SECTION ORIGINAL XXXXXXXXXX ARTICLE https://doi.org/10.1590/1806-9282.20211092 Behavioural intention of hand hygiene compliance in an average Ecuadorian hospital Pía Escudero1* , Mireia Urrea Ayala2,3 , Natalia Romero1,3 , Cintia Pullas1 , Domenica Reina1 , Edison Daniel Miranda Brazales1 , María José Ayora Pérez1 , Ignacio Peñaherrera Suárez1 , Emily Granadillo1,3 , Miguel Martín2,4 SUMMARY OBJECTIVE: This study aimed to characterize hand hygiene behavioural intention by hospital services clusters in a medium-sized hospital in an Ecuadorian city. METHODS: This is a cross-sectional study based on the World Health Organization Hand Hygiene Knowledge Questionnaire for Health-Care Workers. The responses on hand hygiene behavioural intention for the Five Moments for hand hygiene according to the World Health Organization were recorded in three categories: before patient contact, before and after sterile technique and management of body fluids, and after contact with the environment of the patient. The variables were the knowledge regarding the source of germs causing nosocomial infections, the optimal time to achieve disinfection with alcohol, hospital services clusters (clinical medicine, surgery, and therapeutic services), and history of previous formal hand hygiene training. The variables in each moment were analysed using a saturated log-linear model. RESULTS: The average age of participants was 34 years (Q1 32.1–Q3 36.4). Of them, 62% belonged to the clinic cluster and 87.6% had previous formal hand hygiene training. The incorrect response rates for before and after sterile technique and management of body fluids, before patient contact, and after contact with the environment of the patient were 30.2, 88.4, and 99.2%, respectively. In before patient contact, the incorrect responses for optimal time depended on the department (worse surgery cluster situation), and in before and after sterile technique and management of body fluids and after contact with the environment of the patient, the incorrect responses for source of germs depended on the previous formal hand hygiene training and the department (worse surgery and clinic clusters). CONCLUSION: The incorrect answer related to hand hygiene behavioural intention was high compared to other reports, and the worse situation was found in after contact with the environment of the patient and before patient contact. These data suggest the need of strengthening permanently the hand hygiene programme. KEYWORDS: Hand hygiene. Hospital medicine. Health education. INTRODUCTION settings3-5. Although the implementation of strategy was suc- In 1846, Ignaz Semmelweis demonstrated that the hands of cessful worldwide and across all categories of health workers, health personnel transmitted puerperal fever1, and 150 years hospitals, wards, and hospital departments, it is advisable to later (2009), the World Health Organization (WHO) pub- adapt the strategy to local resources, maintain training, and lished the “Guidelines on Hand Hygiene in Health Care.” The evaluate compliance6. WHO defines hand hygiene (HH) as any standard adopted for Lack of HH leads to an increased risk of healthcare-related a hand cleaning procedure that applies hand scrubbing with an infections, disability and mortality in patients, and high expense alcoholic base or handwashing with soap and water to elimi- for the healthcare system7-9. Knowledge of the source of germs that nate or decrease germ colonization on hands and contribute cause nosocomial infections and the time required for an alcoholic to achieving a correct HH2. disinfectant to act constitute two of the essential factors for achiev- Healthcare personnel should perform HH in “Five Moments” ing optimal HH; however, healthcare personnel have observed a according to the WHO multimodal strategy in patient-centred significant gap between knowledge and practice of this technique10. 1 International University of Ecuador, School of Medicine – Quito, Ecuador. 2 Hospital Sant Joan de Déu Barcelona 2020 – Barcelona, Spain. 3 The Network Grups de Recerca d’Amèrica i Àfrica Llatines – Barcelona, Spain. 4 Universitat Autònoma de Barcelona, Facultat de Medicina, Unitat de Bioestadística – Barcelona, Spain. *Corresponding author: piescuderobu@uide.edu.ec Conflicts of interest: the authors declare there is no conflicts of interest. Funding: Universidad Internacional del Ecuador (UIDE-DGIP-MAT-PROY-17-033). Received on February 24, 2022. Accepted on June 02, 2022. 