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Impact of hand hygiene intervention: a comparative study in health care facilities in Dodoma region, Tanzania using WHO methodology

Impact of hand hygiene intervention: a comparative study in health care facilities in Dodoma... Background: Compliance with guidelines on hand hygiene (HH) is pivotal to prevent and control health-care associated infections and contributes to mitigating antimicrobial resistance. A baseline assessment in Dodoma region, Tanzania in March 2018 showed inadequate HH levels across health care facilities. We evaluated the impact of training in HH as part of a water, sanitation and hygiene (WASH) interventions of “Maji kwa Afya ya Jamii” (MKAJI) project. Methods: A comparative HH assessment was conducted in June 2019 involving health care facilities under MKAJI project (n = 87 from which 98 units were assessed) vs non-MKAJI facilities (n = 85 from which 99 units were assessed). Irrespective of MKAJI interventional status, baseline assessment in March 2018 were compared to re- assessment in June 2019 in all health care facility units (unpaired comparison: 261 vs 236 units, respectively), and in facilities assessed in both surveys (paired comparison: 191 versus 191 units, respectively). The ‘WHO HH Self- Assessment Framework Tool, 2010’ with five indicators each counting 100 points was used. The cumulative scores stratified each health facility’s unit into inadequate (0–125), basic (126–250), intermediate (251–375) or advanced (376–500) HH level (score). The HH compliance rates were also assessed and compared. Results: The overall post-intervention median HH score [interquartile range (IQR)] was 187.5 (112.5–260). MKAJI health facilities had significantly higher median HH scores (IQR) [190 (120–262.5)] compared with non-MKAJI facilities [165 (95–230); p = 0.038]. Similarly, the HH compliance rate of ≥51% was significantly higher in MKAJI than non-MKAJI facilities [56.1% versus 30.3%; chi2 = 13.39, p < 0.001]. However, the recommended WHO compliance rate of ≥81% was only reached by 6.1 and 3.0% units of MKAJI and non-MKAJI facilities, respectively. Both paired and unpaired comparisons during baseline and re-assessment surveys showed increase in HH level from inadequate to basic level. (Continued on next page) * Correspondence: senijj80@gmail.com Department of Microbiology and Immunology, Weill Bugando School of Medicine, Catholic University of Health and Allied Sciences, P. O. Box 1464, Mwanza, Bugando, Tanzania Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Wiedenmayer et al. Antimicrobial Resistance and Infection Control (2020) 9:80 Page 2 of 9 (Continued from previous page) Conclusion: The overall HH level after the combined WASH and training intervention was at basic level. Higher median HH scores (IQR) and HH compliance rates were evident in health facilities of the MKAJI project, underscoring the impact of the intervention and the potential value of a national roll-out. Keywords: Hand hygiene, Health care facilities, Tanzania Introduction services, with 55% availability in least developed coun- Healthcare-associated infections (HCAIs) are challenging tries. One out of six health care facilities (16%) world- health care facilities across the world [1]. The burden of wide is estimated to have no hygiene services at all, HCAIs is further complicated by a particularly high translating into 896 million people with no access to hy- prevalence of multi-drug resistant (MDR) pathogens in giene services in their health care facilities. Of note, hospitals, resulting in significant morbidity, mortality availability of water services was estimated to be three and extra health-care expenditure [2–4]. In the United times less in the rural health care facilities compared Republic of Tanzania (Tanzania hereinafter), MDR infec- with those in urban settings [20]. This situation poses a tions are higher among patients admitted in hospitals wide-reaching challenge to the Sustainable Development than those with community-associated infections. Goals (SDGs) outlined in the Agenda 2030 on Sustain- Reports from Mwanza city and Dodoma – Tanzania’s able Development – above all – SDG 3 (‘to ensure capital city showed that the proportions of women de- healthy lives and promote well-being for all at all ages’) veloping surgical site infections post-caesarean section and SDG 6 (‘to ensure availability and sustainable man- were 11 and 48%, respectively [5, 6]. Moreover, children agement of water and sanitation for all’)[21]. under 5 years of age, specifically neonates with sepsis re- In April 2017, Tanzania launched its National Action main also vulnerable to MDR infections [7, 8]. Plan on AMR (2017–2022) in response to the global