinki Declaration on research involving human subjects.[16] Ethical approval was obtained from the Institutional review board of the local institution. Written consent was obtained from all participants and confidentiality of their information assured.

This was a cross-sectional study conducted in March 2021 among eye health care workers involved with clinical duties at the Guinness Eye Center, a tertiary eye hospital in Onitsha, South-East Nigeria. A census of all consenting eye care workers was done. Data were obtained from all consenting eye care workers that routinely interact with patients in the course of their clinical duties. Excluded were workers that do not routinely have clinical patient interactions in the course of their duties such as security personnel, administrative staff, and those in the works department of the hospital. Also excluded were those who did not give consent for the study.

The World Health Organization Hand Hygiene Perception questionnaire (2009 Revision),[17] was used for our study. The questionnaire sought information on the participants’ age, gender, professional category, work experience, formal training in hand hygiene, routine use of hand sanitizer, availability of running water, soap, hand sanitizer, and poster on hand hygiene. It also contained 16 questions on hospital-acquired infections and hand hygiene perception including two open ended questions and 14 questions with Likert-type responses. Of these 14 questions each with five options, 11 had “don’t know” as 5th option. For these 11, the score assigned for the responses was 0 to 4 because “don’t know” was scored zero. For the remaining three questions, the score assigned was 1 to 5. Total score obtainable was 59. Overall scores were expressed in percentage (out of 59) and then ranked; an overall score of ≥75% was considered as good, 50% to 74% moderate, and <50% poor perception.

Data from all participants were then collated and processed using the Statistical Package for Social Science (SPSS) version 23 (SPSS Inc. Chicago, IL, USA). Data were analyzed using descriptive and inferential statistics; Chi-square or Fishers exact test was used to test association between variables while Analysis of Variance (ANOVA) or t test was used to compare means where applicable. Tukey posthoc test was used to determine differences in group means. The alpha level was set at 0.05.

  Results Top

There were 53 participants including doctors, nurses, laboratory scientists, and hospital attendants were studied; there were 11 (20.8%) males and 42 (79.2%) females with age range was 28 to 68 years, mean age was 43.8 ± 9.0 years. Work experience ranged from 1 to 40 years; mean 18.5 ± 9.6 years. Nurses, 24 (45.3%) closely followed by doctors 23 (43.4%) constituted the highest number. [Table 1] shows the socio-demographic characteristics of the participants. Thirty-three (62.3%) participants received training on hand hygiene in the preceding 3 years while 20 (37.7%) did not receive any. A higher proportion of nurses, 23 (95.8%), than other professional categories received hand hygiene training (P = 0.001). Distribution of participants by hand hygiene training and professional category is shown in [Table 2]. Twenty (37.7%) participants routinely used hand sanitizer while 33 (62.3%) did not.
Table 1 Socio-demographic characteristics

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Table 2 Hand hygiene training by professional category

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Running water was reported to be available at service points by 49 (92.5%). Of these, 11 (22.4%) had water all the time, 32 (65.3%) had water half of the time while 6 (12.3%) had water less than half of the time. Fifty-one (96.2%) eye health workers had soap and water provided at their service point. Soap and water were available all the time to 13 (25.5%) participants, half the time to 35 (68.6%), and less than half of the time to 3 (5.9%). Alcohol-based hand sanitizer was provided at service points to only 12 (22.6%); out of which, 5 (41.7%) had alcohol-based hand sanitizer all the time, another 5 (41.7%) had it half of the time, while 2 (16.7%) had it less than half of the time.

Thirteen (24.5%) participants had posters showing technique of hand washing at their service point. Twenty-two (41.5%) of the participants did not know the average percentage of hospitalized patients that will develop HCAI if sanitation breaks down; this was followed by 16 (30.2%) who thought HCAI would occur in 1% to 20% of hospitalized patients [Table 3]. There was no statistically significant association between perception on hospital acquired infections and professional category; (Fisher exact = 13.389; P = 0.69).
Table 3 Distribution of eye care workers’ perception on average percentage of hospitalized patients that will develop HCAI

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Only 11 (20.7%) had good perception, 32 (60.4%) had moderate perception while 10 (18.9%) participants had poor perception. The mean overall perception score was 36.2 (61.4%) ± 9.0 (15.3%), ranging between 12 (20.3%) and 53 (89.8%). There was no statistically significant difference in mean within gender, age, and experience groups. There was a statistically significant difference (F2,50 = 3.372; P = 0.04) between the mean perception scores of the different professional categories; doctors (39.7 ± 8.0) than nurses (33.5 ± 8.0) and other professionals (33.2 ± 13.4; P = 0.04) [Table 4]. Using Tukey posthoc test, there was a trend towards perception score of doctors being higher (39.7 ± 8.0) than nurses (33.5 ± 8.0); (P = 0.048). There was no statistically significant difference between the mean score of doctors or nurses and other professionals (P > 0.05).
Table 4 Perception score by socio-demographic characteristics

