Year : 2013 | Volume : 1 | Issue : 2 | Page : 41 - 43  

Original Articles
Assessment of hand hygiene levels among health care settings of a coastal city in Andhra Pradesh
  1. Samara Simha Reddy1, V.V.Durga Prasad2, S. K. Mishra3, M. Amarnath4, Somuvenkatesh.5

1&2PG student, 3Prof. & HOD of Community Medicine, GSL Medical College, Rajahmundry. 4Professor of Community Medicine, Pinnamalai Siddhartha Institute of Medical Sciences & Research Foundation, Vijayawada. 5MBBS Scholar, GSL Medical College, Rajahmundry.


Background: it is known that hand hygiene practice among medical and paramedical play an important role in preventing the transmission of infections. Magnitude of Health Care Associated Infection is very high in developing countries like India due to the numerous factors like under staffing, poor hygiene, lack of basic equipment, inadequate structures and overcrowding. Improved compliance with hand washing was associated with a significant use in overall rate of nosocomial and respiratory infections in particular. Although guidelines for hand hygiene practice among health care settings are present non compliance remains a major problem among these hospitals. Due to the paucity of studies on hand hygiene practices particularly in this area the present study was undertaken.

Objectives: To assess the hand hygiene level among different hospitals in a coastal city of Andhra Pradesh.

Methods: This is a descriptive cross-sectional study done among the health care settings of the coastal city. WHO hand hygiene self assessment framework, 2010 is used as a study tool. There are seventy two listed hospitals in the city and among them every second hospital is selected for the study. Data was collected from these hospitals after taking consent from the hospital authorities. The data was entered in MS EXCEL 2007 and the results are expressed in percentages and proportions.

Results: Among the health care setting selected in our study 7% are government hospitals, 93% are private hospitals. After assessing the hand hygiene level 64% hospitals have basic hand hygiene level, 36 % hospitals have intermediate hand hygiene level.

Conclusion: No hospitals in the current study have neither inadequate nor advanced hand hygiene level. There is much scope for the improvement of both hand hygiene levels and practices among health care settings and health workers respectively with the given recommendations

Key-words: Hand hygiene levels, health care settings, hand hygiene practices

Corresponding Author Dr. N. Samara Simha Reddy, PG Student, Dept. of Community Medicine, GSL Medical college, NH 5, Laxmipuram, Rajahmundry, 533296.



Hand hygiene is considered the primary measure to reduce the transmission of nosocomial pathogens. The most common cause of health care associated infections in developed countries were inadequate hand hygiene levels, prolonged length of stay in hospital, surgery, I.V. and sedative medications.[1-7] The magnitude and scope of HCAI burden worldwide appear to be very important and greatly underestimated. Simple preventive measures have been identified and proven effective and they are much simpler to implement such as hand hygiene. [8] Many factors contribute to poor hand washing among health care workers- Ignorance about the importance of hand hygiene in reducing the spread of infections and how hands become contaminated, lack of understanding of correct hand hygiene technique, understaffing and overcrowding, poor access to hand washing facilities, irritant contact dermatitis associated with frequent exposure to soap and water, lack of institutional commitment to good hand hygiene are important factors. [11] Although guidelines for hand hygiene practice among health care settings are present non compliance remains a major problem among these hospitals. [9] Due to the paucity of studies on hand hygiene levels among the health care settings particularly in this geographic area the present study was undertaken with the objective to assess the hand hygiene level among different hospitals in coastal city of Andhra Pradesh and to give recommendations for proper adaptation of hand hygiene practices among staff members of these health care settings in the coastal city.

Materials and Methods:

A Cross sectional study was carried out among the different health care setting of a coastal city over a period of twomonths. Out of the total seventy two listed hospitals/ nursing homes in this coastal city, every second hospital was selected for the study. Among them two hospitals refused to participate and one was non functional. Data was collected from the rest of hospitals covering the list. The study tool used was Hand Hygiene Self-Assessment Framework 2010 by World Health Organization (WHO). [10] Study tool have five components consisting of system change, education and training, evaluation and feedback, reminders in work place, and institutional safety climate for hand hygiene. The tool is scored for a total of five hundred with hundred for each component. MS EXCEL 2007 was used and the results are expressed in percentages and proportions. Prior Institutional ethical committee approval was taken. Prior permissions from the corresponding hospital authorities were also taken. Data was collected from all the selected hospital by detailed inspection, interviewing the hospital staff and the concerned hospital authorities.


