ABSTRACT

A complex interplay of cognitive, socio-economic and technical factors may determine hand-washing practice among hospital- based health workers, particularly doctors, regardless of the location of the country or hospital they work in.
Objective: To assess quality of care with respect to handwashing practice as a routine measure of infection prevention in Keren hospital, a provincial referral hospital, second largest in Eritrea; with a view to putting in place quality standards and effective means of monitoring and evaluation.
Design: Qualitative study with a participatory and iterative/dynamic design.
Methods: Semi-structured interviews and focus group discussions were held with 34 members of the hospital staff; and a total of 30 patients in the medical, surgical and obstetric wards were interviewed. Direct observation of handwashing practice and facilities were also employed.
Results: Although only 30% of health workers routinely washed their hands between patient contact, the study revealed genuine interest in training and the need to reward good practice in order to motivate health workers. Educational intervention and technical training resulted in significant improvements in health workers’ compliance with hospital infection prevention standards. Patient satisfaction with health workers’ hygiene practices also improved significantly.
Conclusion: Hospital-based health workers’ handwashing practice needs to improve globally. There is no room for complacency, however, in Eritrea (as indeed in other African countries) where public health services need to keep patients’ welfare at heart; particularly with respect to women in childbirth, as mothers continue to bear the lion’s share of post-war rebuilding of lives, livelihoods, and the country as a whole.
African Health Sciences 2005; 5(1): 4-13

INTRODUCTION

The Hungarian physician Ignác Fülöp Semmelweis (1818-1865) was first to demonstrate that the simple act of hand washing could save lives, especially when health workers do it routinely and thoroughly. Unfortunately, hospital acquired infections (HAI) continue to plague both western industrialized and non-western resource poor countries, often for lack of observance of this simple hygiene practice – but why?

As a young doctor working in a small Vienna hospital, Semmelweis suspected a ‘cause and effect’ relationship between two observations of his own: one, doctors and medical students were going straight from the autopsy room to the delivery room to perform internal examinations on expectant mothers without washing their hands; and two, many of the women were dropping dead from puerperal fever caused by infection with Streptococcus pyogenes bacteria. Semmelweis’ seniors believed that “childbed fever” was caused by “ backlog of clotted breast milk”, when in actual fact the women were being infected by “cadaver particles” introduced by the doctors and medical students’ own hands.¹ To prove his point, Semmelweis instated compulsory hand washing in choride solution for every medical attendant before they touched the women; and lo and behold, the rates of “childbed fever” and subsequent maternal mortality in that hospital fell dramatically. Unfortunately, Semmelweis’ superiors did not change their minds and reward him for his life saving discovery. His work remained unrecognized until long after his death; and his lessons still remain unheeded in hospitals around the world even today. ^2-6

Observations of hospital facilities revealed that all wards had running water, 60% had functioning and conveniently located sinks. Ninety five percent of the sinks had good drainage and functioned well even if the location of some was inconvenient. All observed health workers’ washed their hands after contact with blood, body fluids or contaminated objects. Seventy two percent washed their hands for 10-15 seconds and 30% washed their hands thoroughly, rubbing between fingers and around nails. Only 30% of health workers routinely washed their hands between patient contact. The rest used gloves.

In their focus group discussion, most doctors admitted that they did not wash their hands between patient contact. Various reasons were mentioned: lack of adequate and conveniently located sinks, lack of adequate hand towels, lack of water, poor quality soap, lack of hand lotions/lubricants for use after hand washing, and lack of time – see Table 2. When asked to propose solutions to the problem of inadequate levels of hand washing, doctors, nurses and other health workers who participated in the focus group discussions suggested that staff training and sufficient supplies where necessary; that mechanisms for continuous supervision and follow-up should be put in place; and that good practices should be rewarded – Table 2.

The interview results concurred with the focus group discussion findings. Fifty percent of the health workers interviewed said that they prefer to wear gloves, and admitted that they do not change their gloves between patient contacts. Those who preferred gloves saw them as protective devices for themselves, rather than for their patients. These same health workers considered hand washing to be time consuming. Some said that the reason they did not wash their hands was because they did not like to use common towels to dry their hands after washing.

