Knowledge, practice on hand hygiene and some related factors among health workers at three district hospitals in thai binh province in 2019

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH HANOI MEDICAL UNIVERSITY DANG THI NGOC ANH KNOWLEDGE, PRACTICE ON HAND HYGIENE AND SOME RELATED FACTORS AMONG HEALTH WORKERS AT T

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH

HANOI MEDICAL UNIVERSITY

DANG THI NGOC ANH

KNOWLEDGE, PRACTICE ON HAND HYGIENE AND SOME RELATED FACTORS AMONG HEALTH WORKERS

AT THREE DISTRICT HOSPITALS IN THAI BINH PROVINCE IN 2019

MASTER THESIS: PUBLIC HEALTH

HANOI - 2019

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH

HANOI MEDICAL UNIVERSITY

DANG THI NGOC ANH

KNOWLEDGE, PRACTICE ON HAND HYGIENE AND SOME RELATED FACTORS AMONG HEALTH WORKERS

AT THREE DISTRICT HOSPITALS IN THAI BINH PROVINCE IN 2019

Major: Public Health Code: 8720701

MASTER THESIS

Supervisors: Assoc Prof Nguyen Dang Vung, MD, PhD

Assoc Prof Vu PhongTuc, MD, PhD

HANOI - 2019

ACKNOWLEDGMENTS

Foremost, this work would not have been possible without the support from the Hanoi Medical University (HMU), Institute for Preventive Medicine and Public Health, the Post Graduate Department, the Department of Population, and VOHUN scholarship I would like to express my sincere appreciation to my advisors: Assoc Prof Nguyen Dang Vung and Assoc Prof

Vu Phong Tuc, for their excellent guidance, caring, patience, and providing me with the tremendous support for during this research Without your support, I could not complete this thesis

I would like to express my sincere thanks to the Institutional Review Board of Hanoi Medical University for approving the research protocol

In the preparation of this thesis, I have received tremendous support from the hospital authorities and health workers in three district hospitals, including Dong Hung General Hospital, Kien Xuong General Hospital, and

Vu Thu General Hospital, for helping me with data collection

I place on my record, my sincere gratitude to all members in my research group and my colleagues in Department of Environmental Health, Thai Binh University of Medicine and Pharmacy for sharing expertise, valuable support, and encouragement extended to me

Last but not least, I owe you sincere thanks for my family, who were always willing to listen to me and support me to overcome many challenges

in my life Thank you so much

COMMITMENTS

Respectfully addressed to:

- The Boards of Training - Hanoi Medical University

- The Boards of Post – Graduated Training - Institute for Preventive Medicine and Public Health

- The Department of Population

- The Boards of Dissertation Assessment

I declare that the thesis ―Knowledge, practice on hand hygiene and some related factors among health workers at three district hospitals in Thai Binh province in 2019‖ is my own work under the guidance of Assoc Prof Nguyen Dang Vung - Vice Director of the Institute of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Viet Nam, and Assoc Prof Vu Phong Tuc - Head of Faculty of Public Health, Thai Binh University

of Medicine and Pharmacy, Thai Binh, Vietnam

All data and results in this thesis were honest This thesis was compliant with ethical standards in research and has not been published in any journal or scientific work I contend that the work presented in this thesis is my own, except in instances where due references have been made to other referenced material This thesis was compliant with ethical standards in research

The author of the thesis

TABLE OF CONTENT

LIST OF ABBREVIATIONS i

LIST OF TABLES ii

LIST OF FIGURES, GRAPHS iii

INTRODUCTION 1

CHAPTER 1 LITERATURE REVIEW 3

1.1 The scientific evidence related to hand hygiene 3

1.2 Overview of hand hygiene 9

1.3 The researches of knowledge and practice on hand hygiene of health workers in the world and in Vietnam 13

1.4 Some factors related to knowledge and practices on hand hygiene of health workers in the world and in Vietnam 16

1.5 Conceptual framework 19

1.6 Description of research sites 20

CHAPTER 2 METHODOLOGY 22

2.1 Research participants 22

2.2 Research sites and time 22

2.3 Research methods 23

2.4 Methods of evaluating the knowledge and practice on hand hygiene 28

2.5 Data analysis 30

2.6 Data quality control 31

2.7 Research ethics 32

CHAPTER 3 RESULTS 33

3.1 Demographic characteristics of participants 33

3.2 Knowledge and practice of hand hygiene 34

3.3 Some factors related to the knowledge and practice on hand hygiene

of health workers in three hospitals 42

CHAPTER 4 DISCUSSION 64

4.1 Knowledge and practice on hand hygiene of health workers 644.2 Some factors related to the knowledge and practice on hand hygiene 714.3 Strength and limitation of the study 76

CONCLUSIONS 78 RECOMMENDATION 79

LIST OF ABBREVIATIONS

ABHR Alcohol-based hand rub

CDC Centre for Disease Prevention and Control

CFU Colony-forming units

HAI Healthcare-Associated Infection

HH Hand hygiene

HWs Health workers

ICU Intensive care unit

MoH Ministry of Health

NI Nosocomial infection

WHO World Health Organization

LIST OF TABLES

Table 3.1 Demographic characteristics of respondents 33

Table 3.2 The general situation of three hospitals 34

Table 3.3 Correct knowledge on the healthcare-associated infection 34

Table 3.4 Correct knowledge on hand hygiene actions protecting patient and health workers 35

Table 3.5 Correct knowledge on hand hygiene 36

Table 3.6 Correct knowledge on hand hygiene methods required in certain situations 37

Table 3.7 Correct knowledge on the factors that contribute to hand colonization 38

Table 3.8 Hand hygiene compliance rate in each hospital 39

Table 3.9 Hand hygiene compliance rate according to occupation 40

Table 3.10 Hand hygiene compliance according to five moments 40

Table 3.11 Distribution of appropriateness of hand hygiene among different methods in three hospitals 41