ac- The clonal spread of these pathogens suggests a com- tion plan on combating AMR [22, 23]. In this national mon source [9–11]; however, delineation of the ultimate plan, the Priority Area 6 is focusing on IPC in health source remains to be explored. Various reports on infec- care systems with hand hygiene being a critical compo- tion prevention and control (IPC) in Tanzania have stip- nent [22]. In this context, health centres and dispenas- ulated specific guidelines, standard procedures and ries in Dodoma region received support for WASH communication strategies to ensures IPC and ultimate interventions by the ‘Maji kwa Afya ya Jamii’ (MKAJI) patient safety [12–14]. Nevertheless, there are a number project aiming to upgrade water supply and sanitation in of challenges to address and overcome, including scar- these primary health facilities (https://www.eda.ad- city of material resources/items required for IPC, a lack min.ch/dam/countries/countries-content/tanzania/en/ of technical know-how by medical personnel, adminis- 601.0-00_Factsheet _SDC_MKAJI_EN.pdf). The MKAJI trative, logistical and financial constraints [12–15]. project covered a total of 90 health care facilities be- Despite the fact that adherence to hand hygiene prac- tween 2014/15 and 2018/19; with activities ongoing in tices was shown to be pivotal in reducing carriage of four additional health care facilities. WASH infrastruc- MDR pathogens by healthcare workers’ hands and sub- ture and capacity development/training among health sequent transmission to patients, compliance has plat- care workers was provided by the project. A baseline as- eaued at around 40% in a multi-centre studies across the sessment on hand hygiene among health care facilities in world [16–18]. To ensure uniformity and objective as- Dodoma region in March 2018 demonstrated inadequate sessment of hand hygiene practices, the ‘WHO Hand levels of hand hygiene calling for a more refined strategy Hygiene Self-Assessment Framework Tool (2010)’ was to address this low compliance, notably in dispensaries introduced to promote hand hygiene [17, 19]. This and health centres (Wiedenmayer & Seni., 2018, unpub- multimodal strategy has been designed to take into ac- lished data available at http://hssrc.tamisemi.go.tz/stor- count individuals as well as system related factors in as- age/app/uploads/public/5bf/a92/34c/ certaining the healthcare workers compliance with the 5bfa9234cb9f1296356496.pdf). IPC measures when providing routine care to the pa- To explore whether the capacity building and WASH tients in health facilities, irrespective of the level of training provided within MKAJI had an effect on hand health facilities or economic status [17]. hygiene, the Swiss-funded Health Promotion and System An extensive global assessment on water, hygiene and Strengthening (HPSS) project planned to conduct a sanitation (WASH) conducted jointly by the WHO and comparative study between those health care facilities UNICEF in 2016 showed that globally approximately under the MKAJI interventional project and non-MKAJI three quarters of health care facilities have basic water facilities to guide future IPC measures. Moreover, a Wiedenmayer et al. Antimicrobial Resistance and Infection Control (2020) 9:80 Page 3 of 9 comparison between the baseline level of hand hygiene Committee (CREC/358/2019)] and the National Institute obtained in March 2018 and the re-assessment in June for Medical Research (NIMR/HQ/R.8a/Vol. IX/3116). 2019 post-intervention was conducted. Data management Sources of data Methodology Data were collected from in-charges of health facility’s Assessment design and settings units via interviews and observations using the ‘WHO This was a comparative study which involved MKAJI Hand Hygiene Self-Assessment Framework 2010 Tool’. and non-MKAJI health care facilities in Dodoma region This tool is divided into five components containing 27 in June 2019. Dodoma region hosts the capital city of indicators. The five components are i) system change Tanzania and is located in the central zone of the coun- (SC); ii) training and education (TE); iii) evaluation and try. It has a population of 2,083,588 as per National feedback (EF); iv) reminders in the work place (RW); Housing and Population Census, 2012. Dodoma region and v) institutional safety climate (ISC). Each of these is divided into 8 district councils (DC) with 8 hospitals, components has a subtotal score of 100, amounting to 30 health centres and 284 dispensaries. The district an overall maximum hand hygiene score of 500 [19]. councils are Dodoma City Council, Chamwino DC, Kon- doa DC, Kondoa Town Council, Bahi DC, Chemba DC, Preparation for data collection Mpwapwa DC and Kongwa DC. However, in the analysis