Hand hygiene compliance and its predictors among healthcare providers in primary healthcare settings in the Girawa District, Eastern Ethiopia

Hands and clothes of healthcare workers (HCWs) are the most common vehicle for the transmission of healthcare-associated pathogens from patient to patient and within the healthcare environment. Healthcare-associated infections (HCAIs), also referred to as ‘nosocomial’ or ‘hospital’ infections, are infections that patients acquire while receiving treatment for medical or surgical conditions and are the most frequent adverse event during care delivery. HCAI is a major problem for patient safety, and its impact can result in prolonged hospital stays, long-term disability, increased resistance of microorganisms to antimicrobial agents, a massive additional financial burden for the health system, high costs for patients and their families, and excess deaths (WHO 2011). Hand hygiene is a frequently missed lifesaving opportunity during patient care (Trampuz & Widmer 2004). World Health Organization (WHO) has estimated that hundreds of millions of patients are affected by HCAIs leading to deaths in one among 10 infected patients every year (WHO 2020). Globally, out of every 100 patients in acute-care hospitals, seven patients in high-income countries (HICs) and 15 patients in low- and middle-income countries (LMICs) acquired at least one HCAI during their stay (WHO 2022). Thus, hand hygiene is vital in reducing HCAIs and preventing the spread of antimicrobial resistance.

In response to these challenges, assessing water, sanitation, and hygiene (WASH)-related risks and WASH measures is pivotal to mitigating the spread of infectious diseases and ensuring a safe environment for patients, visitors, family members, and health and care workers. However, HCW hand hygiene compliance with optimal practices remains low in most settings, particularly in developing countries (Allegranzi & Pittet 2009; Haque et al. 2020). Furthermore, inadequate Infection Prevention and Control (IPC) practices were reported among HCWs, sanitary workers, and even in IPC experts (Sahiledengle et al. 2018; Tolera et al. 2024).

Hand hygiene is a general term referring to any action of hand cleaning that is related to the removal of visible soil, and the removal or killing of transient microorganisms from the hands while maintaining good skin integrity resulting from a hand care program (WHO 2009). According to the WHO guidelines, handwashing remains the most effective measure to prevent the mode of transmission of microorganisms (WHO 2009). The WHO has recommended five times for the hand hygiene approach, to effectively interrupt the spread of HCAIs (Sax et al. 2007). This approach encourages HCWs to clean their hands before patient contact, before an aseptic procedure, after body fluid exposure, after patient contact, and after contact with patient's surroundings (WHO 2009). However, the hand hygiene compliance rate in sub-Saharan Africa is estimated to be 21.1% (Ataiyero et al. 2019).

Despite being vital for safe health delivery, hand hygiene practices at the point of care remain suboptimal worldwide (World Health Organization 2023). Significant disparities between high- and lower-income countries exist. Clearly, a better understanding of factors influencing hand hygiene behavior is needed, as is prioritization of research areas where gaps still exist. The studies conducted among health workers in hospitals in Northern and Eastern Ethiopia found 68 and 35% overall compliance of hand hygiene, respectively (Umar et al. 2022; World Health Organization 2023; Daba et al. 2024).

In LMICs like Ethiopia, the primary healthcare institutions are relatively accessible, require low cost, and the majority of patients primarily visit when they get sick (World Health & United Nations Children Fund 2018). Additionally, various studies conducted in handwashing compliance among health workers focused on hospitals, or they are inconsistent in covering important indicators such as handwashing critical time (Awoke et al. 2018), with limitations in including all potential predictors and healthcare professionals (Desta et al. 2018). Furthermore, most studies relied on a self-reported questionnaire that could be subjected to an overestimation of hand hygiene compliance (Abdo et al. 2020; Tadesse et al. 2022). As a result, a structured questionnaire-based study embedded with an observation-based assessment of the existing WASH facilities as proxy indicators for hand hygiene practice can help to determine the extent to which professionals reported and observed practices differ. Therefore, this study planned and assessed the level of hand hygiene compliance and its predictors among healthcare providers in primary healthcare facilities in the Girawa District, Eastern Ethiopia, using a structured pretested questionnaire and observational checklist.