Table 3.12 Hand hygiene compliance according to observation shift 41

Table 3.13 The relationship between demographic characteristics and knowledge on hand hygiene 43

Table 3.14 Multivariate analysis of associated factors 44

Table 3.15 Bivariate analysis of associated factors with HH compliance 44

Table 3.16 Multivariate analysis of associated factors 46

Table 3.17 Self-reported reasons for hand hygiene noncompliance 48

Table 3.18 Themes from qualitative analysis 50

LIST OF FIGURES, GRAPHS

Figure 1.1 Five moments for hand hygiene 10

Figure 1.2 Washing hand protocol 11

Figure 3.1 Results of assessing the level of knowledge on hand hygiene 39

Figure 3.2 Hand hygiene compliance rate in different departments 40

Figure 3.3 Overall hand hygiene compliance rate in three hospitals 42

Figure 3.4 Factors improving hand hygiene compliance as suggested by health workers among three hospitals 46

to severe consequences for hospitalized patients and their familiesin income countries such as Germany, Greece, French, and the USA by giving rise to other diseases,prolonged hospital stays, reducing the functional ability, financial burden, and increased mortality[2],[3],[4],[5] The prevalence and the burden of HAIs in middle and low-income countries even were severe than in high-income countries[6],[7],[8],[9] Therefore, HAI has long been an issue that attracts great concern and poses an enormous challenge for the health sector not only in Vietnam but also in the world

high-The hand of health workers (HWs) has been considered as the main route

of transmission of HAIs among patient in healthcare settings Therefore,hand hygiene (HH) isthe single most important measure to avoid the transmission of pathogens and prevent HAIs[10] However, HWs often perform HH less than half as often as they should not only in high-income countries but also in middle and low-income countries [11],[12],[13] In Vietnam, hand hygiene education in healthcare facilities is not a new concept, however, it has not been understood and practiced fully and accurately yet The overall hand hygiene

compliance was quite low [14],[15],[16] There are many barriers that impact

on hand hygiene adherence such as limited resources, work overload, lack of human resources, skin irritation with hand sanitizers, and especially improper perception about the role of hand hygiene [14],[17] However, the data on hand hygiene compliance in healthcare settings in Vietnam, especially in district hospitals are limited With the desire to learn about the knowledge, and practice

of hand hygiene among health workers as well as the factors related to compliance at three district hospitals, thereby propose appropriate measures to improve the quality of examination and treatment at district hospitals, study

“Knowledge, practice on hand hygiene and some related factors among

health workers at three district hospitals in Thai Binh province in 2019”is

conducted to the following objectives:

1 To describe the level of knowledge, practice on hand hygiene of health

workers at three District Hospitals in Thai Binh province in 2019

2 To describe some related factors influencing knowledge and practice

on hand hygiene of these health workers

CHAPTER 1 LITERATURE REVIEW 1.1 The scientific evidence related to hand hygiene

1.1.1 The history of hand hygiene

In the late 1800s, the study by Ignaz Semmelweis in Vienna, Austria, found that it is different between maternal mortality rates among two obstetrics obstetric clinics at the University of Vienna General Hospital (16% versus 7%) In 1847, he observed that the doctors and medical students often went to the delivery room after performing an autopsy and had an unpleasant smell on hands, although hand washing with soap and water before entering the clinic He hypothesized that puerperal fever is caused by ―cadaverous particles‖ on the hands of doctors and students Therefore, he recommended that rubbing hand with a chlorinated lime solution before every patient contact and particularly after leaving the autopsy room Thanks to the recommendation of Semmelweis, the rate of maternal mortality decreased swiftly to fewer than 3% In Austria, Semmelweis Hospital was built and he was recognized as the pioneer of the theory of sterility and the theory of hospital infections [18]

Another pioneer of hand hygiene is Florence Nightingale, who is acknowledged as the founder of modern nursing When most people believed that foul odors called miasmas are the reason for infections, she implemented handwashing and other hygiene practices to reduce the infections in wounded soldiers in the Crimean War

In 1975 and 1985, the CDC published official guidelines on hand hygiene practices in hospitals HWshas guided that washing hand with plain soap and water after touching the patient and washing hand with an antiseptic soap before and after performing invasive procedures.Meanwhile, disinfection with alcohol is applied when the hand sink is not available[19]

Many studies confirmed that hand hygiene with an alcohol-based formula

is the most important to prevent the spread of pathogens in healthcare facilities Pittet and colleagues pointed out remarkable results in hand hygiene compliance improvement (increased from 47.6% to 66.2%) and HAIs reduction (dropped from 16.9% to 6.9%)[19] In addition, he introduced an alcohol-based hand rub (ABHR) In 2002, the term alcohol-based hand rubbing was applied

as the standard of care for hand hygiene practices in healthcare settings In

2004, WHO established and guided hand hygiene practices in healthcare settings and developed the WHO Hand Hygiene Improvement Strategy

In Vietnam, the health sector has paid attention to hand hygiene In 2006, the Ministry of Health (MoH) started the project strengthening hospital hygiene; including washing hand with soap and water was a strategic measure The project launched "handwashing week" in 21 hospitals with about 7000 participants In 2009, compliance with hand hygiene is included in the circular No.18/2009/TT-BYT dated 14/10/2009 After that, this circular was instead of the new circular No 16/2018/TT-BYT (July 20, 2018) on regulating the infection control in medical treatment and examination facilities of MoH[20]

1.1.2 The natural bacteria flora on hands

In 1938, Price P.B divided the natural bacterial flora on hands into two

groups, including transit flora and resident flora[21]

The resident flora consists of microorganisms residing under the

superficial cells of the Stratum corneum and can also be found on the surface

of the skin.Staphylococcus epidermidis is the dominant species Other resident bacteria include S hominis and other coagulase-negative staphylococci