The project assessment team underwent a 5-day training Kondoa DC and Kondoa Town Council were combined session on the general principles of hand hygiene in the together. context of IPC, the assessment protocol and pre-testing of the data collection tool in six dispensaries in Dodoma Study population, sampling strategy and sample size city council. This was followed up by a feedback session, A total of 236 participants (out of 242 eligible partici- where questions, inquiries and concerns were addressed pants) from 7 hospitals, 16 health centres and 155 dis- ensuring that all research assistants would be conversant pensaries were recruited in June 2019. Of these, 87 were with the data collection tool. The same research assis- MKAJI health care facilities (seven health centres and 80 tants deployed in the baseline assessment in March dispensaries from which 98 units were assessed) and 85 2018, were involved in the re-assessment in June 2019. non-MKAJI health care facilities (9 health centres and 75 dispensaries from which 99 units were assessed). One Data quality checks unit was included for assessment for dispensaries (i.e. Research assistants were divided into three groups each labour wards/rooms), 3 units were included in health with a team lead. The later was tasked to oversee the centres (i.e. labour wards/rooms, theatre and outpatient) data quality at the end of each day, and do the necessary and 6 units were included in hospitals (i.e. labour ward, corrective actions. Then, filled data collection tools were theatre, outpatient, laboratory, pharmacy and surgical sent to the data quality officer on weekly basis. The final wards). Individuals who were in-charge of a health facil- data quality assessment was done by the co-investigators ity’s unit and who gave their consent to be involved in and the principal investigator. the study were included (i.e. all 236 participants from 236 units were included). Health care facility units under Data analysis MKAJI were compared to units not under MKAJI inter- Data collected was entered into an Excel sheet for clean- ventional project based on the hand hygiene scores, ing and consistency checks and then exported to levels and compliance. Furthermore and irrespective of STATA version 13.0 software (StataCorp®, College Sta- MKAJI interventional status, baseline hand hygiene tion, Texas, USA) for analysis. Cumulative scores of five scores and their corresponding levels (obtained in March indicators stratified each health facility’s unit into inad- 2018) were compared with those obtained in this post- equate (0–125), basic (126–250), intermediate (251–375) interventional re-assessment i.e. in June 2019. In the or advanced (376–500) hand hygiene (score) level. Cat- later, unpaired comparison included all health care facil- egorical variables such as type of professional cadre, ity units assessed (261 units in March 2018 versus 236 health care facilities levels (i.e. dispensary, health centre units in June 2019), and paired comparison involved or hospital) and hand hygiene levels were described as only health care facility units which were both involved proportions and compared using a Chi-squared (Chi2) in the baseline and re-assessment (191 versus 191 units, test. Participants’ ages were presented as mean ± stand- respectively). ard deviation, whereas the hand hygiene scores were This project was approved by institutional board [the presented by median scores (interquartile range). Com- Joint Catholic University of Health and Allied Sciences/ parison of median hand hygiene scores in various vari- Bugando Medical Centre Research and Ethics ables such as district councils, health facility ranks, Wiedenmayer et al. Antimicrobial Resistance and Infection Control (2020) 9:80 Page 4 of 9 health facility units and MKAJI project status was done dispensaries [175 (100–247.5); p = 0.0136]. Although not sta- using a two-sample Wilcoxon rank-sum (Mann-Whit- tistically significant, median hand hygiene score (IQR) was ney) test. The significance cut off was set at p < 0.05 for also higher in health centre units [188.8 (115–260)] than in associations between hand hygiene level/score and other dispensaries [175 (100–247.5); p = 0.458]. All health care fa- variables. cility units had basic hand hygiene levels, except surgical units which had an intermediate hand hygiene level (Table Results 1). All seven city/district councils in Dodoma region had Demographic information of participants and health care basic hand hygiene level, except Bahi district council which facilities had inadequate hand hygiene level with median hand hy- The majority of participants were female (60.2%) and giene score (IQR) of [90 (70–130)]. 