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Year : 2021  |  Volume : 14  |  Issue : 6  |  Page : 623-630  

Hand hygiene in housekeeping staffs: An assessment of their perceptions and practices in a tertiary care hospital of Kolkata

Department of Community Medicine, IPGME and R, Kolkata, West Bengal, India

Date of Submission26-Jul-2020
Date of Decision01-Sep-2020
Date of Acceptance25-Sep-2020
Date of Web Publication19-May-2021

Correspondence Address:
Ankita Mishra
Department of Community Medicine, 1st Floor, Academic Building, IPGME&R, 244 AJC Bose Road, Kolkata-700 020, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_415_20

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Background: Hand hygiene is the single most important measure for preventing infection. However, this is often insufficiently recognized by the housekeeping staffs, who are not involved in direct patient care but have frequent contact with the patient's environment. This could lead to increase in transmission of nosocomial infections. Objectives: The objectives of this study were to analyze the knowledge, attitude, and practice regarding hand hygiene among housekeeping staffs of a tertiary care hospital in Kolkata. Materials and Methods: A descriptive type of observational study with cross-sectional design was conducted on 260 housekeeping staffs of a tertiary care hospital in Kolkata in 2019 using a predesigned, pretested, and structured schedule. The statistical analysis was done using Microsoft Office Excel 2007 (Microsoft Corp., Redmond, WA, USA) and Statistical Package for the Social Sciences (SPSS) version 25.0. Results: 83.5% and 60.4% of the study population had satisfactory attitude and practice regarding hand hygiene, respectively, but only 37.3% had a satisfactory knowledge. Working in pediatrics and OBG departments had statistically significant odds of satisfactory knowledge (P < 0.05). Female gender and working in surgical/medical departments showed statistically significant odds (P < 0.05) of having positive attitude. Experience of ≤5 years in this work and receiving training had a positive association with good practice of hand hygiene. Conclusion: The overall low scores on the knowledge items indicate that these staffs require continuous in-house training on hand hygiene throughout their employment.

Keywords: Hand hygiene, housekeeping staff, personal protective equipment, training

How to cite this article:
Dutta S, Mishra A, Basu M. Hand hygiene in housekeeping staffs: An assessment of their perceptions and practices in a tertiary care hospital of Kolkata. Med J DY Patil Vidyapeeth 2021;14:623-30

How to cite this URL:
Dutta S, Mishra A, Basu M. Hand hygiene in housekeeping staffs: An assessment of their perceptions and practices in a tertiary care hospital of Kolkata. Med J DY Patil Vidyapeeth [serial online] 2021 [cited 2021 Nov 30];14:623-30. Available from: https://www.mjdrdypv.org/text.asp?2021/14/6/623/316427

  Introduction Top

Health-care-associated infection is a major problem worldwide and its prevention must be the first priority for settings and institutions committed to making health-care safer. In an era witnessing global emergence and reemergence of microbial infections, it remains a basic fact that the majority of the communicable diseases can be effectively controlled, and prevented with good hand hygiene practices. The WHO has defined hand hygiene as any action of hand cleansing to remove dirt, organic material, and/or microorganisms physically or mechanically.[1] Hand hygiene is a way of cleaning one's hands that substantially reduces potential pathogens on the hands. It is considered as a primary measure for reducing the risk of transmitting infection not only among patients and health-care personnel but also among housekeeping staffs who are not involved in direct patient care but have frequent contact with the patient's environment which could lead to the transfer of infectious organisms.

According to the WHO guidelines,[1] the hands are considered to be safe if washed for 20–30 s using alcohol-based hand rub or for 40–60 s when applying soap and water.

Systematic reviews conducted across the globe have suggested that handwashing with soap reduced the risk of diarrhea by 48%[2] and caused a 16% reduction in risk of respiratory infections.[3] Hand hygiene compliance rates of ≤50% have been documented repeatedly, along with considerable difficulties in improving them, for many years.[4],[5],[6],[7],[8]

In India, although hand hygiene is imbibed as a custom and promoted at school and community levels to reduce the burden of diarrhea, there is a paucity of information on activities to promote hand hygiene in health-care facilities. Behavioral, educational, organizational, sociocultural, socioeconomic, and sociopolitical factors appear to influence the hand hygiene behavior personnel involved in health settings directly or indirectly.[7],[8],[9],[10],[11],[12] Proper training and basic awareness about handwashing guidelines among the hospital staff not directly related to patient care is required to reduce this burden of nosocomial infections.