93% of hospitals participated in the study are private & 7% are government (Fig.1). Among all hospitals participated in the study, 64% hospitals have basic hand hygiene levels and 36% hospitals are having intermediate hand hygiene level(Fig.2). No hospitals in the study are having advanced hand hygiene level. All the government and teaching hospitals are having basic hand hygiene levels and among private hospitals, 42% hospitals have intermediate level and 58% are having basic hand hygiene level.

The system change component has got a total scoring of 65% with 68.33% as highest scoring in the private hospitals and lowest being the teaching hospitals with 35% and among all components of study, system change for hand hygiene has got the highest scoring. Training and education has got an average scoring of 62% with teaching hospitals in top place with 70% scoring. Coming to the evaluation and feedback component, teaching hospitals are having a very low scoring of only 10% compared to the overall scoring of 43.5% and with private hospitals having better scoring of 55%. Reminders in the work place has got the least scoring of all components with scoring of only 9% and that too with teaching hospitals and government hospitals not having even a single reminder of hand hygiene practices(Table 1).


The main problems identified from our study were the absence of remainders in work place, system change, time constraints, lack of education and motivation. Lacks of adherence with recommendations for hand hygiene practice are extremely low in the health care settings. With an improved compliance, the use of alcohol based hand rub at bedside as compared to the classical soap and water, GopalRao et al; observed a consistent reduction in proportion of hospital acquired methicillin resistant staphylococcus aureus (MRSA) infection or colonization (from 50% to 39%) over 2 years12. The system change that must be addressed in most hospitals concerning the leading risk factor for non compliance with hand hygiene: time constraint. In health care context “no time for hand washing is not an excuse but a reality.” strict compliance would mean that at least a fourth of nursing time in busy wards would be spent on practice of hand hygiene. A bed side hand rub with an alcohol based agent requires only 20 seconds11. Providing easy access to hand hygiene materials is mandatory for appropriate behaviour and it should be achieved in all hospitals. Health care workers education and they are obviously very important to modify hand hygiene behaviour and it must be a part of multimodal strategies to enhance compliance in hospitals. With the proper placement of reminders in work place there can be a drastic improvement in the adherence of hand hygiene practice among health care settings especially in intensive care units.The main Limitationof our study was that we could not cover all the health care settings of the city due to lack of resources. A further study can be under taken by taking the swab cultures from all the wards of health care settings and thus identifying the organ specific nosocomial infections in this coastal city.


The Educational resources should be made available to all health-care workers and there should be training campaigns regularly at least once in 6 months. Alcohol based hand rub should be introduced in all hospitals and especially in busy hospitals as it is most time saving. Hand hygiene compliance observers should be appointed in all the health care settings. There should be audit about damage and replacement of equipments regularly used in the hand hygiene practices as required at least annually once. A workplace reminder plays a drastic role in the adherence improvement and should be located in the facility. There should be a system for recognition and utilisation of Hand Hygiene role models and champions and thus improving the compliance. In Less health care settings patients are informed about the importance of hand hygiene who are main persons who should know. So, for making patients aware about hand hygiene, Formalized programme of patient engagement should be undertaken. Hand hygiene institutional target should be there for every health care setting. There should be communications that regularly mention hand hygiene. Hand hygiene should be given first priority among all the national health programmes as an effective measure in infection control. Strong legislations should be brought up to improve adherence with the present recommendations.

Key Message

Our study identified that the absence of remainders in work place, system change, time constraints, lack of education and motivation, Lack of adherence with recommendations for hand hygiene practice as the major problems for poor hand hygiene levels among the health care settings and appropriate solutions were identified.


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Table 1: scoring of components of study by different hospitals of study


Government hospitals

Medical college hospitals





System change





Training and education





Evaluation and feed back





Reminders in work place





Institutional climate for hygiene







Acknowledgement: I sincerely thank different hospitals participated in the study and Dr. Karun devsharma, assoc. prof, Kamineni Academy of Medical Sciences and Research Centre

Source of Support: Nil. Conflict of Interest: None.


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