Resident flora has two main protective functions: microbial antagonism and the competition for nutrients in the ecosystem In general, resident flora is less likely to be associated with infections but may cause infections in sterile body

cavities, the eyes, or on non-intact skin To eliminate resident flora, the surgical team has to hand hygiene with alcohol-based hand rubs or liquid soap containing 4% chlorhexidine for a minimum of 3 minutes[21]

The transit flora, concentrating the surface layers of the skin Transient microorganisms often do not multiply on the skin, but they exist and proliferate

on the skin surface They are usually acquired by HWs when direct contact with the patient or the contaminated environmental surface next to the patient and are the most frequent organisms linked to HAIs The transmissibility of transient flora depends on the species present, the number of microorganisms

on the surface, and the skin moisture However, the transit flora may be easier

to remove by routine hand hygiene (washing hand with soap and water or rubbing hand with an ABHR in 20-30s)

Therefore, hand hygiene before and after touching each patient is the most important method in infection prevent and control The hands before performing surgery have to eliminate both transit and resident floras, thus

requiring surgical hand antisepsis[21]

1.1.3 The evidence of the transmission of pathogens through hands

All healthcare activities such as medical examination, patient care of HWs are through their hands Therefore, the hand is the most important link

in the chain of the transmission of healthcare-associated pathogens This chain includes the following steps: (1) Organisms which presented on patient skin or in the inanimate environment, transfer to HWs‘ hands; (2) Organism survival and multiply on hands because of inappropriate hand cleansing; and (3) Cross-transmission of organisms by contaminated hands[22]

Healthcare-associated pathogens can be present not only on the infected or open wounds, blood, body fluid or waste of patients but also on normal, dry patient skin and on environment surfaces [23],[24],[25],[26] Each square

centimeter of intact skin of some patients can contain up to 100 to 106 CFU, especially in the inguinal areas, the axillae, trunk, and upper extremities (including the hands) [25],[27],[28] As a consequence, the hands of HWs are easily contaminated via touching patient even while performing a low-risk procedure like taking a pulse or measuring body temperature [24] Moreover, a large number of squames containing microorganisms are shed in a single day, which in turn contaminating the patient‘s clothes, bed linen, furniture and medical equipment [29],[23],[30],[31] Thus, HWs‘ hands are at high risk for contamination when touching the patient surrounding

The chain of cross-transmission of organisms from one patient to another can be started when soiled hands of HWs contact directly with other patient or touch the furniture, medical equipment, and the patient‘s surrounding environment Germs removed improperly can be survived, multiplied on the hands and then spread into the environment in hours [32] For example,

Methicillin-resistant Staphylococcus aureus strain can survive for more than

150 minutes [33]

The inadequate or entirely omitted hand hygiene before patient care has been acknowledged asa dangerous contributor to the spread of pathogens.In the research in a tertiary Vietnamese hospital, Salmon and his colleagues found that the hands of HWs before performing hand hygiene contained

average 1.65 log(10), including Acinetobacter baumannii, Klebsiella

pneumoniae, and Staphylococcus aureus.Most notably, HWs without direct

patient carehad the highest average count before practicing hand hygiene ((2.10 ± 0.11 log(10)) [34] In another study in a hospital in India, the authors also found out that 47.5% of samples collected from HWs‘ hands showed

growth of microorganisms Staphylococcus aureus was the most commonly isolated microorganism [35].In addition, Gram-negative bacilli also

persistently colonized on the hands of HWs such as Pseudomonas spp.,

researchesreinforced the evidence that all HWs have to perform hand hygiene regardless of whether they are directly involved in patient care

1.1.4 The role of hand hygiene

1.1.4.1 Healthcare-associated infections

According to WHO, Healthcare-Associated Infections (HAI) also called

―Nosocomial Infection‖ (NI) and sometimes ―Hospital-Acquired Infection‖,

an infection acquired in the course of care in a hospital or another healthcare facilityand did not demonstrate or incubating at the time of admission Infections that become clinically manifest 48 hours or more after hospitalization are usually considered nosocomial infections This also includes an infection that occurs after the patient was discharged but acquired during hospitalization In addition, the definition also mentioned occupational infections among health care workers[38]

1.1.4.2 The burden of healthcare-associated infections

According to WHO's statistics, HAI affects 5-15% of hospitalized

patients in general and 9-37% of patients in intensive care units (ICU) in high-income countries [39],[40] A large-scale survey conductingby CDC and pushing in 2014estimatedthat about722,000 HAIs occurred in 648,000 inpatients and approximate 75,000 infected-patient deaths in U.S acute care hospitals [41].In 2016, the European Centre for Disease Prevention and Control estimated that more than 2.6 million new cases of HAI occur every year in Europe [1]

HAIs lead to massive consequences not only for hospitalized patients but also for patient‘s families and health systems such as more severe diseases, increased antimicrobial resistance, prolonged hospital stays, financial burden,

and increased mortality According to a meta-analysis of costs and financial influence on the US health care system in 2013, the total yearly cost for 5 main infections were $9.8 billion ((95% CI, $8.3-$11.5 billion) [5] In a German university hospital also illustrated HAIs created considerable extra costs, about

€5,823-€11,840 ($7,453-$15,155) per infected patient [2] The burden of HAIs

on patients, patient‘s families, and society was also witnessed in Greece, French, such as increased Disability Adjusted Life Years, the extra length of hospital stay and costs, or doubled the risk of death [3],[4]

The prevalence and the burden of HAIs in middle and low-income countries were quite high as compared withhigh-income countries [6],[7],[8],[9] HAIs were observed as the cause of the increased mortality and prolonged hospital stay of patients in Indian and Taiwan [42],[43] Southeast Asian area is also the most vulnerable area of the burden of healthcare-associated infections The pooled prevalence of overall HAIs in this area was 9.0% (95% CI 7.2%-10.8%), leading to the mortality rate and extra length of hospital stays of infected patients range from 7% to 46% and 5 to 21 days, respectively [44]