The hospital staffs do not consider hand hygiene (either by washing or disinfection) as an important and effective measure in the prevention of infection in health-care settings.[12] Although many studies have been conducted worldwide related to hand hygiene among the trained health-care workers (HCWs), there are only a few studies on the perceptions of housekeeping staffs working in a health-care facility. Indian studies on hand hygiene among housekeeping staff are even fewer. In a health-care facility, such staffs are surrounded by many infected patients and have chances of acquiring infection from the patient's environment if proper precautions are not taken. The fact that housekeeping staffs do not receive training like other HCWs (doctors and nurses) to protect themselves from infections adds to their susceptibility. Due to close proximity to patient care and lack of formal training (like HCWs), the housekeeping staff remain a vulnerable group for acquiring and transmitting nosocomial infections. Hence, they were included in the current study. These facts also justify the need for this knowledge, attitude, and practice (KAP) study. Thus, this study aims to assess the KAP regarding hand hygiene among the housekeeping staffs of a tertiary care hospital in Kolkata and to estimate the association, if any, of KAP regarding hand hygiene with the sociodemographic and other variables.

  Materials and Methods Top

Study type and design

A descriptive type of observational study with cross-sectional design was conducted on housekeeping staffs of Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital (IPGME and R and SSKMH), Kolkata.

Study participants

All housekeeping staffs employed with M/s Reliable Hospital Services and M/s Ex-Servicemen Resettlement Society at the time of the study working in the premises of IPGMER and SSKMH were included in the study after obtaining informed written consent. Staffs directly involved in patient care were excluded from the study.

Sample size

The sample size was calculated using the formula, n = Z2pq/l2, where Z = 1.96, P = proportion of housekeeping staffs compliant to hand hygiene, q = 1−p, l = 5% of p. Considering that 86.5% had satisfactory hand hygiene,[13] with a precision of 5% and confidence level of 95%, the sample size was calculated as 240. After considering a nonresponse rate of 5%, we deduced a sample size of 252. Thus, the study was conducted on a sample of 260 housekeeping staffs. Simple random sampling technique was used to select the study participants.

Data collection

Data were collected by face-to-face interview using a predesigned, pretested, validated structured schedule as well as by observation of handwashing and personal hand hygiene practices using a checklist after ensuring anonymity and confidentiality from September 27 to October 24, 2019, for a period of 4 weeks.

Statistical analysis

Data were then tabulated in Microsoft Office Excel 2010 (Microsoft Corp, Redmond, WA, USA), and analysis was done using Statistical Package for the Social Sciences (SPSS) version 25.0. Descriptive statistical measures were employed to summarize the data. Binary logistic regression was performed to ascertain relationship between the dependent (satisfactory knowledge, positive attitude, and good practice scores) and the independent variables (sociodemographic variables and training). The dependent variables (satisfactory knowledge, positive attitude, and good practice) did not follow normal distribution (Kolmogorov–Smirnov test: P = 0.00; Shapiro–Wilk test: P = 0.00). Data were checked for multicollinearity. Variance inflation factor was found to be <10 and tolerance was >0.1. P < 0.05 was considered as statistically significant. The total attainable knowledge score ranged from “0” to “7,” and it included 7 questions which took knowledge about the need to follow a particular set of steps while washing hands; best way of maintaining hand hygiene; personal protective equipment (PPE) needed during work; disadvantages of handwashing; duration for cleaning hands using soap and water; duration of washing hands using alcohol-based hand rub; and articles to be avoided when on duty. Each correct response was awarded with a score of “1” and each incorrect response was allocated a score “0.” The total attainable attitude score ranged from “0” to “2.” The attitude score was based on 2 questions which enquired about their views on “importance of hand hygiene in their profession” and “possibility of maintaining proper hand hygiene in a practical hospital setting.” A score of “1” was allotted for a desirable attitude, while for an undesirable attitude, a score “0” was assigned. The total practice score ranged from “0” to “2;” it considered two more scores, namely handwashing score (number of steps of handwashing performed) and personal hygiene score (trimmed nails, unstained hands, absence of jewelry or threads, and absence of scars/lesions on hands). The participants performing 6 steps (median number of steps performed by the participants) or more were awarded a handwashing score of “1” while others were allocated a score “0.” A personal hygiene score of “1” was granted to those who had trimmed nails, unstained hands, no jewelry/threads, and no scars or lesions on their hands while those who did not satisfy any of these 4 criteria were given a score “0.” KAP scores more than or equal to the median were considered satisfactory, and P < 0.05 was considered as statistically significant.