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Only 20 (37.7%) felt that HCAI had high or very high impact on clinical outcome of patients while 28 (52.8%) felt the impact was low and 5 (9.4%) felt the impact was very low. Thirty-two (60.4%) thought that hand hygiene is given high or very high priority at their institution [Table 5]. Concerning perception on actions that could be effective in improving hand hygiene, 50 (94.3%) participants felt that support and promotion of hand hygiene by leaders in their institution would be effective in increasing hand hygiene practice; 32 (60.4%) felt education on hand hygiene will be at least moderately effective; 21 (39.6%) opined that provision of hand sanitizer will not be effective, 18 (34.0%) thought that hand hygiene posters will not be effective, and 23 (43.4) felt use of patients as reminders for hand hygiene will not be effective [Table 6]. [Table 7] shows the importance accorded hand hygiene in the hospital. While 30 (55.6%) respondents felt that institutional heads attached high or very high importance to hand hygiene, 9 (16.9%) stated that their superiors were either indifferent or attached no importance to hand hygiene. On the other hand, 38 (71.7%) felt that their colleagues attached high or very high importance to hand hygiene while only 15 (28.3%) felt that patients attach high or very high importance to hand hygiene. [Table 8] shows what respondent felt were the magnitude of effort put in carrying out hand hygiene while caring for patients. While 21 (39.6%) considered it big effort, 1 (1.9%) considered it no effort. Forty-three (81.1%) participants performed hand hygiene in 61% to 100% of situations in which it would be necessary to do so.
Table 5 Perception of priority accorded hand hygiene at the hospital

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Table 6 Perception of effectiveness of actions taken by institution to improve hand hygiene

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Table 7 Perception of importance accorded hand hygiene in the hospital

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Table 8 Effort required for hand hygiene

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  Discussion Top

From our study, it was encouraging to find that majority of the eye care workers had moderate to good perception of hand hygiene. This could help ensure compliance of hand hygiene. Similar findings were reported in Saudi Arabia.[18] A higher mean perception score was reported in Malaysia.[6] Doctors in our study, exhibited higher mean perception scores than nurses. The lack of significant difference between doctors and other health professionals may be due to the low number of the other professionals in this study. The finding that majority of the participants think that support and promotion of hand hygiene by leaders in their institution will be effective in improving hand hygiene compliance highlights the crucial role of the leaders and administration of healthcare institutions in hand hygiene and infection prevention and control. This finding is similar to those reported in other studies.[6],[18]

The perception by many of the participants that availability of hand sanitizer would not improve hand hygiene points to a need for reorientation on the importance and use of hand sanitizers. This is in contrast to findings of a study in Pakistan where availability of hand sanitizer was perceived as a key strategy in improving hand hygiene.[11] Also, majority felt that the use of patients as reminders for hand hygiene will not be effective in improving hand hygiene. Another study found that some health care workers did not support the idea of being reminded by patients to perform hand hygiene. The major reasons given for this negative attitude were that it was not part of the patients’ role. Other reasons were that it would be too time consuming, upsetting or humiliating, and could cause loss of confidence in the competence of healthcare worker by the patient.[19]

The perception by over 90% that the head of their institution, colleagues, and patients considered hand hygiene by the participants important could serve as a factor that could drive compliance to hand hygiene in these health workers. This is further reinforced by the finding that majority of the participants’ consideration of themselves as role models to others was thought to be an effective strategy in improving hand hygiene practice. The finding that nearly 40% of participants consider the effort they put into hand hygiene as big effort is worrisome. If health care workers consider hand hygiene burdensome, then the practice may not be adhered to. In this situation, nosocomial infection should be of real concern.

Though >80% of participants will perform hand hygiene at least two-thirds of the required time, self-reported methods of assessing compliance, and practice of hand hygiene are not very objective and are prone to bias.

A little over one-third of participants had not received any training on hand hygiene in the preceding 3 years. This highlights a need for intensifying effort and coverage of hand hygiene training for eye care workers, more so for doctors, majority of whom had not receive any recent training. This will help improve and sustain compliance with good hand hygiene practices considering that training in hand hygiene had been found to improve compliance with hand hygiene.[20],[21] Much higher proportions of health workers received training in a study in Ethiopia[12] and Saudi Arabia[18] while a lower proportion was reported in Zaria, Nigeria.[22] These differences may be a reflection of varying institutional policies on hand hygiene.

Materials needed for hand hygiene such as running water, soap, and hand sanitizer were not available all the time to the participants. This implies that some opportunities for hand hygiene could be missed even when the participants have good perception of hand hygiene or are sufficiently self-motivated to do so. This underscores a need to ensure constant availability of hand hygiene materials to all workers at all times thereby breaking one of the known barriers to hand hygiene practice.[23] Similarly, infrequent availability of hand hygiene materials was reported in another tertiary hospital in Nigeria.[22] The finding that only about a quarter of the participants had posters on hand hygiene is less than ideal, considering that posters are nudges that have been reported to improve hand hygiene practice[24] and majority of the workers are not exposed to these effective reminders. The World Health Organization estimated that 10% of hospitalized patients in developing countries develop healthcare-associated infections.[25] Only a third of the participants had correct perception of the rate of HCAI among hospitalized patient, meaning that the magnitude of the problem of HCAI is not well known by these workers. This may negatively impact the practice of hand hygiene which is essential in the control of HCAI. This finding is also reflected in the finding that most of the participants did not feel that HCAI had a high impact on clinical outcome. In contrast to our findings, it was reported in another study[18] that majority of health workers thought HCAI had high impact on clinical outcome.

In conclusion, perception of hand hygiene practice was only moderate among the participants. Factors responsible for this lower than expected finding include inadequate training, lack of steady running water, and soap at service points. Training of eye care workers on hand hygiene, reminders by use of posters, provision of steady water and soap supply at service points as well as encouragement and support from leaders of health institutions are recommended to help improve perception as well as practice of hand hygiene among eye care workers.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]


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