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

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)


12

-

Step 1: Wet hands with water, apply enough soap and rub hands
palm to palm

-

Step 2: Right palm over left dorsum with interlaced fingers and vice versa

-

Step 3: Palm to palm with fingers interlaced

-

Step 4: Backs of fingers to opposing palms with fingers interlocked

-

Step 5: Rotational rubbing of left thumb clasped in right palm, vice versa

-

Step 6: Rotational rubbing, backward and forwards with clasped
fingers of the right hand in left palm and vice versa. Rinse hands
under running water from your wrists and dry hands.

Note: Each step should be done at least 5 times; the duration of the entire
procedure is 40-60 sec.
1.2.3.2. Rubbing hands with an alcohol-based solution
Rubbing hands with an alcohol-based formula is considered as a faster,
more effective and at killing bacteria, and better for the skin than hand washing,
thereby increasing hand hygiene adherence among HWs[51],[52]. Therefore, it
is highly recommended by the CDC and WHO guidelines for routine hygiene
hand antiseptic during patient care if hands are not visibly dirty [48], [53].
The placement of alcohol-based hand rubs:

With the aim of improving compliance with hand hygiene, every
department in the hospital, especially the clinical wards, should install the
alcohol-based hand rubs at the point of care. Alcohol-based hand rubs should
be equipped with at least the following positions[54]:
-

At the bedside of ER, ICU, infectious department.

-

At all entrances to and exits from the departments.

-

Outside inpatient rooms at the entrances.

-

At the injection trolleys

-

At medical examination tables, medical laboratory tables.


13

The procedure:
-

Step 1: Apply a palmful of the product in a cupped hand, covering all
surfaces enough soap, and rub hands palm to palm.

-

Step 2: Right palm over left dorsum with interlaced fingers and vice versa

-

Step 3: Palm to palm with fingers interlaced

-

Step 4: Backs of fingers to opposing palms with fingers interlocked

-

Step 5: Rotational rubbing of left thumb clasped in right palm and
vice versa

-

Step 6: Rotational rubbing, backward and forwards with clasped
fingers of the right hand in left palm and vice versa. Rubbing the
hands until hands are dry.

Note: Each step should be done at least 5 times; the duration of the entire
procedure is 20 - 30 sec or ends when dry hands.
1.2.4. Other aspects of hand hygiene
- Make sure the hands are completely dry before starting patient care

procedures.
- Do not wear artificial fingernails or extenders, jewelry on hands when
taking care of patients.
- If unnecessary, during patient care, avoiding contact with the surface
surrounding, equipment to prevent infection from surrounding and vice versa
because of soiled hands.
- Do not wash hands after rubbing hands with an ABHR.
1.3.

The researches of knowledge and practice on hand hygiene of

health workers in the world and in Vietnam
1.3.1. In the world
To cope with the burden of HAIs in global, some of the world's leading
health organizations had been recommended many effective methods, including


14

the "Five moments for hand hygiene", Universal Precautions, Standard
Precautions, etc. Many studies found that compliance with hand hygiene is an
effective way to prevent and control HAIs[55],[56],[57],[58]. In a recent survey
in a private hospital in Bangladesh, Begum and his colleagues again emphasized
that the rate of HAIs was the lowest when the percentage of hand hygiene
compliance was highest [59].
On the other hand, the percentage of complying with hand hygiene was
quite low. When researching about the knowledge, attitude, and practices of
infection control among health workers in ICUs in a tertiary hospital in Nigeria,
Adegboye and his colleagues found out that 86% of participants known that
hand is the most common vehicle of transmission of infection. However, the

percentage of HWs knew about the indications and 6 steps of handwashing
technique were 53.8% and 32.5% respectively. Only 28% of doctors here
practiced the six steps of the handwashing technique and 7.5% of them had ever
attended a training course on infection control [60].
A descriptive cross-sectional study conducted among 100 nurses
working in private hospitals in Sana'a City, Yemen also showed that most of
the nurses had fair knowledge and practices about nosocomial infections (87%
and 71% respectively). However, the percentage having good knowledge and
practices were quite low with only 4% and 26% respectively[61].
In addition, some observational studiesindicated the fact that although
the number of hand hygiene opportunities of patient care was high and even
the percentage of hand hygiene compliance is good too; the applied technique
may be inadequate.
In a survey assessing knowledge, attitude, and practices of hand hygiene
in an Indian healthcare setting, Jose GE noted that none of HWs had poor
knowledge whereas up to 54% bypassedhand hygiene. It was interesting to


