Intervening with healthcare workers’ hand hygiene compliance, knowledge, and perception in a limited-resource hospital in Indonesia: a randomized controlled trial study

We report the first cluster randomized controlled trial evaluating the effect of three different educational programs on HCWs’ hand hygiene compliance and knowledge-perception in a limited-resource hospital in Indonesia. Particularly in our hospital, educational programs on hand hygiene were not applied regularly. Therefore, the educational programs used in this study were introduced in our hospital for the first time. In the departments with an intervention of role model training (i.e., pediatrics and internal medicine), the hand hygiene compliance improved, but only pediatrics department with the sole intervention of role model training was significantly better than the control group. The hand hygiene compliance improvement co-occurred with a statistically significant improvement of the knowledge score. Therefore, we conclude that role model training has the most impact on improving hand hygiene compliance in this setting. Erasmus et al. and other studies have also pointed out the importance of role models [14–16]. However, it is possible that the factor of positive role models is even more important in societies where job seniority plays a great role, such as in Indonesia.

The improvement in the pediatrics department might also be associated with fewer activities related to hand hygiene opportunities in patient care (n?=?577) compared to internal medicine (n?=?763), surgery (n?=?733), and obst-gyn (n?=?693). Pittet et al. reported the inverse relationship of activity level in the ward with hand hygiene compliance rate [17, 18]. The low activity level might also be associated with the improvement of hand hygiene adherence in general in wards and in rooms with class III type facilities. Overall, however, the hand hygiene compliance rate was low. Compared to Pakistan, also a low-middle income country [1], overall hand hygiene compliance rate in our study was lower. On the other hand, the HCW assured that they performed hand hygiene very well based on the perception survey (85.5% and 75.1% in the pre- and post-intervention phase, respectively). Therefore, the HCW may not change behavior [12]. Additionally, only good knowledge about the hand hygiene procedure did not lead to the high hand hygiene compliance among HCW. Other factors including awareness, action control, facilitation, social influence, attitude, self-efficacy, and intention might also be associated with the adherence to hand hygiene procedure. However, further investigation is needed [2].

Although hand hygiene compliance improved after intervention, we noted higher compliance rates after a procedure or body fluid exposure risk (although for only a low number of observed opportunities) and after touching a patient than before performing patient care. The lowest adherence was at the moment after touching a patients’ surroundings. Therefore, the reason to perform hand hygiene was more to protect the HCW themselves than patients [1, 17, 19, 20]. In addition, effectiveness of hand hygiene to prevent HAIs was hampered by inappropriate clothing such as hand-accessories and long sleeves by most HCW, so transmission of pathogens was unavoidable.

Based on healthcare profession, hand hygiene adherence improved among doctors and nurses in general, although it was not significant in the surgery department. The hand hygiene performance among students did not improve significantly, and even decreased in the surgery and pediatrics departments. This might be associated with the weekly rotation of students’ traineeships in our hospital leading to missing education programs, the attitudes of mentors and role models, curriculum enforcement, beliefs, and the use of gloves [21]. In such situations, students may transmit the pathogens causing HAIs from patient to patient [22].

Our data showed that wearing gloves regardless of the recommendation for gloves during patient care (i.e., wearing gloves when writing in the patient medical record) hampered HCWs’ hand hygiene adherence. WHO observed such misuse of gloves not only in limited-resource hospitals, but also in hospitals where gloves are widely available [6]. After intervention, wearing gloves without indication decreased but shifted to handrubbing while using gloves during patient care. Then, HCW did not change gloves between patients or between contacts of different sites on the same patient. Nurses declared that glove decontamination resulted from a limited examination gloves supply in our hospital (750 pairs per room in Class III). However, WHO does not recommend glove decontamination [6] because of material damage, which can endanger the protective function of gloves. Similar problems were encountered by the WHO in Ebola-affected countries, where gloves were frequently disinfected with chlorine solutions [23].

This study has some limitations. Firstly, the preparation of national hospital accreditation was held in the same period as this study, which may have influenced the knowledge and perception on hand hygiene among HCW. In addition, the HCW were busy preparing the accreditation, so participation in the knowledge and perception survey after intervention was limited. Secondly, the HCW may have changed behavior during hand hygiene observation because of their awareness of the observer (Hawthorn effect) [24, 25]. This could also be an additional explanation for the significant improvement in hand hygiene compliance in the control department. Thirdly, the study was performed in a tertiary academic hospital that included medical students and nursing students, in the delivery of patient care. Modification of the hand hygiene educational program is suggested when it is applied in either secondary or non-academic hospitals according to the hospital resources.