1.1.4.3 The role of hand hygiene in the prevention of HAIs

According to WHO, hand hygiene is recognized considered a made, feasible and cost-effective vaccine and can save millions of lives Nowadays, a series of studies on the effectiveness of hand hygiene in preventing infections have been carried out and provided convincing evidence A study in Switzerland showed that the HAI rate decreased from 16.9% to 9.9% when the percentage of HWs performing hand hygiene increased from 48% to 66 %[19]

self-In a study of Kapil and colleagues, they found that after use of alcohol hand rub with a proper hand hygiene technique, it was found that the

percentage of transient flora reduction was 95-99% among doctors and nurses [45] Monistrol et al also provided the evidence on the role of hand hygiene compliance in reducing the level of HWs‘ hand contamination [46]

In Vietnam, Truong Anh Thu pointed out that the average number of hand hygiene per day of each HW was 7.9; the rate of HAI was 21% Meanwhile, the percentage of HAI was 30.3% if the average number was 5 [47].In another survey in 2014, the sharp reduction of bacterial counts were witnessed after rubbing hands with ABHR (1.4 log(10); P < 0.0001) and 4% chlorhexidine gluconate with filtered water (0.8 log(10); P <0.0001) [34]

1.2 Overview of hand hygiene

1.2.1 Definition of terms

Hand hygiene: A general phrase that mentioned to any activities of hand cleansing including handwashing (washing hands with soap and water), antiseptic handwash, antiseptic hand rub (i.e alcohol-based hand sanitizer including foam or gel), or surgical hand antisepsis

Handwashing: An action cleansing hands with plain soap and water Antiseptic handwashing: washing hand with water and soap, or other cleaners that contain disinfectant ingredients

Antiseptic handrubbing (or handrubbing): Using an antiseptic hand rub for the entire surface of the hands to decrease or hinder the microbial growth

in case water and other devices are not available

Surgical hand antisepsis: The hand hygiene practices (Antiseptic handwashing or antiseptic hand rubbing) are applied by the surgical team before surgery to remove transient flora and reduce the resident flora on the skin These disinfectant preparations often have an antimicrobial activity over

a prolonged period[48]

The purposes of hand hygiene in health care facilities are eliminating visible soil on hand with the naked eyes, minimizing the spread of microorganisms from the community into the hospital, preventing the spread of pathogens from the hospital to the community, and reducing HAIs[49]

1.2.2 The moments of hand hygiene

Hand hygiene is an underlying component of precautionary measures and the most effective measure to prevent and control the transmission of pathogens in healthcare settings The compliance with hand hygiene in critical moments of HWs is greatly contributed to caring for inpatients According to the recommendations of WHO (Figure 1) and the guideline instituted by Vietnamese MoH[48],[49],[50], there are five vital times that any HW directly involved in patient care must perform hand hygiene, as follows:

1 Before touching a patient

2 Before clean/aseptic procedure

3 After body fluid exposure risk

4 After touching a patient

5 After touching patient surrounding

Figure 1.1 Five moments for hand hygiene (WHO, 2009)

In addition, hand hygiene should be performed when moving from a contaminated body site to a clean body site on the same patient, before donning and after removing gloves, before entering and after leaving the disease chamber[22],[48]

According to the hand hygiene guidelines of Vietnamese MoH, there are two routine hand hygiene procedures:

1 Washing hands with soap and water

2 Rubbing hands with an alcohol-based hand rubs

1.2.3 Routine hand hygiene procedures

1.2.3.1 Washing hands with soap and water

Washing hand with soap and water is indicated when hands are visibly soiled, feel dirty or after contact with blood, body fluids, secretions, and excretions Furthermore, this procedure is required to perform at the start and end of a working day

The infrastructures required for hand washing

- The placement of hand sinks should be convenient and accessible

- Clean hand sinks, faucets with the lever

- Continuous availability of water supply

- Soap (bar, liquid soap) and the racks for drainage soap

- Hand towels (if possible, use single-use paper towels)

- Paper waste receptacles/dirty towel bins

- The washing hand protocol should be posted over hand sinks as a reminder

The procedure

Figure 1.2Washing hand protocol (Ministry of Health, 2007)

- Step 1: Wet hands with water, apply enough soap and rub hands palm to palm

- Step 2: Right palm over left dorsum with interlaced fingers and vice versa

- Step 3: Palm to palm with fingers interlaced

- Step 4: Backs of fingers to opposing palms with fingers interlocked

- Step 5: Rotational rubbing of left thumb clasped in right palm, vice versa

- Step 6: Rotational rubbing, backward and forwards with clasped fingers of the right hand in left palm and vice versa Rinse hands under running water from your wrists and dry hands

Note: Each step should be done at least 5 times; the duration of the entire

procedure is 40-60 sec

1.2.3.2 Rubbing hands with an alcohol-based solution

Rubbing hands with an alcohol-based formula is considered as a faster, more effective and at killing bacteria, and better for the skin than hand washing, thereby increasing hand hygiene adherence among HWs[51],[52] Therefore, it

is highly recommended by the CDC and WHO guidelines for routine hygiene hand antiseptic during patient care if hands are not visibly dirty [48], [53]

The placement of alcohol-based hand rubs:

With the aim of improving compliance with hand hygiene, every department in the hospital, especially the clinical wards, should install the alcohol-based hand rubs at the point of care Alcohol-based hand rubs should

be equipped with at least the following positions[54]:

- At the bedside of ER, ICU, infectious department

- At all entrances to and exits from the departments

- Outside inpatient rooms at the entrances

- At the injection trolleys

- At medical examination tables, medical laboratory tables

The procedure:

- Step 1: Apply a palmful of the product in a cupped hand, covering all surfaces enough soap, and rub hands palm to palm