Ethics statement

Data collection was initiated after approval from the Institutional Ethics Committee of IPGMER/SSKM hospital.

Operational definitions

  • Handwashing: The act of cleaning hands for the purpose of removing soil, dirt, and microorganisms. The accepted method of handwashing as per WHO[14]

    • Soap and water: 40–60 s
    • Sanitizer: 20–30 s

  • Housekeeping: General cleaning of hospitals and clinics, including the floors, walls, and certain types of equipment, tables, and other surfaces
  • Training: Includes both formal training (certified training by the authority) and informal training (not certified by the authority but have been guided by either a doctor or a nurse).

  Results Top

[Table 1] shows the distribution of the study population based on sociodemographic characteristics. A total of 260 housekeeping staffs were interviewed and observed, of which 39.2% belonged to the age group of 31–40 years, 74.2% were males, 83.9% followed Hinduism, and 57.7% were of general caste. Most of them resided in rural areas (55%) and had attained an education of less than secondary level (58.5%). 42.3% of the sample belonged to Class III as per Modified BG Prasad Scale 2019.[15]
Table 1: Distribution of the study population according to their sociodemographic profile (n=260)

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26.5% of the participants of the study did not receive any training on hand hygiene [Figure 1]. Out of 260 participants, 139 had no knowledge about the diseases that can be prevented by proper hand hygiene [Figure 2].
Figure 1: Distribution of the study population based on receipt of training on hand hygiene (N = 260)

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Figure 2: Bar diagram showing distribution of the study population based on their knowledge about diseases that can be prevented by proper hand hygiene (N = 260)

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[Figure 3] shows that most of the study population (60.4%) had good practice, while only 37.3% had satisfactory knowledge regarding hand hygiene. However, about 80% of the housekeeping staff had a positive attitude. 30.4% of the study population was found wearing jewelry or sacred thread on duty.
Figure 3: Percentage bar diagram showing distribution of the study population based on their knowledge, attitude, and practice scores of hand hygiene (N = 260)

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Irrespective of the knowledge score, over 80% of the study population had positive attitude. 60.8% of the participants with satisfactory knowledge had good practice while the percentage of participants with unsatisfactory knowledge, but satisfactory practice was 60.1%. 58.5% of the participants with negative attitude had good practice while the percentage of participants with negative attitude with good practice was 69.8%. However, the knowledge-attitude, knowledge-practice, and attitude-practice gaps were not statistically significant.

Binary logistic regression was performed between the independent (sociodemographic profile and training) and the dependent variables. Working in pediatrics and OBG departments (odds ratio [OR] = 4.6, P = 0.003) was positively associated with satisfactory knowledge [Table 2]. Positive attitude was negatively associated with male gender (OR = 0.35, P = 0.025) while working in surgical/medical departments had a positive association (OR = 3.7, P = 0.022) [Table 3]. Experience of >5 years (OR = 0.44, P = 0.048) in this work had a negative association with good practice of hand hygiene while receiving training (OR = 2.09, P = 0.015) was positively associated [Table 4].
Table 2: Binary logistic regression between knowledge of hand hygiene and sociodemographic profile and training (n=260)

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Table 3: Binary logistic regression between attitude regarding hand hygiene and sociodemographic profile and training (n=260)

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Table 4: Binary logistic regression between practice of hand hygiene and sociodemographic profile and training (n=260)

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We tried to take suggestions from the participants on ways to improve hand hygiene. 67.3% of the participants did not feel the need for any support for maintenance of proper hand hygiene while the rest of the participants suggested that they would be able to maintain better practice of hand hygiene if they are provided assistance from the authorities in terms of training, PPE, waste management, sanitizer/soap, provision of time, and other assistance.

