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Original Article

Hand Hygiene Practice among Healthcare Workers in a Public

Hospital in North‑Western Nigeria
Garba D. Gwarzo
Department of Paediatrics, Bayero University, Kano, Nigeria

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

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

Introduction In Switzerland, Pitet et al.[9] found poor hand hygiene among

Hospital‑acquired infections contribute significantly to
morbidity and mortality of patients in hospital settings.
Infections acquired through poor hand hygiene among health
care workers (HCWs) caring for these patients has been
documented to be among the major causes of such infections.[1,2]
According to the Centre for disease control (CDC), healthcare
workers must institute standard hand washing procedures
before attending to each patient.[3] Unfortunately, compliance
with this point‑of‑care standard has been low in many parts
of the world including Nigeria.[4‑6]
There are differences in the practice of hand washing among
various HCWs while on duty,[7‑19] despite recommendations
by the World Health Organization (WHO). The WHO
recommends routine use of alcohol‑based hand rubs before
or after contact with patients, after contact with body fluids,
and before performing invasive procedure on patients.[8] It
also recommends the use of soap and water when hands are
visibly dirty or soiled or when alcohol‑based hand rubs are
not available.
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doctors compared with nurses even after intervention, and soap
and water were commonly used. Similarly, Kingstone et al.[10]
reported nonavailability and poor acceptability of alcohol‑based
hand rub among the major barrier to its use among Irish doctors,
and as of 2015, only 86% of the doctors studied were compliant
with hand hygiene. In Italy, Chittaro et al. found a very low (less
than 30%) overall compliance rate among HCWs following the
introduction of alcohol‑based hand rubs.[19]
In southern Nigeria, Bello et al. found that more than two‑thirds
of healthcare providers in a teaching hospital had good hand
washing practices, and nurses had higher handwashing
frequency than other healthcare providers.[7] Similarly, in
another south Nigerian study, Alice et al. found that compliance
with standard precaution was the highest among doctors
working in a tertiary hospital whereas nurses had the highest
compliance with hand hygiene.[16] Similar results were found
Address for correspondence: Dr. Garba D. Gwarzo,
Department of Paediatrics, Bayero University, Kano, Nigeria.
E‑mail: gardgwarzo@yahoo.com
This is an open access journal, and articles are distributed under the terms of the Creative
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For reprints contact: reprints@medknow.com

DOI: How to cite this article: Gwarzo GD. Hand hygiene practice among
10.4103/njbcs.njbcs_40_17 healthcare workers in a public hospital in North-Western Nigeria. Niger J
Basic Clin Sci 2018;15:109-13.

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Gwarzo: Hand hygiene among healthcare workers