The study was conducted in primary healthcare facilities in the Girawa District with latitude: 8° 54′ 59.99″ N and longitude: 41° 39′ 59.99″ E, Eastern Ethiopia. Its' borders are Gola Oda Meyu Mulike District in the south, Bedeno in the west, Kurfa Challe District in the north, and Fedis in the east. The administrative center of the District is Girawa town. The District is located 575 km away from the capital city of Addis Ababa and 75 km away from Harar. The total population is estimated to be 365,359 in the District and 340,631 in the rural areas. Regarding the health sector, the district has one primary hospital, nine health centers, 47 health posts, two private clinics, and three pharmacies.

A facility-based cross-sectional study was conducted from November 1 to December 1, 2023.

All healthcare providers working in the governmental health facilities in the Girawa District were source population. The study population was all healthcare providers (medical staff, nurses, nurses' assistants, midwives, laboratory personnel, dentists, pediatricians, physiotherapists, and anesthetists) in the selected public health facilities in the Girawa District available during the study period. All healthcare providers who were recruited and available during the study period, and willing to participate, were included in the study. Healthcare providers who had no active contact with patients and were not available during the data collection period were excluded from the study.

The sample size was calculated by a single population proportion formula by considering the proportion of hand hygiene compliance, 38% (Soboksa et al. 2021), 95% confidence interval (CI), and margin of error (5%), and the calculated sample size was 362. By considering a 10% non-response rate, the final minimum sample size became 400. A single proportion formula used to determine the sample size for this study was n = (Z² × pq)/d². Here, n is the minimum sample size required for the study, Z with a confidence interval of 95% (Z= 1.96), p indicates a 38% of prevalence of hand hygiene compliance from a similar study, q = 1 − p, and d = is a tolerable margin of error (d = 0.05).

Data were collected by three trained BSc nursing professionals and three BSc environmental health workers, and supervised by three senior professionals. Data were collected using the tools adapted from WHO WASH guidelines (WHO 2016). The structured self-administered questionnaire containing four sections was used. Part I was about socio-demographic characteristics of the HCWs. Part II includes questions that were relevant to assessing institutional factors that influence the practice of hand hygiene. Part III contains hygiene behaviors related to knowledge, attitude, and training questions for health workers that were adapted from WHO (WHO 2016). Part IV contains self-administered questions with regard to their hand hygiene practices or compliance.

The questionnaires were administered to healthcare professionals after the purpose of the study was explained, and informed consent was obtained from each participant, and the questionnaire had no personal identification to keep their confidentiality. Participants who were not interested in participating in the study have the right to quit the study. They could also ask any question at any time during the study. The questionnaire was administered to the study participant in a private place. Finally, filled questionnaires were collected by data collectors immediately.

The dependent variable was hand hygiene compliance, and the independent variables were socio-demographic factors: age, sex, religion, marital status, work experience, educational level, institutional factors: availability of soap and water, availability of alcohol-based hand rub (ABHR), availability of handwashing setup, presence of IPC manual and unit of work, work shift, WASH policy and programs, and behavioral factor: knowledge, attitude, working hours, workload, training, busyness, forgetfulness, skin irritation by ABHR, hand hygiene.

Favorable attitude refers to a HCW who scored the mean and above the mean value of the hand hygiene attitude score (Gebresilassie et al. 2024).

Good hand hygiene compliance: healthcare providers who reported that they practiced all of the hand hygiene moments according to the WHO checklist (WHO 2016).

Good knowledge refers to a HCW who scored the mean and above the mean value of the knowledge question value (Gebresilassie et al. 2024).

Poor hand hygiene compliance: a healthcare provider who reported that they did not practise at least one of the hand hygiene moments on the WHO checklist (WHO 2016).