1172 Rev Assoc Med Bras 2022;68(9):1172-1177 Escudero, P. et al. In contrast, several questionnaires have been applied to mea- Variables sure hand hygiene behavioural intention (HHBI). The WHO We used the following WHO-Q questions: the identification Hand Hygiene Knowledge Questionnaires for Health-Care of the source of the germs causing infections (SG) in two cat- Workers (WHO-Q), revised in 2009, is previously validated egories: germs in the hospital environment (correct response) and published in a Spanish version; correct answers were pro- and germs in the water or the patients; to point out that 20 s is vided by WHO and the questionnaire items and domains are the optimal time needed for an alcoholic disinfectant to elim- administered independently11. This questionnaire is used in inate most hand germs (OT), the fact of having received HH cross-sectional studies, clinical trials, and results comparison. training at some point in their professional career (pT), and Another advantage is that it allows for unit, services, or ward three services clusters (clinical medicine, surgery, and support). analysis of a hospital. The survey was applied by three trained interviewers, keeping In Ecuador, there are no data on the rate of HHBI by confidentiality and privacy and in the break time of the par- hospital services. With this background, we set out to char- ticipants’ working hours. The application took approximately acterize the HHBI compliance considering services clusters 20 min. The data were collected from 4 May to 30 June 2019. of a medium-sized hospital in a sizeable Ecuadorian city to better understand inappropriate HHBI and generate strate- Response variables gies to improve it. Hand hygiene behavioural intention was defined for each moment of HH in three categories, and the basis was the WHO-Q available in Spanish. Table 1 presents the questions METHODS Context Table 1. General characteristics of the 129 participants. The participating hospital has a level 2 complexity. It offers 81 Variable n (%) beds, various medical specialties services, and outpatient con- Cluster sultation. For this study, we organized the services into three Clinical medicine 80 (62.0) clusters: clinical medicine cluster (paediatric and internal med- Surgery 41 (31.8) icine department, outpatient clinics, emergency department, Therapeutic services 8 (6.2) and an intermediate care unit with 7 beds), surgery cluster Did you ever receive hand hygiene training (five operating theatres and gynaecology and obstetrics ward), during professional practice? and therapeutic services cluster (physiotherapy and respiratory Yes 113 (87.6) therapy). The hospital has hand-rub dispensers according to No 16 (12.4) the WHO standards. Source of germs causing nosocomial infections Germs in the hospital environment 30 (23.3) Participants Germs from hospital water or present in the patient 99 (76.7) Resident doctors, nurses, nursing assistants, therapists, Minimum time required for an alcoholic disinfectant and cleaning staff with a full-time contract in the hospital to remove most germs from the hands at least 3 months before the study, and final-year medical 20 s 86 (66.7) students with a stay of not less than 3 months participated. Other than 20 s 43 (33.3) Each of the participants worked in a specific hospital ser- BPC vice in the 3 months before the survey. Of the 96 health Complies 15 (11.6) workers, all comply with rotating shift work. Although Fails 114 (88.4) shift work time was a maximum of 8 h for nurses, assis- BAMF tants, and therapeutic services department personnel, it Complies 90 (69.8) was not possible to confirm if any participant was work- Fails 39 (30.2) ing a double shift at the time of the survey. For resident ACEP doctors and students, it was a maximum of 24 h. In addi- Complies 1 (0.8) tion, the 33 visiting medical specialists who do not have Fails 128 (99.2) fixed hours were included. Of the 131 participants, 129 BPC: before patient contact; BAMF: before and after antiseptic technique and completed the questionnaire. management of body fluids; ACEP: after contact and environment of the patient. 1173 Rev Assoc Med Bras 2022;68(9):1172-1177 Behavioural intention of hand hygiene in an average Ecuadorian hospital that feed each of these three moments: “before patient con- Description of the moments and tact” (BPC), “before and after antiseptic technique and man- associated variables agement of body fluids” (BAMF), and “after contact with the In the BPC moment, 114 (88.4%) participants gave incor- environment of the patient” (ACEP). The questions that were rect answers, while in BAMF, they were 39 (30.2%), and in considered for the construction of the category “compliance of ACEP, they were 128 (99.2%). The lowest incorrect response HH activities” in each moment were defined using the nom- rates (12.5–39.5%) were found in BAMF compared to those inal group