112 (47.5%) were nurses. Other professional cadres were clinicians 23.7% (medical specialists, medical doctors, as- Evaluation of hand hygiene indicators in health facility sistant medical doctors, clinical officers and clinical as- units sistants), medical attendants 19.1%, laboratory staff 5.5%, Post-intervention evaluation of the five hand hygiene in- pharmacy staff 2.5%, and others 1.7%. The mean age ± dicators in 236 units across various health care facilities SD of participants was 34.4 ± 9.8 years, ranging from 20 in Dodoma region showed that the respective median years to 60 years. hand hygiene score (IQR) were SC [45 (35–55)] and EF The overall distribution of the 236 health facility units [50 (25–67.5). These indicators were relatively higher across seven district councils was similar (range: 27 to compared to TE [25 (5–55)], RW [30 (5–50)] and ISC 33 per council), with exception of Dodoma city council [37.5 (20–60)]. Continuous supply of clean and running which accounted for 20.7% of all units. The majority of water was observed in approximately 90.3% (213/236), units involved were labour wards/rooms (75.0%) whereas the presence of alcohol hand rub was observed followed by outpatient units (10.2%) (Table 1). in 30.9% (73/236) of the health care facility units. It was reported that TE among health care workers on hand Hand hygiene scores and levels across health care hygiene had never been received in approximately 44.1% facilities in Dodoma region (n = 104), whereas in 37.7% (n = 89), training has been Hand hygiene scores and levels by health care facility units received only once. On the other hand, approximately and district councils 14.8% (n = 35) and 3.0% (n = 8) have regular and The overall post-intervention median hand hygiene score mandatory training in their workplaces, respectively. (IQR) across 236 health care facility units in Dodoma region The compliance rates were relatively higher among cli- was 187.5 (112.5–260), with the minimum and maximum nicians and nurses, compared to medical attendants and scores being 25 and 425, respectively. The distribution of other professional cadres (Fig. 1). The compliance rates hand hygiene levels across health care facility units post- above 50% and the WHO recommended rate of ≥81.0% intervention were inadequate 31.4% (n = 74), basic 40.3% specific to each professional cadres were found to be as (n = 95), intermediate 25.4% (n = 60), and advanced 3.0% follows; clinicians 48.2% (n = 27) and 7.2% (n = 7), nurses (n = 7). The median hand hygiene score (IQR) was signifi- 45.5% (n = 51) and 7.1% (n = 8), medical attendants cantly higher in hospital units [235 (147.5–320) than in 42.2% (n = 19) and 0.0%(n = 0) and others 30.5% (n =7) and 4.4% (n = 1), respectively (Fig. 1). Comparison of hand hygiene scores between MKAJI Table 1 Post-interventional hand hygiene scores and levels by health care facilities and non-MKAJI facilities health facility units in Dodoma region Of the 236 health care facility units, 197 units from health Health facility unit Median hand hygiene score Hand hygiene centres and dispensaries were subjected to a sub-analysis. (IQR) level Those health care facility units involved in the MKAJI inter- Labour ward (n = 182.5 (105–250) Basic vention project had significantly higher median hand hygiene 177) scores (IQR) [190 (120–262.5)] compared with non-MKAJI Outpatient (n = 24) 205 (143.8–272.5) Basic facilities [165 (95–230); p = 0.038]. The overall median hand Theatre (n = 14) 185 (115–250) Basic hygiene scores (IQR) were also higher among MKAJI health Laboratory (n = 8) 197.5 (111.3–307.5) Basic care facilities compared with non-MKAJI facilities in both Pharmacy (n = 7) 180 (115–195) Basic labour wards [190 (120–265) versus 166.3 (90–230)]; and Surgical ward (n = 327.5 (235–347.5) Intermediate outpatient units [178.8 (155–243.8) versus 147.5 (127.5– 6) 260)]. The median hand hygiene scores (IQR) differences Total (N = 236) between the two groups were also evident in all district IQR Interquartile range councils. The hand hygiene scores (IQR) for indicators which Wiedenmayer et al. Antimicrobial Resistance and Infection Control (2020) 9:80 Page 5 of 9 Fig. 1 Self-reported hand hygiene compliance using WHO tool (or similar techniques) among health workers by professional cadres demonstrated significant differences between MKAJI versus baseline [median score (IQR): 80 (60–145], it increased to non-MKAJI units were TE [32.5 (5–55) versus 10 (0–40), basic level after the re-assessment in 2019 [median score p < 0.001); and EF [55 (25–70) versus 40 (20–60), p = 0.043]. (IQR): 187.5 (112.5–260; p<0.001] (Table 2). On the other hand, the remaining three indicators did not show significant differences: SC [45 (35–50) versus 40 (30– Paired comparison of hand hygiene among