These findings were disseminated among the study participants and other health workers who attended the one-day data interpretation workshop. 71 participants including members of the hospital management team attended this participatory workshop aimed at engaging everyone in problem solving. Workshop participants agreed that the hospital facilities were in fact adequate for hand washing, and so the reasons for the observed and reported lack of hand washing may have been more associated with inadequate training in infection prevention. It was also agreed that regular and sufficient supplies of protective materials including cleaning agents, facilitative supervision and follow-up were necessary ingredients of success in implementing prevention of HAI. The workshop ended with the formation of a new IPC for Keren hospital comprising of the hospital medical director, surgeons, gynaecologists and obstetricians, hospital matron, pediatrician, operating room nurses, surgical and laboratory technicians, pharmacist and laundry staff.

The post intervention test results showed that health workers’ knowledge about infection prevention practice had improved significantly – there was a 25% rise in post intervention scores when compared with preintervention. Marked improvement in compliance with infection prevention standards were noted with respect to hand washing after removing gloves (from 76% pre to 100% post intervention), cleaning beds and bedside equipments with disinfectant (from 12% pre to 87% post intervention), changing masks and oxygen catheters and tubes between patients (from 26% pre to 80% post intervention), and availability of isolation rooms for infectious patients (from 24% pre to 90% post intervention).

Patient Satisfaction

In the case of Eritrea, patient protection and infection prevention policy and practice have started on the right foot, bearing the legacy of veteran health workers’ motivation and dedication to compassion and not just competence. Ironically, this can be more of a challenge at peace time than it was at war time; but it is by no means insurmountable. The findings of this study make two major contributions to the literature on nosocomial infection prevention.

Firstly, the study confirms that both cognitive and technical input are necessary for infection prevention - it is not an ‘either-or’ proposition. Promotion of hand washing is also relevant to clinics and health stations which do not accommodate in-patients. A study conducted in Belgium has shown that General Practitioners’ hand washing practice left more to be desired, highlighting the need to target them as well.⁴⁰ However, the point of international comparison is not to encourage complacency among Eritrean (and other African) doctors. The view that “even rich countries have this problem, so why bother?” needs to be tackled head on. In Eritrea, the challenge is to at least maintain previously documented and celebrated standards of cleanliness and patient care; if not to excel. Can doctors who can’t be bothered to wash their hands get away with using gloves? In the case of Keren hospital, doctors’ preference to use gloves, and their failure to change them between patient contact seemed to be indicative of two basic misconceptions: one, that gloves are meant to protect the doctor, and not the patient; and two, that repeated use of the same pair of gloves does not matter to either the doctor, the patient, or for both. Studies have shown the use of gloves to be hazardous for both patient and health worker unless certain precautions are taken. Latex gloves can easily get punctured and/or provide ambient medium (moisture and warmth) for bacteria to breed rapidly. Washing hands and donning them with antimicrobial substances before gloving (particularly for unsterile vinyl gloves) and washing hands immediately after removing the gloves (even when using sterile gloves) is recommended⁴¹, but much depends on the particulars of the hospital unit concerned. In one study involving nurses in a teaching hospital ICU, no significant differences were found between antiseptic hand washing and the use of nonsterile gloves over washed hands; or between the use of antiseptic donning technique, prior antiseptic hand washing and the use of individually packaged sterile gloves.⁴² Unmentioned by the authors, this may be more a reflection of nurses’perfection of the art of hand washing than the relative merits of sterile or non-sterile gloves versus hand washing. While the majority (72%) of Keren hospital health workers were observed washing their hands for 10-15 seconds, only 30% washed their hands thoroughly. Other studies have shown that many operating room nurses wash their hands for as short as half the recommended time of 5 minutes for surgical nurses⁴³, but the technique used is clearly more important than the amount of time spent washing hands.

Secondly, this study’s major contribution in the area of patient participation is important. A recent systematic review has highlighted the significance of patient involvement in quality of health care and service planning and improvement in the UK.⁴⁴ The review concluded that “the effects of involving patients were likely to be complex, affecting different aspects of services in different ways. The views of patients are among many factors that influence change in health services, and providers of health care remain the final arbiter of how much weight is attached to patients’ views.” (p. 1267) This may hold true for Eritrea as well, although the Eritrean health service does not easily lend itself to simple categorization by political orientation. According to Gill Walt’s careful analysis, so-called “Egalitarian-authoritarian” systems such as those of Cuba and China have been characterized by resource redistributive policy and practice, often with positive health effects such as declines in infant mortality.⁴⁵ Eritrea shows a similar trend,⁴⁶ however, the findings of this study concerning patients’ views deserve careful consideration. Improvements in hand washing practice and general cleanliness of beds and disinfecting of the equipment and surroundings of patients’ beds in the post-intervention phase of this study are praiseworthy. Patients’ voices definitely carry more weight in this regard as health workers may be expected to over-report good practice. This study had controlled for such bias through triangulation: by using multiple sources and methods of data collection; and participant involvement in the interpretation of research findings.