  Discussion Top

Knowledge of the study population in the present study was unsatisfactory considering the fact that only 37.3% scored above median. This observation was distinctly less than the results of the survey by Anargh et al.[16] on HCWs in a tertiary care hospital in Pune (85%). Creating awareness regarding importance and correct method of handwashing should be encouraged by continuous in-house training. Display of posters at appropriate points will also act as a constant reminder to the staff to practice proper hand hygiene.

83.5% of the participants in this study had a positive attitude which was way higher than the study by Nair et al.[17] on nursing (52.1%) and medical students (12.9%) at a tertiary health-care center in Raichur. This difference may be because the participants in the Raichur study were students and would never be held responsible for their actions, while the participants in our study were employees who may be dismissed from their job if they exhibit an undesirable attitude.

In the present study, we found a compliance rate of 60.4% which was comparable to the findings of a study by Sendall et al.[18] where focus groups were conducted with 12 cleaning staffs at a large Australian hospital implementing the National Hand Hygiene Initiative (65%). However, in our study, compliance was relatively high when compared to surveys by Sureshkumar et al.[19] and Sharma et al.[20] on ancillary staff (51%) and HCWs (43.2%), respectively. Explorations by Chavali Set al.[13] and Patwardhan and Patwardhan et al.[21] among staffs in Indian hospital setting pointed out a compliance rate of 86.5% and 94%, respectively, which was higher than our study. A 24-h observational study in a teaching hospital of Nottingham, UK, by Randle et al.[22] stated a compliance rate of 59% for ancillary and other staff which was lower than our finding. 30.4% of the study population wore jewelry or sacred thread while on duty. Regular inspection of hands by the supervisor will ensure that such unhygienic habits are not practiced. Again 39.6% of the study population had an unsatisfactory practice score. Providing incentives to the staffs for maintaining proper hand hygiene may be a good method for ensuring better handwashing practices.

As per our study, 73.5% had received training related to maintenance of hand hygiene, either formal, informal, or both. This was relatively less than the findings of the study by Pirincci and Altun[12] in Turkey where 96.4% of the staffs were trained. The current study and the studies by Diwan[23] and Buffet-Bataillon et al.[24] in teaching hospitals of Ujjain district (India) and France, respectively, revealed a positive association between training and maintenance of hand hygiene. Moreover, the French study also showed the influence of age on compliance of hand hygiene, which was not observed in our study. Our study revealed that female gender was positively associated with hand hygiene which was contrary to the findings of the Turkish study.[12] In our study, we found a negative association between years of service and hand hygiene which was not in line with the findings of Pirincci and Altun.[12]

Participants in the study conducted by Joshi et al.[25] suggested that institutional leadership, influence of role models, setting up institutional guidelines, provision of checklists, and positive reinforcement could motivate them to maintain better compliance of hand hygiene. 67.3% of the housekeeping staffs in the present study did not need any support while 33.7% of the staffs felt that provision of training, PPE, waste management, sanitizer/soap, adequate time, and other assistance from the authorities would be helpful. Nearly one-third of the study population in our study felt the need for greater assistance from the authorities for better hand hygiene practice. Over 25% of these people felt that PPE should be made available. Hence, adequate supply of gloves, aprons, gumboots, etc., should be ensured by the authorities to inculcate better hand hygiene behavior.

  Conclusion Top

This study unearthed some interesting facts. First, in our study, the percentage of participants with positive attitude and good practice exceeded the percentage of participants with a satisfactory knowledge regarding hand hygiene. Second, it has been found in previous studies[12] that with increasing experience, there is improvement in practice, but in our study, a work experience of >5 years was observed to have a negative association with practice of hand hygiene. Finally, though more than 70% of the participants had received training on maintenance of hand hygiene, still more than half were clueless about the diseases that could be prevented by the following hand hygiene practices.

Thus, imparting knowledge only through training programs may not be sufficient alone to change the attitude and practice regarding hand hygiene. We have to ensure that the training provided to these housekeeping staff does not only remain confined to their cognitive domain only but gets reflected in their affective and psychomotor domains as well.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4]


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