technique12. Based on the results of four rounds of of the other two moments (81.3–99.2%). Table 3 presents the the questionnaire sent to a panel of three experts, the identi- factors related to non-compliance with the HH procedure in fied responses were aggregated and shared with the experts after each study setting. each round. The experts could adjust their answers in three Table 4 shows the results of the saturated log-linear model subsequent rounds, based on how they interpret the compli- between non-compliance with the HH procedure in each ance with HH activities in each moment. moment and the variables. In BPC and ACEP, the knowledge of SG depends on the pT (χ2 4.69, p-value 0.03; χ2 4.71, Pilot study p-value 0.03, respectively), adjusted for other factors, and in A pilot study was carried out in the last week of April 2019 BAMF, it depends on the department (χ2 4.47, p-value 0.04) to ensure understanding of the questions, apply the nom- and pT (χ2 6.40, p-value 0.04). inal group technique, and record the questionnaire appli- cation time. On average, participants’ time was 20 min per survey (SD 5). DISCUSSION From our literature review, this is one of the first works focus- Statistical analysis ing on the analysis of HHBI in services considered as clusters Differences in proportions between study factors and incor- and not in health professionals themselves13-15. The work at rect responses of the HH methods in each moment were a hospital is assured when it is proposed to do so as a team, analysed with the χ2 statistic. Due to all the variables’ cate- which leads to effective and efficient practices that offer the best gorical nature and to analyse the interdependence between possible patient care16. In this context, we found high rates of them, a multivariable descriptive analysis was carried out unawareness of HHBI in the services clusters (clinic, surgery, using a saturated log-linear model of the multidimensional and therapeutic services). This lack of knowledge was equally table formed by all the variables considered for each moment. high for the BPC and ACEP moments (81.3–99.2%, in both) In the use of a single adjustment, the relationships between and improvement for the BAMF moment (12.5–39.5%). The the variables were analysed, between two variables, as well literature has not described ranges of HH unawareness before as the orders of three dimensions (interactions) and higher and after patient contact as high as that found in this study, orders. A p-value of 0.05 was considered the cut-off point suggesting the need to evaluate the strategy and reinforce on-go- for statistical significance. ing training of health care staff. Studies outside Latin America that have analysed health Ethics statement professionals’ command of WHO-Q knowledge have also All necessary permits were obtained from a Bioethics Committee shown worrying data. A study carried out in 105 health- of the International University of Ecuador and the hospital care providers from private clinics in Pakistan revealed high authorities (UIDE-DGIP-MAT-PROY-17-033). rates of inadequate knowledge of the standard guidelines for HH17. Studies that analysed all dimensions of WHO-Q in hospitals in the Republic of Korea and Iran showed differ- RESULTS ent levels of knowledge overall, and all had serious weak- nesses in knowledge14,18. In a university hospital in Cairo, Descriptive analysis the assessment in different departments showed that the The average age of the participants was 34 years (Q1 32.1-Q3 highest mean score was in the neonatal intensive care unit 36.4). Notably, 62% belonged to the clinic cluster. pT was paediatric department19. In 2136, tests provided by Spanish recorded in 114 (87.6%) participants, of which 99 (79.7%) nurses during their accreditation processes in 5 years, those did not have a correct knowledge of SG. Table 2 presents the with the highest accreditation level had the highest average general characteristics of the study variables. number of correct answers18. 1174 Rev Assoc Med Bras 2022;68(9):1172-1177 Escudero, P. et al. Table 2. Factors related to non-compliance with the hand hygiene procedure in each studied environment. Environment Study factor n (%)* χ2 p-value Cluster 2.71 0.26 Clinical medicine 68 (85.0) Surgery 39 (95.1) Therapeutic services 7 (87.5) Received training 0.90 0.34 Yes 101 (89.4) BPC (n=114) No 13 (81.3) Germ source 0.10 0.75 Hospital environment 27 (90.0) Water and patient 87 (87.9) Disinfecting time 1.36 0.24 20 s 78 (90.7) Other than 20 s 36 (83.7) Cluster 2.98 0.23 Clinical medicine 22 (27.5) Surgery 16 (39.0) Therapeutic services 1 (12.5) Received training 0.46 Yes 33 (29.2) BAMF (n=39) No 6 (37.5) Germ source 0.24 0.63 Hospital environment 8 (26.7) Water and patient 31 (31.3) Disinfecting time 2.65 0.10 20 s 22 (25.6) Other than 20 s 17 (39.5) Cluster 0.62 0.73 Clinical medicine 79 (98.8) Surgery 41 (100.0) Therapeutic services 8 (100.0) Received training 0.14 0.71 Yes 112 (99.1) ACEP (n=128) No 16 (100.0) Germ source 0.31 0.58 Hospital environment 30 (100.0) Water and patient 98 (99.0) Disinfecting time 2.02 0.16 20 s 86 (100.0) Other than 20 s 42 (97.7) BPC: before patient contact; BAMF: before and after antiseptic technique and management of body fluids; ACEP: after contact and environment of the patient. * All the percentages express the total of the category. 