- Step 2: Right palm over left dorsum with interlaced fingers and vice versa

- Step 3: Palm to palm with fingers interlaced

- Step 4: Backs of fingers to opposing palms with fingers interlocked

- Step 5: Rotational rubbing of left thumb clasped in right palm and vice versa

- Step 6: Rotational rubbing, backward and forwards with clasped fingers of the right hand in left palm and vice versa Rubbing the hands until hands are dry

Note: Each step should be done at least 5 times; the duration of the entire

procedure is 20 - 30 sec or ends when dry hands

1.2.4 Other aspects of hand hygiene

- Make sure the hands are completely dry before starting patient care procedures

- Do not wear artificial fingernails or extenders, jewelry on hands when taking care of patients

- If unnecessary, during patient care, avoiding contact with the surface surrounding, equipment to prevent infection from surrounding and vice versa because of soiled hands

- Do not wash hands after rubbing hands with an ABHR

1.3 The researches of knowledge and practice on hand hygiene of health workers in the world and in Vietnam

1.3.1 In the world

To cope with the burden of HAIs in global, some of the world's leading health organizations had been recommended many effective methods, including

the "Five moments for hand hygiene", Universal Precautions, Standard Precautions, etc Many studies found that compliance with hand hygiene is an effective way to prevent and control HAIs[55],[56],[57],[58] In a recent survey

in a private hospital in Bangladesh, Begum and his colleagues again emphasized that the rate of HAIs was the lowest when the percentage of hand hygiene compliance was highest [59]

On the other hand, the percentage of complying with hand hygiene was quite low When researching about the knowledge, attitude, and practices of infection control among health workers in ICUs in a tertiary hospital in Nigeria, Adegboye and his colleagues found out that 86% of participants known that hand is the most common vehicle of transmission of infection However, the percentage of HWs knew about the indications and 6 steps of handwashing technique were 53.8% and 32.5% respectively Only 28% of doctors here practiced the six steps of the handwashing technique and 7.5% of them had ever attended a training course on infection control [60]

A descriptive cross-sectional study conducted among 100 nurses working in private hospitals in Sana'a City, Yemen also showed that most of the nurses had fair knowledge and practices about nosocomial infections (87% and 71% respectively) However, the percentage having good knowledge and practices were quite low with only 4% and 26% respectively[61]

In addition, some observational studiesindicated the fact that although the number of hand hygiene opportunities of patient care was high and even the percentage of hand hygiene compliance is good too; the applied technique may be inadequate

In a survey assessing knowledge, attitude, and practices of hand hygiene

in an Indian healthcare setting, Jose GE noted that none of HWs had poor knowledge whereas up to 54% bypassedhand hygiene It was interesting to

observe that among 46% performing HH, only 16% had proper HH practice which is the true compliance of this study [62] Complying with HH but done poorly was also point out in many other studies with the rate ranged from 0%

to under 25% between professional categories[63],[64],[65],[66].Moreover, while the minimum recommended time for HH using an ABHRwas 20 seconds, 94.3% of hand disinfections were performed for ≤15s and the average duration was 7.6s in two ICUs at a German medical school[67] Another survey in an Indian Medicine College also highlighted that 49% of HWs took less than the time recommended [62]

1.3.2 In Vietnam

In a survey at a Large Central Hospital, Le Cam Dung indicated that the overall compliance was 30.6% with the lowest compliance rate was seen in physicians (15%) and the internal medicine department (16%)

The survey of Nguyen Nam Thang and Le DucCuong was conducted to assess knowledge and practices on routine handwashing of nurses at two general hospitals in TienHai district, Thai Binh province in 2017 Results showed that in many knowledge questions, the percentage of nurses having the correct answer was low (fewer than 50%) For example, the minimal time needed for handwashing and handrubbing (47.3% and 49.6% respectively), the appropriate hand hygiene method when moving from a contamination body site to a clean body site (12.5%) The proportion of nursing regarded as good knowledge at TienHai District General Hospital and Nam TienHai General Hospital were 66.4% and 50.5% respectively (p<0.05)[68] Regarding the practical skill of routine handwashing, the results illustrated that the rates of nurses regarded as Qualified at two hospitals were very low, with 45.0% and 25.8% (p<0.05) of nurses respectively at TienHai District General Hospital and Nam TienHai General Hospital[69]

In 2014, Phung Xuan Thuy assessed the compliance with handwashing and some related factors of healthworkersin Vinh Phuc Provincial General Hospital The results showed that 65.8% of HWs had good knowledge on handwashing meanwhile only 14.8% had proper handwashing practice[70] The proper HH compliance rate was quite low in moment 5 (after touching patient surroundings), followed by moment 1 (before touching a patient) with 3.1% and 18.4% respectively

Another study of Bui HuuUyen assessing knowledge, attitude, and practices on handwashing during patient care among nurses at Lang Son Province Hospital in 2012 showed that 56.9% of nurses known the duration of handwashing Meanwhile, the percentage of nurses performing all 6 steps of routine handwashing and the duration of handwashing was 49.2% and 42.7% respectively [71]

The study of Bui ThiThanhHuyen and colleagues also found that the percentage of HWs at KhanhHoa Province Hospital in 2012 having a fair knowledge and complying with HH were 72% and 34% respectively[15]

In 2012, Truong Anh Thu and colleagues conducted a survey among 629 HWs at 36 hospitals Results showed that the percentage of nurses having knowledge ofSPs were high (83.9%-99.2%) The attitudes on performing hand hygiene before wearing gloves and after touching the patient's surroundings were 54.5% and 54.8% respectively [16]

1.4 Some factors related to knowledgeand practices on hand hygiene of health workers in the world and in Vietnam

Several studies have proved that there were multi factors influencing compliance with recommended hand hygiene According to WHO, these factors have been identified as influencing adherence to recommended HH practices, including (a) lack of access to HH facilities at point of care, (b) time

constraints, (c) skin irritation from frequent hand washing, (d) lack of knowledge of the potential risks of transmission of microorganisms to patients and the impact of improved HH on reducing HAI, (e) misconceptions about