by Ekwere and Okafor.[18] In northeastern Nigeria, only 13%

Table 1: Demographic characteristics of 173 healthcare
of the HCWs studied had adequate knowledge of universal
workers
precautions.[20] There is a paucity of studies on hand hygiene
among HCWs in the northwestern part of Nigeria. Frequency Percent
Gender
This study investigated compliance with hand hygiene Male 94 54.3
guidelines and barriers to standard hand hygiene practice Female 79 45.7
among healthcare workers practicing at the reference hospital Age (years)
in Kano, Nigeria. Less than 25 17 9.8
26-35 100 57.8
Patients and Methods
36-45 49 28.3
This was a cross‑sectional study conducted at the Murtala
46 and above 7 4.0
Mohammed Specialist hospital, a reference hospital in Kano, Profession
northwestern Nigeria, from August to November 2017. This Doctor 61 35.3
large public hospital caters to a majority of over 10 million Nurse 23 13.3
inhabitants of Kano state. It has various specialty departments Physiotherapist 19 11.0
including Medicine, Surgery, Paediatrics, Obstetrics and Laboratory scientist 13 7.5
Gynaecology, Ophthalmology, Laboratory services, and Laboratory technician 13 7.5
Physiotherapy. Ethical clearance to conduct the research was CHEW/JCHEW* 11 6.4
obtained from the hospital’s management board. Community health worker 33 19.1
Years of Practice
HCWs who came in direct contact with patients in their routine
Less than 1 40 23.1
works in the hospital were included in the study. These HCWs 1-5 64 37.0
included medical doctors, nurses, physiotherapist, laboratory 6-10 25 14.5
scientists, laboratory technicians, community health workers, More than 10 44 25.4
and community health extension workers (CHEWs). *CHEW, Community Health Extension Worker; JCHEW, Junior
Participants were selected using simple random sampling Community Health Extension Worker
method from the list of staff. Each of those selected gave
informed consent at the time of enrolment in the study. always followed correct sequence in hand washing. However,
Questionnaire was distributed to and filled by the selected only 64 (37.0%) washed their hands for at least 20 s.
HCWs. Biodata and data on the knowledge and practices of
Lack of water and soap were the major constraints against
standard hand washing at work station was obtained.
washing hands among HCWs in their place of work, as shown
The data were entered in Microsoft Excel 2016 computer in Table 2. Lack of knowledge of how to wash hands was
software and analyzed using Statistical Package for Social reported as a constraint by only 13 (7.5%).
Sciences (SPSS) version 16. Tables and charts were used to
The respondents used various things to clean or wash their
present the results. A P value of less than 0.05 was considered
hands at their work lace. These included soap and water,
statistically significant.
chlorhexidine solution, and alcohol‑based hand wash, as shown
in Table 3. Soap and water was used by 101 (58.4%) of the
Results respondents whereas 24 (13.9%) used water only.
One hundred and seventy‑three health workers participated
Free air drying was the preferred method of hand drying after
in the study. There were 94 (54.3%) males and the remaining
washing, as seen in 78 (45.1%) of the participants [Table 3].
were females. Medical doctors constituted 61 (35.3%) of
the respondents. One hundred and four (60.1%) of the 173 One hundred and thirty (75.1%) of the 173 respondents were
respondents were working in the healthcare facility for 5 years trained on washing hands. Many of them learnt from multiple
or less. The demographic characteristics of the respondents sources. Majority (82.1%) of 173 workers learnt it in school,
are shown in Table 1. as shown in Figure 1. Forty‑three (24.9%) had no training on
hand washing from anybody or from anywhere.
All of the 173 respondents practiced hand washing in their place
of work. Table 2 shows various reasons why the respondents Significantly (P = 0.0008) more doctors had training on how
washed their hands at the workplace. Only 25 (14.5%) washed to wash their hands from somebody than other healthcare
their hands on arrival at their work place, whereas 126 (72.8%) workers. Age, gender, and length of practice were not
washed hands while going home after day’s work. The most significantly associated with prior training on hand washing,
common (87.3%) reason for washing hands among respondents as shown in Table 4.
was after contact with patient’s body fluid.
Logistic regression analysis shows that profession was
Majority of the respondents knew how to wash their hands correctly, significantly associated with learning how to wash hands
as shown in Table 2. One hundred and twenty‑seven (73.4%) correctly by the healthcare workers [Table 5].

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Gwarzo: Hand hygiene among healthcare workers

Table 2: Practice of hand washing among 173 healthcare Table 4: Demographic features of workers who had
workers formal training on hand hygiene and who did not have
Practice of hand Always (%) Sometimes (%) Never (%) Trained on Not trained on X2 P
washing hand hygiene hand hygiene
Reason for washing N=130,n(%) N=43, n(%)
hands
Gender
On arrival at the 25 (14.5) 70 (40.4) 62 (35.8)
Male 69 (53.1%) 25 (58.1%) 0.332 0.564
hospital*
Female 61 (46.9%) 18 (41.9%)
Before contact with 70 (40.4) 77 (44.5) 26 (15.0)
patients Age (years)
After contact with 135 (78.0) 37 (21.4) 1 (0.6) Less than 36 92 (70.8%) 25 (58.1%) 2.340 0.126
patients 36 or more 38 (29.2%) 18 (41.9%)
Before a procedure 91 (52.6) 60 (34.7) 22 (12.7) Profession
After a procedure 130 (75.1) 36 (20.8) 7 (4.0) Doctor 55 (42.3%) 6 (14.0%) 11.314 0.001*
After contact with 151 (87.3) 16 (9.2) 6 (3.5) Other health 75 (57.7%) 37 (86.0%)
body fluid workers
After a day’s work 126 (72.8) 36 (20.8) 11 (6.4) Duration of
How the hands were Practice (years)
washed 10 or less 97 (74.6%) 32 (74.2%) 0.0007 0.980
Correct sequence 127 (73.4) 41 (23.7) 5 (2.9) More than 10 33 (25.4%) 11 (25.6%)
Rubbed for 20 s 64 (37.0) 64 (37.0) 34 (19.7) *P‑value significant
before rinsing
Constrains to hand
washing Table 5: Logistic regression of learning how to wash
Lack of water 32 (18.5) 104 (60.1) 37 (21.4) hands versus health workers’ profession, gender, age
Lack of soap 36 (20.8) 100 (57.8) 37 (21.4) group, and years of practice
No place to wash 31 (17.9) 62 (35.8) 80 (46.2)
Variable Odds ratio 95% CI P
hands
Profession 4.8433 1.7928-13.0841 0.001
I easily forget 10 (5.8) 68 (39.3) 95 (54.9)
Gender 0.9770 0.4562-2.0923 0.952
Lack of time 9 (5.2) 50 (28.9) 114 (65.9)
Age group 1.7530 0.6712-4.5785 0.251
Too many patients# 34 (19.7) 66 (38.2) 67 (38.7)
Years of practice 0.4094 0.1417-1.1826 0.093
Did not know how 8 (4.6) 5 (2.9) 139 (80.3)
to wash hands§
*16 did not respond. 11 did not respond. #6 did not respond. §21 did not
respond. Note: respondents had multiple constrains Did not learn from anybody 24.9