1175 Rev Assoc Med Bras 2022;68(9):1172-1177 Behavioural intention of hand hygiene in an average Ecuadorian hospital Table 3. Results of the saturated log-linear model between non-compliance with the hand hygiene procedure in each moment and the study factors. Environment Interactions χ2 p-value Incorrect answers for the moment × 6.10 0.05 Disinfecting time × Cluster Germ source × Cluster 5.65 0.06 Germ source × Received training 4.69 0.03 BPC Disinfectant time × Cluster 0.27 0.88 Incorrect answers for the 2.34 0.13 environment × Disinfecting time Incorrect answers for the 1.47 0.48 environment × Cluster Germ source × Cluster 6.40 0.04 BAMF Germ source × Received training 4.47 0.04 ACEP Germ source × Received training 4.71 0.03 BPC: before patient contact; BAMF before and after antiseptic technique and management of body fluids; ACEP after contact and environment of the patient. The scope of the unawareness also includes healthcare stu- hospital departments (as clusters); the analysis focused on dents in training. A high percentage of medical and nursing participants or professions could vary the results. (4) We students in Spanish universities reported always or almost did not have the authorization to analyse by individuals. always not carrying out HH at BPC or BAMF20. A study (5) We did not consider the role of each participant (i.e., in 69 nursing students in Nigeria revealed that HHBI was senior, junior, and student). lowest in the 1st year of study21. A study carried out in 2018 showed that 15.2% of healthcare personnel in Islamabad pri- vate clinics had inadequate knowledge about the OT17, and CONCLUSIONS Soon’s study showed serious weaknesses in knowledge of the The general proportion of incorrect answers about HHBI question “What is the most frequent SG?”14. In our study, we among hospital services clusters in a medium-sized hospital also found that the analysis of the associations between the in a sizeable Ecuadorian city is high. The worst situation is in variables revealed the participants’ lack of knowledge about the BPC and ACEP moments. The results highlight areas for the analysed indicators of HH knowledge, despite claiming improvement and the need to reinforce the WHO multimodal to have received training. strategy in patient-centred settings. The correct performance of the HH is an individual and collective responsibility22. It is important to emphasize that knowledge about the SG, the OT, and the technique to be ACKNOWLEDGMENTS used for HH, by itself, does not guarantee the adherence and This research was supported by International University of effectiveness of HH in health personnel in the different hos- Ecuador Research grant 2017. pital areas23, but the application of an HH educational plan, based on a standardized multimodal HH strategy, proved to be effective in improving HH compliance24. AUTHORS’ CONTRIBUTIONS Finally, in this study, we recognize the following lim- PE: Conceptualization, Funding acquisition, Methodology, Project itations. (1) This study did not include the evaluation of administration, Visualization, Writing – original draft, Writing patients’ knowledge, an aspect that, according to Srigley – review & editing. MU: Conceptualization, Methodology, et al. is essential for an overview of HH knowledge and edu- Writing – review & editing. NR-S: Conceptualization, Formal cational interventions25. (2) It was not possible to confirm Analysis, Funding acquisition, Methodology, Writing – origi- if the work shift influenced the knowledge of the activities nal draft. CP: Data curation, Formal Analysis, Writing – origi- to ensure HH. (3) This study concentrated on the charac- nal draft. MM: Data curation, Formal Analysis, Methodology. terization of HHBI in the three defined moments at the DR: Writing – original draft. EG: Writing – original draft. 1176 Rev Assoc Med Bras 2022;68(9):1172-1177 Escudero, P. et al. REFERENCES 2020;61(1):E9-14. https://doi.org/10.15167/2421-4248/ jpmh2020.61.1.741 1. 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