HH, (f) uncertainty of the essential times to clean hands in health care settings, and finally, (g) a lack of role models among colleagues and superiors [48] Many previous studies reported that occupation status was one of the main factors influencing HH compliance; particularly the compliance rate among nurses was higher than doctors and nursing assistants [48], [72], [73].Additionally, the type of ward was observed as association with non-compliance Those who worked in high-risk areas were likely to omit HH more than those who worked at non-high-risk areas[48] However, results in other studies proved the opposite [74], [75], [72]

The absence of HH facilities at point of care was a major barrier to HH compliance among HWs Asking a busy HW to walk away the patient zones

to seek for hand sink or ABHR was a great reason to noncompliance with

HH Conversely, the presence of HH facilities was found to be significantly associated with HH compliance [76]

Lack of knowledge of guidelines for hand hygiene, lack of recognition of hand hygiene opportunities during patient care, and lack of awareness of the risk of microbial cross-transmission constitute barriers to hand-hygiene compliance The misunderstanding about the patient zone as well as the importance of five HH moments led to noncompliance among HWs before touching the patient or after touching the patient‘s surroundings[72] Thus, HWs who had good knowledge of HH had 3.8 times more compliance than poor knowledge [77]

Many studies also supported the important effect of work overload and the emergency situation on non-compliance with HH [76], [78] In a

qualitative study in Singapore, HWs stated that they had to pay more attention

to resolve immediate issues in patient care and safety than the remote possibility of contracting HAIs from HH noncompliance[79] In the studies in Vietnam, the authors also mentioned that work overload was the reason

leading to insufficient time for HH [70], [74], [14]

Wearing of gloves might represent a barrier to compliance with hand hygiene Noncompliance had been identified among glove users in many studies in Vietnam and internationally[77], [76], [80].It is important to recognize that hand hygiene is required whether or not gloves are used or changed However, HWs often perceive that wearing gloves can be used as an alternative to HH; thus,skipping HH after removing gloves

Furthermore, some perceived factors affecting to appropriate HH include the lack of hand-hygiene promotion, the lack of institutional priority for HH, the scarcity of administrative sanction of non-compliers or rewards of

compliers, lack of reminders or role model by senior health worker, etc.[48]

Significant initiatives have been implemented to counter linked infections Guidelines for proper hand hygiene have been initiated by international organizations, such as the ―Five Moments‖ introduced by the WHO[48] Hand hygiene is judged to be crucial in preventing the spread of infections, but it is also important to specify the ―when‖ and ―how‖ of hand hygiene [81] and to educate HWs about those procedures Leaflets representing the ―Five Moments‖ of hand hygiene and guidelines for proper hand rubbing techniques have been released by the WHO with a recommendation for medical institutions to use those as a reference for HW awareness Furthermore, the system change and its two essential elements (the access to ABHR at point of care, and to soap, clean towels as well as to a safe, continuous water supply) were confirmed as a key to hand hygiene

hand-hygiene-improvement in different settings and suitable to be used also for other infection control interventions The importance of routine monitoring HH compliance and infrastructure, along with providing performance feedback to HWs has long been emphasized in many previous studies[48] Last but not least, maintaining an institutional safety climate that facilitatesawareness-raising about patient safety issues while guaranteeing consideration of hand hygiene improvement as a high priority at all levels

1.5 Conceptual framework

1.6 Description of research sites

The study wasconducted at three governmentalhospitals among twelve district general hospitals in Thai Binh province, including Dong Hung General Hospital (DHGH), KienXuong General Hospital (KXGH), and Vu Thu General Hospital (VTGH)

1.6.1 Dong Hung General Hospital

Dong Hung General Hospital is secondary care, one of twelve district general hospitals in Thai Binh province The hospital has 12 clinical departments, 5 para-clinical departments, and 6 functional offices with a bed capacity of 300 beds (planned) and 372 actual beds Regarding human force, the hospital has a total of 245 employees Among 50 doctors working in the hospital, more than 5% were postgraduate doctors The main functions and duties of the hospital are medical emergencies, medical examination, and treatment for 44 communes and towns in the district and some communes in the surrounding areas The totalof outpatients per dayis 700-800 patients The number of inpatients is more than 350 patients In addition, the hospital is an advanced training place for commune health workers and a practical place for medical students of University and College in Thai Binh province In recent years, the infection prevention and control has been as one of the hospital‘s most important duties, and thus the equipment and facilities at the hospital are regularly upgraded and expanded to serve the examination and treatment requirements in the hospital

1.6.2 KienXuong General Hospital

KienXuong General Hospitalissecondary care, one of twelve district general hospitals in Thai Binh province The hospital has 12 clinical and para-clinical departments, and 5 functional offices with 250 actual beds Regarding human force, the hospital has a total of 150 employees (17 postgraduate, 32

HWs at the university level, 19 HWs at the college level and the remaining part is at professional secondary school) The main functions and duties of the hospital are medical emergencies, medical examination, and treatment for 37 communes and towns in the district and some communes in the surrounding areas In addition, the hospital is an advanced training place for commune health workers and a practical place for medical students of University and College in Thai Binh province The infection prevention and control is gradually improving under the direction of the Department of Health and the leadership of hospital authorities

1.6.3 Vu Thu General Hospital

Vu ThuGeneral Hospital is secondary care, one of twelve district general hospitals in Thai Binh province The hospital has 11 clinical and para-clinical departments, and 4 functional offices with a bed capacity of 180 beds (planned) and 270 actual beds Regarding human force, the hospital has a total of 185 employees (2 masters, 1 specialist II, 17 Specialist I, 47 HWs at the university level, 21 HWs at the college level and the remaining part is at professional secondary school) The total of outpatients per day is 500-600patients The number of inpatientsis 250 patients.The main functions and duties of the hospital are medical emergencies, medical examination, and treatment for 29 communes and 1 town in the district Moreover, the hospital is an advanced training place for commune health workers and a practical place for medical students of University and College in Thai Binh province.The infection prevention and control in general and hand hygiene, in particular, are the lead interest of hospital authorities and health workers