Before analysis, data were collected, edited, and coded. Any error identified at this time was corrected after a review of the original data using the code numbers. After this, data were entered using Epi-Data version 3.1, and were analyzed using STATA 17 statistical software. Descriptive statistical analysis such as simple frequencies, measures of central tendency, and measures of dispersion was used to describe the characteristics of participants. The result was presented using frequencies, summary measures, tables, and figures. Bivariate and multivariate logistic regression models were used to identify predictors of hand hygiene practice. Finally, variables with p-value ≤ 0.25 in the bivariate analysis were taken into the multivariable model to control all possible confounders. Hosmer Lemeshow was done to test for model fitness. Multi-collinearity is checked to see the linear correlation among the independent variables by using a variance inflation factor and standard error. Variables with variance inflation factor >10 and a standard error >2 were dropped from the multivariable analysis. Odds ratios with a 95% CI were estimated to identify predictors' handwashing practices using multivariable logistic regression analysis. The level of statistical significance was declared at p-value ≤ 0.05.

Self-administered questionnaire checklists were prepared in English. Prior to actual data collection, a 2-day training was given to data collectors and supervisors on the data collection tool, data collection procedure, aim of the study, and confidentiality of the collected data from respective HWs. A pre-test on a self-administered questionnaire was conducted on 5% of final study subjects in non-selected facilities to ensure its validity, reliability and to check the wording of the questionnaires. The completeness of each questionnaire was checked by supervisors on a daily basis and finally it was confirmed by the principal investigator. Double data entry was done by two data clerks, and consistency of the entered data was cross-checked by comparing the two separately entered data.

Before starting the data collection process, the study protocol was approved by the Haramaya University, College of Health and Medical Sciences, Institutional Health Research Ethics Review Committee (IHRERC) (Ref. No.: IHRERC/194/2023). Official letters of cooperation were written by Haramaya University College of Health and Medical Sciences to the Girawa District Office to obtain their cooperation in facilitating the study. ‘Informed, voluntary, written, and signed consent’ was obtained from all study participants after a clear description of the objectives, procedures, potential risks, and benefits of the study by the data collectors before proceeding with data collection. The study participants were informed of their right to refuse or withdraw from the study at any time. Privacy and confidentiality of participants were maintained by excluding names and identifiers in the questionnaire. Informed, voluntary, written, and signed consent was obtained from all respondents throughout the study.

A total of 398 healthcare providers participated in the study with a response rate of 99.5%. The majority of the respondents, 256 (64.32%) were in the age group of 25–34 years, with a mean age of 29.73 (± 5.26 SD) years. More than half (56.03%) of the participants were male. With regard to their work experience, 205 (51.51%) of them had ≤5 years of experience, and 128 (32.16%) were working in the hospital (Table 1).

More than half, 218 (54.77%), of the respondents took in-service WASH training. Around 250 (63.81%) of the respondents reported that their health facility or healthcare unit did not have handwashing facility setup, and 221(55.53%) of respondents did not obtain water for their handwashing in their facility (Table 2).

The majority, 249 (71.84%), of respondents scored more on attitude showing they had a positive attitude toward hand hygiene (Table 3).

Of the study participants, 207 (52.51%) were scored higher than a mean of the knowledge questions, which showed that they had good knowledge about hand hygiene (Table 4).

Overall, the hand hygiene compliance of HCWs was 30.15% [95% CI: 25.68–34.92]. One hundred and thirteen (28.39%) of the HCWs always washed their hands before direct contact with the patient, while 98 (24.62%) always washed their hands before performing invasive procedures. One hundred and eleven (27.89%) always washed their hands before giving injections, whereas only 108 (27.14%) always washed their hands after contact with blood, body fluids, wounds, catheter sites, or drainage sites (Table 5).

In the bivariate analysis, variables like age, sex, years of working experience, educational level, availability of handwashing setup, attitude toward hand hygiene, being trained on hand hygiene, and knowledge about hand hygiene have shown a significant association with hand hygiene compliance at a p-value of <0.25, and were considered as candidates for multivariable analysis.