15

observe that among 46% performing HH, only 16% had proper HH practice
which is the true compliance of this study [62]. Complying with HH but done
poorly was also point out in many other studies with the rate ranged from 0%
to under 25% between professional categories[63],[64],[65],[66].Moreover,
while the minimum recommended time for HH using an ABHRwas 20
seconds, 94.3% of hand disinfections were performed for ≤15s and the
average duration was 7.6s in two ICUs at a German medical school[67].
Another survey in an Indian Medicine College also highlighted that 49% of
HWs took less than the time recommended [62].
1.3.2. In Vietnam

In a survey at a Large Central Hospital, Le Cam Dung indicated that the
overall compliance was 30.6% with the lowest compliance rate was seen in
physicians (15%) and the internal medicine department (16%).
The survey of Nguyen Nam Thang and Le DucCuong was conducted to
assess knowledge and practices on routine handwashing of nurses at two
general hospitals in TienHai district, Thai Binh province in 2017. Results
showed that in many knowledge questions, the percentage of nurses having
the correct answer was low (fewer than 50%). For example, the minimal time
needed for handwashing and handrubbing (47.3% and 49.6% respectively),
the appropriate hand hygiene method when moving from a contamination
body site to a clean body site (12.5%). The proportion of nursing regarded as
good knowledge at TienHai District General Hospital and Nam TienHai
General Hospital were 66.4% and 50.5% respectively (p<0.05)[68]. Regarding
the practical skill of routine handwashing, the results illustrated that the rates of
nurses regarded as Qualified at two hospitals were very low, with 45.0% and
25.8% (p<0.05) of nurses respectively at TienHai District General Hospital and
Nam TienHai General Hospital[69].


16

In 2014, Phung Xuan Thuy assessed the compliance with handwashing
and some related factors of healthworkersin Vinh Phuc Provincial General
Hospital. The results showed that 65.8% of HWs had good knowledge on
handwashing meanwhile only 14.8% had proper handwashing practice[70].
The proper HH compliance rate was quite low in moment 5 (after touching
patient surroundings), followed by moment 1 (before touching a patient) with
3.1% and 18.4% respectively.
Another study of Bui HuuUyen assessing knowledge, attitude, and
practices on handwashing during patient care among nurses at Lang Son

Province Hospital in 2012 showed that 56.9% of nurses known the duration of
handwashing. Meanwhile, the percentage of nurses performing all 6 steps of
routine handwashing and the duration of handwashing was 49.2% and 42.7%
respectively [71].
The study of Bui ThiThanhHuyen and colleagues also found that the
percentage of HWs at KhanhHoa Province Hospital in 2012 having a fair
knowledge and complying with HH were 72% and 34% respectively[15].
In 2012, Truong Anh Thu and colleagues conducted a survey among 629
HWs at 36 hospitals. Results showed that the percentage of nurses having
knowledge ofSPs were high (83.9%-99.2%). The attitudes on performing
hand hygiene before wearing gloves and after touching the patient's
surroundings were 54.5% and 54.8% respectively [16].
1.4.

Some factors related to knowledgeand practices on hand hygiene of

health workers in the world and in Vietnam
Several studies have proved that there were multi factors influencing
compliance with recommended hand hygiene. According to WHO, these
factors have been identified as influencing adherence to recommended HH
practices, including (a) lack of access to HH facilities at point of care, (b) time