CHAPTER 2 METHODOLOGY 2.1 Research participants

2.1.1 Quantitative research

The subject was all health workersworking at clinical departments in three hospitals, including doctors, nurses, and nursing assistants

Inclusion criteria:

 Participating directly in the treatment process

 Being present during the study period

 Agreeing to cooperate fully in the survey

 Being in good health condition

Exclusion criteria:

 Not participating directly in the treatment process

 Being absent during the study period (maternity leave, sick leave, sending on studying/training)

 Refusing to participate in the survey

 Not in good health condition

2.1.2 Qualitative research

The subjects who recruited for the interviewswere the representative of hospital leaders, head of infection control department, the head nurse of the hospital, and chief physician or head nurses of five clinical departments of each participating hospital

2.2 Research sites and time

2.2.1 Research sites

Three district hospitals representing district hospitals were purposively selected based on their location in Thai Binh province They were Dong Hung General Hospital, Kien Xuong General Hospital, and Vu Thu General Hospital

For the survey component of the study, all clinical departments in three hospitals were used as the survey wards

For the direct observation and interview component of the study, five clinical departments including Surgery, Internal Medicine, Emergency &Intensive Care, Pediatrics, and Obstetrics were selected of each participating hospital

2.3.2 Sample size and sampling

2.3.2.1 The survey component

Sample size:Using the formula for estimating a population proportion with specified absolute precision

Sampling method: Choose the entire population according to the inclusion criteria from all clinical departments in three hospitals

2.3.2.2 The observation component

Choose the convenient sample: All opportunities for hand hygiene which occurred before or after one or more hand hygiene moments were observed Five moments for hand hygiene while HWs providing healthcare services to the patients were as follows: before touching a patient, before a clean/aseptic procedure, after body fluid exposure risk, after touching a patient and after touching patient surroundings

A total of 1766 hand hygiene opportunities were observed during the study, in which there were 374 opportunities ―before touching a patient‖, 232 opportunities ―before a clean/aseptic procedure‖, 158 opportunities ―after body fluid risk exposure‖, 851 opportunities ―after touching a patient‖, and

151 opportunities ―after touching patient‘s surroundings‖

2.3.2.3 The interview component

Choose the purposive sample: 01 representative of hospital leader, 01 head

of infection control department, 01 head nurse of the hospital, and 05 chief physicians or head nurses of five clinical departments of each participating hospital Our sample consisted of 24HWs; 06 doctors and 18 nurses

2.3.3 Research tools and data collection techniques

2.3.3.1 Quantitative data collection

For direct observation, we observed and recorded hand hygiene compliance among health workers using the SpeedyAudit Hand Hygiene Audit mobile application Before conducting the observation sessions, two observers were trained on hand hygiene compliance observation In the training course, the observers assessed the ―five moments for hand hygiene‖ and theopportunities for evaluation via documents and available free videos on the WHO website https://www.who.int/gpsc/5may/hand_hygiene_video/en/ Each member used the application to record the observation separately while

observing the same HW and the same care sequence in hypothetical situations Thereafter, results were compared The conflicting reports were discussed and received feedback from the expert After consent was sought from the hospital authorities, the observations were carried out randomly in HWs directly contact with the patient or patient surroundings in patient rooms and recorded all possible HH opportunities and HH actions HH actions were considered to be performed correctly if the HWs either washed hand by soap and water or rubbed hand by alcohol-based hand rub as the indications and techniques recommended

by WHO The observations were conducted in 15 selected clinical departments

in three hospitals for 10 days at each hospital consecutively Here, there were 2 sessions per day, during the morning (7 a.m – 10 a.m.) and afternoon (1.30 p.m – 4.00 p.m.) from Monday to Friday, except weekends and holidays as follows:

- Vu Thu General Hospital: 15th April – 26th April 2019

- Kien Xuong General Hospital: 2nd May – 15th May 2019

- Dong Hung General Hospital: 16th May – 29th May 2019

At each department, each observation session lasted for 20 minutes (± 5 minutes) and no more than four HH opportunities were to be done per HW during the observed care sequence These were done by two observers Therefore, not every department was observed on each day due to time constraints To help mitigate the Hawthorne effect, the observations were conducted discreetly and finished before conducting the knowledge survey

For the survey, we utilized a structured questionnaire (Appendix 1) to

collect the data The construction of the questionnaire was based on variables and indicators The content of the questions included the regulations and guidelines from ―Infection control guidelines in healthcare facilities‖ of Vietnam Ministry of Health (2017) [82], Circular No 16/2018/TT-BYT on regulating the infection control in medical treatment and examination

facilities [20], CDC guidelines [83] as well as WHO‘s guidelines [38],[48] The questionnaire consisted of three parts, including demographic characteristics, assessment of knowledge on hand hygiene, and self-reported factors that might affect hand hygiene compliance Participants were required

to choose the answer according to single choice questions and True/False or Yes/No Questions.The questionnaire wastranslated into Vietnamese and used

in pilot testing and revised before conducting a formal investigation Data from the pilot study was not included in the final analysis At the survey, all

of HWs was explained about the purpose of the study required to cooperate and not exchange information by the open letter The questionnaires were given to the head nurse of each department, who distributed the questionnaire

to the rest of the HWs within the department Each questionnaire had a code; therefore, the respondent may be anonymous The survey took about 15 to 20 minutes to be finished and was returned when the participants completed it