In the multivariable logistic regression model, educational level, availability of handwashing setup, attitude toward hand hygiene, being trained on hand hygiene, and knowledge about hand hygiene were significantly associated with hand hygiene compliance at a p-value of <0.05. Health professionals who have taken training about hand hygiene were 2.21 times (adjusted odds ratio (AOR) = 2.21, 95% CI: 1.37–3.57) more likely to have good hand hygiene compliance compared to their counterparts. Health professionals who have a BSc degree were 1.81 times (AOR = 1.81, 95% CI: 1.05–3.10) more likely to have good hand hygiene compliance than those who had a diploma. Study participants who had a handwashing facility setup in the working room were 2.35 times (AOR = 2.35, 95% CI: 1.41–3.92) more likely to have good hand hygiene compliance as compared to those who had no handwashing facility setup in the working room.

Those who had good knowledge of hand hygiene were 1.75 times (AOR = 1.75, 95% CI: 1.09–2.82) more likely to have good handwashing compliance than those who were not knowledgeable for hand hygiene. Furthermore, health professionals who had a positive attitude toward hand hygiene were 3.39 times (AOR = 3.39, 95% CI: 2.01–5.77) more likely to have good hand hygiene compliance as compared to their counterparts (Table 6).

Adequate hand hygiene is the main defense against infections linked to healthcare settings and against the spread of microbes resistant to multiple drugs. Many patients in healthcare settings are affected by healthcare professionals' poor hand hygiene compliance and associated complications (WHO 2009). This study includes the major components of healthcare systems: one general hospital, six health centers, and 26 health posts. From the total healthcare professionals included in this study, 223 (56.03%) were male.

The majority, 76% (302), of the study participants had a diploma and 86 (21.61%) had a BSc degree. Nearly, 45% (180) received formal in-service training related to hand hygiene in the last three years. Of the 309 respondents, 250 (62.81%) reported that their health facility had no handwashing setup in the working room, which is by far inferior to findings of other similar studies elsewhere (Engdaw et al. 2019; Potgieter et al. 2021; Umar et al. 2022). This might result from the large proportion of lower level professionals with inadequate knowledge and minimal authorities' attention given to the service quality in primary healthcare institutions. The present study found that the overall hand hygiene compliance of healthcare providers working in public healthcare settings in the Girawa District was 30.15% [95% CI: 25.68–34.92]. This finding is consistent with a study conducted in eastern Ethiopia (34%) (Umar et al. 2022) and Turkey (31.9%) (Karaaslan et al. 2014). However, this finding is higher than a study conducted in Waghimira Zone (20.6%) (Alene et al. 2022), Addis Ababa (22.2%) (Tadesse et al. 2022), Hiwot Fana Specialized University Hospital (18.7%) (Awoke et al. 2018), Dessie referral hospital (17.6%) (Tesfaye et al. 2022). In addition, this finding is lower than a study conducted in Hararghe Zone (37.4%) (Umar et al. 2022), Addis Ababa (50.4%) (Abdo et al. 2020) and Rwanda (72%) (Ndatimana et al. 2022). This discrepancy could be attributed to variation in the study population, which in some cases focused solely on nurses or physicians, as well as the study period. These uncovered critical gaps among HCWs, urging immediate, targeted educational interventions to fortify adherence and prevent infection outbreaks (Hong & Xu 2024).

In this study, health professionals who have received in-service training about hand hygiene were 2.25 times more likely to have good hand hygiene compliance than those who have not taken the training. This finding is consistent with studies conducted in Finland (Ojanperä et al. 2020), Addis Ababa (Odo & Mekonnen 2021), Waghimira Zone (Alene et al. 2022), Hararghe Zone (Umar et al. 2022) and a study conducted in a university hospital in central Ethiopia (Pfäfflin et al. 2017). These all revealed that training has a significant relationship with hand hygiene compliance among health workers. This may be due to the fact that training builds the knowledge of healthcare providers and helps them to identify risk and benefits of HH practice on the ways of HCAI transmission and how to prevent it (Alene et al. 2022). Besides, factors like advanced professional level and in-service trainings provided in healthcare facilities could lead to a rise in hand hygiene compliance, since health professionals received greater instruction on donning and doffing techniques (Chakma et al. 2024). Even a single lecture on basic hand hygiene protocols had a significant and sustained effect in enhancing hand hygiene compliance in a Swedish hospital (Sopjani et al. 2017).