Observed people washing hands 31.8

Table 3: Items used in washing and drying hands by 173

Special training session 52.6
respondents
Yes Percent Read about it 67.1

Material used in washing hands

Learnt in school 82.1
Soap and water 101 58.4
Water only 24 13.9 0 10 20 30 40 50 60 70 80 90
Percent
Alcohol‑based hand wash 32 18.5
Chlorhexidine solution# 16 9.2 Figure 1: Sources of knowledge of proper hand washing among 173
Drying of hands after washing¶ Healthcare Workers
Single use towel 52 30.1
Shared ward towels 25 14.5 However, among those who washed their hands, 73.4% always
Air drying 78 45.1 followed the right sequence but only 37.0% rubbed their hands
Used hot air machine 7 4.0
for at least 20 s. It is good that a majority of the staff knew and
¶
11 did not respond
followed the correct sequence of washing hands. However, it
appeared that not enough time was spent by the staff in washing
Discussion hands. This may be due to a large number of patients to deal
All the 173 (100%) participants practiced hand washing while with by relatively few staff in a short period. Wetzker et al.[13]
working in the hospital. This shows very high awareness and reported a similar rate of hand washing (overall median 73%)
practice of hand washing in the hospital. Similarly, in larger in a large survey conducted in hospitals in Germany. On the
studies, prevalence of hand washing by medical staff was other hand, some researchers reported low hand washing
high.[11‑14] compliance. In Switzerland, for example, Scheithauer et al.[14]

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Gwarzo: Hand hygiene among healthcare workers
found a mean compliance of 42.39%, which was attributed to
high workload among health workers.
Hand hygiene following contact with the surrounding (hospital
environment) was very low. Only 14.5% of the respondents
always washed their hands on arrival at their working place in
the hospital before actual contact with patient. Randle et al.[15]
also observed the lowest hand hygiene compliance following
contact with hospital surrounding compared with following
contact with patients.
In contrast, 72.8% of them washed their hands after the day’s
work before leaving the hospital. While at work, contact with
patient’s body fluid was the most common reason (87.3%) for
always washing hands. This is comparable with the findings
of Kingston et al.[10] in 2015 in Ireland where 86% and 91% of
the physicians surveyed washed their hands before and after
contact with patients, respectively. A high rate of hand washing
after exposure to body fluids was observed by Lebovic et al.
in Canada.[12]
WHO‑recommended alcohol‑based hand rub formulations
have better antimicrobial property than soap and water or
chlorhexidine.[8] Appropriate washing liquids were not always
used by the respondents. The most commonly used hand
cleaning agent among the respondents was soap and water.
Close to one‑quarter (24.3%) of the participants had never used
alcohol‑based hand rubs to clean their hands in the hospital,
whereas almost two‑thirds (65.4%) either always or sometimes
used water only to clean their hands while at work. This may
be because they were not available or the staff were not using
them. This is similar to what was found in Ireland where only
39% of the physicians almost always used alcohol‑based
hand rub to clean their hands due to dermatological issues,
poor acceptance, or lack of alcohol‑based hand rub in the
facilities.[10]
After washing hands, the participants mostly dried their hands
in the air. Hot air machine had never been used by 84.4% of
them because it was not available or there was no electricity
to operate the machine.
One‑third of the respondents had training on hand washing,
mostly from multiple sources. Many of them had the training
while in school. Other opportunities for training included
special training sessions at working places, observing a senior
washing hands, and reading about washing hand. This shows
that the participants had many opportunities for training on
hand washing which they utilized.
More doctors significantly (P = 0.001) had trainings on hand
washing than other health workers who had direct contact
with patients. This may be due to more robust training of
medical doctors while in school. In Edo state, Nigeria, Alice
et al. found a similar pattern where medical doctors and nurses
had better knowledge of standard practices including hand
washing than other health workers. Number of years on the
job did not, however, significantly affect the chance of training
on hand washing.
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Many constraints to hand washing existed in the hospital. The
main constraints identified by the respondents were lack of
water and/or lack of soap, as well as lack of alcohol hand rub.
Provision of these hand sanitizers is important because basic
hand hygiene is very important in preventing transmission of
infection from one patient to another and from patient to health
workers. A systemic review study found that compliance with
hand hygiene was better with introduction of alcohol hand
rubs.[17]
Other constraints identified included not knowing how to
wash hands, no place provided for washing hands, no time
to wash hands while at work, and not remembering to wash
hands while at work. Not having enough time for washing
hands may be a result of high workload experienced by staff
in many hospitals in developing countries such as Nigeria.
Previous research conducted in Switzerland showed an inverse
relationship between hand hygiene compliance and workload.
Conclusions
Awareness of hand hygiene among the hospital staff surveyed
was high and compliance with hand hygiene was good. The
main constraint to hand hygiene was unavailability of alcohol
hand rub, soap, and water.
Financial support and sponsorship
Nil.
Conflicts of Interest
There are no conflicts of interest.
References
1. Garner JS, Simmons BP. Guideline for isolation precautions in hospitals.
Infect Control 1983;4:245‑325.
2. Larson EA. Causal link between hand washing and risk of infection.
Examination of the evidence. Infect Control 1988;9:28‑36.
3. Centers for Disease Control. CDC. Guideline for hand washing and
hospital environmental control. Infect Control 1986;7:231‑43.
4. Pittet D, Mouronga P, Perneger TV. Compliance with hand washing in a
teaching hospital. Ann Intern Med 1999;130:126‑30.
5. Lankford MG, Zembower TR, Trick WE, Hacek DM, Noskin GA,
Peterson  LR. Influence of role model and hospital design on hand
hygiene of health care workers. Emerg Infect Dis 2003;9:217‑23.
6. Onyeonoro U, Ukegbu A, Emelumadu O, Kanu O. Hand washing
practices among health care providers in a tertiary hospital in South East
Nigeria. J Epidemiol Comm Health 2011;65:470‑1.
7. Bello S, Emmanuel EE, Enembe FO, Olabisi AO. Hand washing
practice among health care providers in a teaching in Southern Nigeria.
Int J Infect Control 2013;9:32‑4.
8. World Health Organization. Guideline: WHO Guidelines on Hand
Hygiene in Health Care. First Global Patient Safety Challenge Clean
Care is Safer Care. Geneva: WHO; 2009. p. 30‑156.
9. Pitet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S,
Perneger T. Effectiveness of a hospital‑wide programme to improve
compliance with hand hygiene. Lancet 2000;356:1307‑12.
10. Kingston LM, Slevin BL, O’Connell NH, Dunne CP. Attitudes and
practices of Irish hospital‑based physicians towards hand hygiene and
hand rubbing using alcohol‑based hand rub: A comparison between
2007 and 2015. J Hosp Infect 2017;97:17‑25.
11. Kowitt B, Jefferson J, Mermel, L. Factors Associated with Hand Hygiene
Compliance at a Tertiary Care Teaching Hospital. Infect Control Hosp
Epid 2013;34:1146‑52.
[Downloaded free from http://www.njbcs.net on Wednesday, March 4, 2020, IP: 43.252.105.90]