Health workers’ training in infection prevention needs to incorporate their own protection as well. With particular reference to autopsy units, the use of gloves, even double layers and strong gauntlets for the nondominant hand are recommended.⁴⁷ Health workers may also protect themselves with gloves from the hazards of ingesting deadly pathogens while reading and licking their fingers in order to turn the pages of hospital patient records.⁴⁸ However, the most important lesson seems to be, doctors: avoid treating gloves as protective devices against your patients. The costs of HAI transmitted by contaminated gloves and hands are enormous for the patient – literally a matter of life and death – and they are also costly to the hospital, the Ministry of Health and to the country as a whole as increased morbidity and mortality means loss of human, social, and economic capital. One study has documented the cost-effectiveness of simple preventive strategies such as health workers’ proper washing and scrubbing of hands to prevent and control nosocomial infections.⁴⁹ This is relevant to Eritrea and to other countries in similar stages of post-conflict reconstruction and health policy and practice improvement.

Finally, the patients’ observations and suggestions concerning health workers’ attitude and behavior is worth discussing. The concerns of hospital patients and their relatives, particularly women in labor, point to the need for training in communications and patient care. Pregnant and newly delivered mothers constitute an important section of any population’s vulnerable groups. In the Eritrean psyche, mothers and motherhood are sacred across the religious, socio-economic, ethnic and cultural spectrum. Women have borne the brunt of hardship wrought by war. Lack of basic respect, if not moral support to women in labor on the part of health workers who happen to abuse their ‘power’ over life and death is therefore both repugnant and intolerable to the Eritrean people, be they rural agro-pastoralists of humble means or urban well-to-do citizens. The quality of maternity health care service provision will remain a litmus test for the level of progress in health care policy and practice in post conflict Eritrea; and health workers entrusted with the care of women in childbirth have a very important role to role to play.⁵⁰

An important strength of this study is its participatory and experimental design which has served to engage hospital-based health workers from all levels of service in problem solving activities and processes. Such studies are iterative and dynamic, rather than linear and static. Thus, the formation of an IPC for Keren hospital representing stakeholders who are inclined to take it upon themselves to raise the standards of quality of health care as they develop a stronger knowledge base of infection prevention and the necessary skills to implement agreed procedures, is a logical outcome of the study. There are indications of positive and dynamic change as health workers are motivated and empowered to work in partnership amongst themselves and with their patients, traditional birth attendants and relatives who may accompany the patients to the hospital and help with their care. This will require sustained high-level commitment and political will to allocate the necessary resources to improve quality of health care services in the country. This study is yet to be replicated in other zonal referral hospitals in the country where both cognitive and technical capacity for infection prevention may be different from those of Keren hospital. The study design and methods are robust and replicable, paving the way for more such studies to be conducted in order to build a strong, reliable and useful evidence-base for policy and practice concerning nosocomial infections that may be applicable to other countries in similar stages of post-war reconstruction and rehabilitation of health services in Africa.

CONCLUSION

Prevention and control of HAI remain major priorities for Eritrea and other countries around the world. It can effectively be advanced through the simple and inexpensive hygiene practice of proper handwashing between patient contact by doctors, nurses, health assistants and other support staff. Whatever their reason for failing to wash their hands at critical times, health workers who spread HAI stand guilty of violating the Hippocratic Oath, Do No Harm, that is sacred to their profession, and should therefore be made accountable in the most appropriate way. Rewarding good practice may be a useful step forward, however, ultimately, only the doctors (and nurses and other health workers) individual as well as collective motivation, sense of professional integrity, and pride in their own work can galvanize collective efficacy and accountability.

ACKNOWLEDGEMENTS

We thank the study team and participants in Keren hospital; the facilitators and instructors of the Institute of Public Health at Makerere University; Minister of Health, Saleh Meky; Director of Clinical Ser vices, Dr Michael Gebrehiwet; Sister Kidisty Habte and Dr Dan Wendo (TASC); Dr Berhane Debru; Dr Leul Banteyinga; and Joanne Ashton. Funding support for literature review and preparation of this manuscript was generously provided by Tufts University’s Henry R. Luce program.