The main aim of this study was to observe HH compliance among caregivers of MDRO inpatients and identify some factors associated with HH practice. HH was observed between March 1 and August 30, 2019, following the WHO’s “My five moments for hand hygiene” concept. Our findings suggest that standardizing HH among caregivers of MDRO inpatients is critical in influencing the effectiveness of infection control. In this study, caregivers who were over 50 years old accounted for 47.1% of the total participants, 16.2% of whom were more than 60 years old, which is a concern. This is because to the best of our knowledge, the physical function of this population is reduced, and their immune system has changed due to aging[23, 24]. Repeated and close exposure to MDRO inpatients increases the risk of infection[16]. This result confirmed that a large proportion of caregivers were not only unable possessed not only the inability to care for patients, but also harbored a high risk of potential infection. Influenced by economic issues and family-oriented concepts, care provided by family members in hospitals accounted for more than 80% of the total participants, few of which had received formal medical education and training, and most of whom were lacking adequate HH and knowledge about disease transmission. This result was in contrast to the mandatory training each HCW received[16, 18].
We found that overall HH compliance rate among caregivers of MDRO inpatients was 46.8%, which is higher than those in caregivers of non-MDRO inpatients[17, 25]. This is often attributed to diagnosed MDRO inpatients and caregivers receiving health education about HH and having access to adequate supplies of equipment like handwashing materials[26, 27]. Optimal levels of adherence were not achieved, however, since HH should be performed in at least 80% of case to interrupt cross transmission in settings with high infection risks[28, 29]. It is suggested that effective measures should be further implemented to improve compliance rate of caregivers. HH compliance also differed between ward type, with the pediatrics ward in the study showing the highest compliancy of 60%, whereby this finding is higher than other studies in the literature[18, 26, 29]. Since we made fewer observations in the pediatrics ward, there is a need for more detailed investigation of pediatrics ward so that this result can be confirmed.
HH compliance was different across the five key moments, with compliance after touching a patient remaining significantly higher than after touching patient surroundings, which was in agreement with the results of other studies[18, 30]. This result may reflect in how participants make judgments about the potential risk of infection resulting from the area they are exposed to. Affected by inherent HH practice, the caregiver’s assessment of the need to wash their hands was strongly influenced by the emotional concepts of “dirtiness” and “cleanliness,” which drive most of HH behavior and come into play when hands are visibly dirty[31]. When a caregiver touched a patient, hands were generally considered dirty, causing an immediate desire to wash hands. HH compliance remained higher for interactions that occurred after approaching a patient rather than before, a finding in agreement with those of other studies[26, 27, 32]. This instinct to protect oneself, rather than protecting the patient, has been confirmed elsewhere[18, 33]. However, touching patient surroundings were not perceived to pose a threat of infection, and were thus given a relatively low compliance rate. The lowest level of compliance was evident for the moment “before clean/aseptic procedures”, a result in line with the observations of the caregivers. Such failure to comply before clean procedures is worrying, as there is a risk of transmitting microbes to the patient. This in turn may increase the danger of cross-contamination, giving rise to some of more severe types of healthcare-associated infections.
We found that compliance rates for HH practices varied during different observation periods and was relatively high during “treatment”. This result might have been influenced by HCWs who followed aseptic techniques during “treatment,” just like social learning theory suggests that people observe and learn by watching the behavior of other HCWs, resulting in caregivers and patients paying increased attention to HH during this period[34]. We observed a low HH compliance rate during “resting”, which was related to either the patients or caregivers, or both, being extremely relaxed physically and mentally, the awareness of HH being weak, and HH compliance rates being less emphasized by HCWs. Therefore, HCWs should pay more attention to the supervision of HH implementation during “resting.”
The strengths of this study are as follows. Most importantly, this is the first study to evaluate HH compliance among caregivers of MDRO inpatients in China using direct observation and makes an important contribution to determining the factors influencing HH compliance. This knowledge can be used to conduct caregiver HH interventions that would reduce infection. There are also limitations. First, data were collected using handwritten notes which may have influenced the observer’s ability to record and recall all the details of their observations accurately. Second, the potential for the Hawthorne effect exists whereby participants alter their behavior as a result of being part of an experiment or study, as was found in another observational study[18]. Third, the study was conducted in a single hospital. Thus, this research only involved a small number of participants who were not blinded.