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

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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 ........... 64 4.2. Some factors related to the knowledge and practice on hand hygiene... 71 4.3. Strength and limitation of the study.................................................. 76 CONCLUSIONS ........................................................................................... 78 RECOMMENDATION ................................................................................ 79 i 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 ii 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 iii 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 1 INTRODUCTION Nowadays, thanks to the outstanding development of science and technology, many dangerous infectious diseases have almost been eradicated or prevented successfully, such as Polio, Smallpox, Measles, Pneumonia, and Diarrhea. However, during the process of implementing medical examination and treatment activities in healthcare facilities, medical errors and other adverse events may occur which include nosocomial infection.In 2016, the European Centre for Disease Prevention and Control estimated that more than 2.6 million new cases of healthcare-associated infections (HAIs) occur every year in Europe [1]. Many pieces of research showed that HAIs can lead to severe consequences for hospitalized patients and their familiesin highincome 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. 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 2 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. 3 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]. 4 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 5 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 6 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 7 persistently colonized on the hands of HWs such as Pseudomonas spp., Acinetobacter spp., andKlebsiella spp.[36],[37],[35].These 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, 8 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 healthcareassociated 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 selfmade, 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]. 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 9 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]. 10 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]. 11 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)
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