2.3.3.2 Qualitative data collection

A semi-structured interview guide with prompts if required was developed, based on a review of existing literature and discussion with experts The semi-structured interview guide was in relation to HAIs, hand hygiene, the associated factors to HH compliance, and the improvement suggestion of HWs The guide was pilot to encourage greater detail, variety,

interview began with a standard introduction, which included meeting the participants, a brief description of the study's aims and procedures, and assurance of participant confidentiality Before beginning, participants

provided written informed consent (Appendix 3), including the responses,

were recorded by digitally recording and note-taking All interviews were

conducted in Vietnamese

Each interview was conducted in a private room The interviewer used a semi-structured question to motivate participants to answer honestly Meanwhile, an assistant took careful notes and monitored recording equipment None of the researchers or research assistants was employed at any of the three hospitals The researchers and research assistants had no direct relationship with the participants The interviews were continued until the researchers saw that no new information was brought up The interviews lasted for 45–60 min each Questioning progressed from asking HWs to disclose the rate of HAIs in their hospitals and necessary controls to prevent the transmission of HAI to hand hygiene compliance barriers, facilitators, and possible solutions

Twenty four interviews were conducted with representative of hospital leaderand health workers in three hospitals For the interview, hospitals were randomly allocated as hospital A, hospital B, and hospital C Interviewees were given a random identifying number to maintain confidentiality

2.3.4 Variables and indicators

 Demographic variables: Age, gender, occupation, department, working experience

 General characteristic of the hospital: Training program, monitoring, and hospital crowding status

 Objective 1:

 Knowledge on hand hygiene:

- Knowledge on HAIs

- Knowledge ofHH indications, HH methods, and HH procedure

- Knowledge of the factors that contribute to hand colonization

 The practice of hand hygiene:

Three themes of the interview as follows:

- Motivational factors for hand hygiene compliance

- Barriers to hand hygiene compliance

- Improvement suggestion

2.4 Methods of evaluating the knowledge and practice on hand hygiene

2.4.1 Evaluating the knowledge on hand hygiene

Evaluation according to the binary scale:

Correct answer: 1 point

Wrong answer: 0 point

The number of questions assessing knowledge on hand hygiene was 30 The total number of scores for all knowledge items ranged from 0-30 and presents as a percentage of the total questions If the percentage was ≥ 70% of

the total scores (≥ 21 correct answers), the respondent had good knowledge

(the answer sheet and a scoring method in Appendix 2)

2.4.2 Evaluating the practice on hand hygiene

Using an observation to assess the HH action

- The hand hygiene opportunity: The need to perform the HH action, whether the reason (the indication that leads to the action) be single or multiple

Single opportunity: one indication/one opportunity

Multiple opportunities: at least 2 indications/one opportunities

- The hand hygiene indication: The reason why HH is necessary at a given moment to effectively interrupt microbial transmission during care There are 5 hand hygiene moments: before touching a patient, before clean/aseptic procedure, after body fluid exposure risk, after touching a patient, and after touching patient surroundings

- The hand hygiene action: response to the HH indication, it can be either a positive action by performing handrubbing/handwashing or negative action by missing handrubbing/handwashing

The percentage of hand hygiene compliance = 𝐴𝑐𝑡𝑖𝑜𝑛𝑠

𝑂𝑝𝑝𝑜𝑟𝑡𝑢𝑛𝑖𝑡𝑖𝑒𝑠 x 100%

2.4.3 Determining the factors influencing knowledge and practice on hand hygiene

The association between demographic characteristics and knowledge on

HH of HWs was determined by the quantitative method

Some factors influencing hand hygiene compliance of HWs was determined by the quantitative and qualitative method

 Quantitative method:

- Through observation results, determine the association between demographic factors and compliance with hand hygiene

- Through survey results, determine the self-reported barriers and facilitators to hand hygiene compliance

 Qualitative method: Through interview results, determine barriers, facilitators to hand hygiene compliance, and possible solutions

2.5 Data analysis

2.5.1 Quantitative data analysis

- The collected data was cleaned, including correct spelling errors, handle missing data and eliminate meaningless information, before encryption

- Data were entered into Epidata 3.1

- The statistical analysis was implemented on Statistical Package for the Social Sciences (SPSS version 20.0) software

- The tables, graphs were used to present the results

- The study used descriptive statistics such as frequencies, percentages, means, and standard deviations

- Determine the correlation between groups, the related factors; the study used the Chi-square test (χ2) with values: χ2, calculating the odds ratio

OR, 95% confidence interval (95% CI), etc

- Bivariate and multivariate regression analyses were computed to identify variables having a significant association with the dependent variable

- All variables having a p-value of less than 0.05 were considered as

significantly associated variables

2.5.2 Qualitative data analysis

All interview audiotape recordings were transcribed verbatim into Vietnam and translated into English by the facilitator and colleague.Transcripts were analyzed manually using content-coding and thematic analysis along with field notes.Transcripts were not examined separately by profession There were three key themes, including factors improving hand hygiene compliance, barriers for

hand hygiene compliance, and interventions to improve With each key theme,

we divided into sub-themes based on the achieved information to facilitate the analysis and synthesis of qualitative information

2.6 Data quality control

2.6.1 Potential bias

- Respondent bias: This bias might happen when participants misunderstand or skip answers or chooseto exceed the number of answersallowing per question

- Recall bias: This bias might happen when participants recall information that happened in the past, so subjects may not remember or incorrectly remember events

- Observation bias: The Hawthorne effect When HWs realizes that they are under observation, hand hygiene performance usually improves

- Interviewer Bias: This is when an interviewer subconsciously gives subtle clues in with body language, or tone of voice, that influences the responses of the interviewee

2.6.2 The solutions to minimize bias

- The questionnaire was designed clearly and coherently

- The definitions, standards were consistent and articulate

- Thoroughly train the data collectors for the content of each question, the observation and interview skills

- Explaining clearly about the research objects and the questionnaire, instructing them the way to answer correctly

- The pilot test was implemented to revise the questionnaire and draw

on experience before conducting the official survey