Gwarzo: Hand hygiene among healthcare workers

12. Lebovic G, Siddiqui N, Muller MP. Predictors of hand hygiene
compliance in the era of alcohol‑based hand rinse. J Hosp Infection
2013;83:276‑83.
13. Wetzker W, Bunte‑Schönberger K, Walter J, Pilarski G, Gastmeier P.
Compliance with hand hygiene: Reference data from the national hand
hygiene campaign in Germany. J Hosp Infect 2016;92:328‑31.
14. Scheithauer S, Batzer B, Dangel M, Passweg J, Widmer A. Workload
even affects hand hygiene in a highly trained and well‑staffed setting:
A prospective 365/7/24 observational study. J Hosp Infect 2017;97:11‑6.
15. Randle J, Arthur A, Vaughan N. Twenty‑four‑hour observational study
of hospital hand hygiene compliance. J Hosp Infect 2010;76:252‑5.
16. Alice T, Akhere A, Ikponwonsa O, Ehidiamhen G. Knowledge and
practice of infection control among health workers in a tertiary hospital
in Edo state, Nigeria. Direct Res J Health Pharmacol 2013;1:20‑7.
17. Erasmus V, Daha T, Brug H, Richardus J. Systematic Review of Studies
on Compliance with Hand Hygiene Guidelines in Hospital Care. Infect
Control Hosp Epid 2010;31:283‑94.
18. Ekwere TA, Okafor IP. Hand hygiene knowledge and practices among
healthcare providers in a tertiary hospital, South West Nigeria. Int J
Infect Control 2013;9:i4.
19. Chittaro M, Calligaris L, Farneti F, Faruzzo A, Panariti M, Brusaferro S.
Healthcare Workers’ Compliance with Hand Hygiene after the
Introduction of an Alcohol‑Based Handrub. Int J Infect Control
2009;5:i1.
20. Abdulraheem IS, Amodu MO, Saka MJ, Bolarinwa OA, Uthman MMB.
Knowledge, Awareness and Compliance with Standard Precautions
among Health Workers in North Eastern Nigeria. J Community Med
Health Educ 2012;2:131.

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