Findings of this study showed that the study participants who had a handwashing facility setup in their working room were 2.3 times more likely to have good hand hygiene compliance as compared to those who had no handwashing facility setup in the working room/unit. This finding is consistent with a study conducted in Finland (Ojanperä et al. 2020), Gondar (Engdaw et al. 2019), and Waghimira Zone (Alene et al. 2022). It is apparent that handwashing set up is a pre-requisite for handwashing practice, and availability and accessibility of resources may promote hand hygiene compliance by increasing level of comfort during handwashing time (Ibrahim & Ibrahim 2020; Endalew et al. 2022). The current study exhibited that health professionals who had a BSc degree were 1.81 times more likely to have good hand hygiene compliance than those who had a diploma. This finding is consistent with studies conducted in Addis Ababa (Abdo et al. 2020), Gondar (Teshager et al. 2015) and Bangladesh (Hsan et al. 2023). This might be due to the fact that as educational level increases, knowledge of the importance of hand hygiene is also improved (Desta et al. 2018; Gammon et al. 2024).

Health workers who had good hand hygiene knowledge were 1.83 times more likely to have good handwashing compliance than their counterparts. This finding is consistent with studies conducted in central Gondor (Engdaw et al. 2019), Hararghe Zones (Umar et al. 2022), and Kuwait (Al-Wazzan et al. 2011). This could be because understanding the importance of hand hygiene enables one to follow suggested practices, weigh the benefits and drawbacks of doing so, and pinpoint the transmission routes and preventative measures for HCAIs (Chakma et al. 2024). Moreover, HCWs who had a favorable attitude toward hand hygiene were 3.52 times more likely to have good hand hygiene compliance as compared to their counterparts. This finding is consistent with similar studies conducted in Ethiopia (Soboksa et al. 2021), the United Arab Emirates (Wai Khuan et al. 2018), and Jordan (Al-Hussami et al. 2011). This might result from societal influences, religious institutions, positive peer pressure, positive professional attitudes regarding hand hygiene compliance, the respondent's educational background, or personal experience (Wai Khuan et al. 2018; Engdaw et al. 2019).

The strength of this study was that it shows the magnitude of hand hygiene compliance among health workers in rural primary healthcare facilities, which is very important to strengthen IPC strategies and practices between patients and HCWs. The study used primary data for obtaining comprehensive information from primary healthcare facilities, which are better accessible and most patients visit for various healthcare services. The main limitation of this study was that the results are based on a self-reported questionnaire. The study also had limitations such as temporality, and causal inferences could not be established because of the nature of the cross-sectional study design.

Nearly two-thirds of the healthcare providers had poor hand hygiene compliance in the study area. Lower professional level, lack of in-service training, limited knowledge, unfavorable attitude, and lack of WASH facilities have significant influences on health workers’ hand hygiene compliance. Hence, the local government and other stakeholders should focus on improving the WASH services by availing all the basic facilities, and providing periodic training to build staff capacity in WASH.

We would like to express our sincere gratitude to Haramaya University for supporting us to write this work, as well as to the data collectors and supervisors. Finally, we would like to acknowledge study participants for their willingness to participate.

Before starting the data collection process, the study protocol was approved by the Haramaya University, College of Health and Medical Sciences, IHRERC. Official letters of cooperation were written by Haramaya University College of Health and Medical Sciences to the Girawa District Office to obtain their cooperation in facilitating the study. ‘Informed, voluntary, written, and signed consent’ was obtained from all study participants after a clear description of the objectives, procedures, potential risks, and benefits of the study by the data collectors before proceeding with data collection. The study participants were informed of their right to refuse or withdraw from the study at any time. Privacy and confidentiality of participants were maintained by excluding names and identifiers in the questionnaire. Informed, voluntary, written, and signed consent was obtained from all respondents throughout the study. This research was done following the Helsinki Declarations and National Ethical Guidelines.

No specific fund was provided for this work.

All authors participated in the development of the manuscript as well as the data review, drafting, methodology, data analysis, and writing the results. The final draft of the manuscript to be published has been read and approved by all authors, who also concur on all other aspects of this work.

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.