facilities 50), p = 0.288]; RW [22.5 (5–50) versus 26.3 (5–47.5), p = sampled at the baseline and during re-assessment in 0.877), and ISC [35 (20–60) versus 35 (15–55), p = 0.408)]. Dodoma region There was no statistical difference on the availability of con- Of the 236 health care facility units involved in the tinuous supply of water in units associated with MKAJI ver- current study, only 191 (80.9%) were enrolled in the sus non-MKAJI units [90.8% (89/98) versus 88.9% (88/99); baseline assessment in March 2018 and therefore, the chi2 = 0.201; p = 0.654]. Similarly, no statistical difference was later allowed for a specific sub-analysis to assess a observed on the availability of alcohol hand rub in MKAJI change in trend. While the overall hand hygiene level units [29.6% (29/98) versus 23.2% (23/99); chi2 = 1.025; p = was inadequate at baseline [IQR of 90 (60–165)], the 0.311]. Hand hygiene compliance rate of ≥51% was signifi- level of those same 191 units had increased to basic level cantly higher in MKAJI units than non-MKAJI units [56.1% by the time of the re-assessment [IQR of 190 (120–260); (55/98) versus 30.3% (30/99); chi2 = 13.39; p < 0.001]. How- (p < 0.001)] (Fig. 3). ever, the recommended WHO compliance rate of ≥81% was only reported in 6.1 and 3.0% for MKAJI and non-MKAJI Discussion units, respectively (Fig. 2). Approximately 90% of the health care facilities involved in this study were dispensaries, whereas the remaining Baseline hand hygiene versus hand hygiene re- facilities being either health centres or hospitals, and the assessment in Dodoma region irrespective of MKAJI majority (75.0%) of units were labor wards. This higher intervention status proportion of labor wards is because this unit is present Overall baseline and re-assessment hand hygiene score in all three levels of health care facilities i.e. dispensaries, across health care facilities heath centres and hospitals. Previous studies in various While the overall hand hygiene level among the 261 units in units in Ethiopia, China and Switzerland have reiterated Dodoma region was found to be inadequate during the the need for a wide coverage of units to allow Wiedenmayer et al. Antimicrobial Resistance and Infection Control (2020) 9:80 Page 6 of 9 Fig. 2 Comparison of self-reported hand hygiene compliance using WHO tool (or similar techniques) among health workers by MKAJI status generalization of the findings in the context of patients to health centres and dispensaries may relate to the fact care services [24–26]. Similar to previous work in that most hospitals are better equipped with material re- Ethiopia, China and Italy, the current study showed a sources, have higher staff numbers and better access to in- predominance of females and nurses [24, 25, 27]. This formation regarding hand hygiene. The significant may be related to the fact that the nursing profession is improvement since the baseline assessment may be attrib- a predominant health cadre in Tanzania irrespective of uted to the on-going MKAJI project interventional mea- the rank of the health care facilities. sures, post-baseline assessment sensitization sessions and The overall post-intervention hand hygiene level was provision of hand hygiene tools to various health care fa- basic with a median score of 187.5, and was higher than cilities by the HPSS project and in collaboration with the the inadequate level reported in the baseline assessment council health management teams. In this regard, in March 2018 (both in paired and unpaired compari- strengthening of hand hygiene activities in health centres sons). This is comparable to a similar study in India which and dispensaries should be emphasized so as to have com- reported a hand hygiene score of 225 [28]. Similar to the prehensive coverage and subsequently reduce potential baseline assessment, the hand hygiene score was higher in HCAIs in all ranks/tiers of health care facilities in Dodoma hospitals than in health centres and dispensaries. The rela- region and other areas in Tanzania with similar epidemio- tively higher level of performance in hospitals as opposed logical predisposition [1, 16]. It was evident that continuous supply of clean water Table 2 Comparison of baseline and hand hygiene re- through conventional or improvised sinks was remark- assessment in health care facility units in Dodoma region ably high (90.3%), in contrast to the presence of alcohol- Health care Baseline median HH Re-assessment median HH based hand rub which was observed in only one third of facilities score (IQR) (n = 261 score (IQR) (n = 236 units) the health care facilities’ units. Nevertheless, our finding units) on alcohol based hand rub was higher than the 11.5% re- Hospitals 107 (80–182.5) 235 (147.5–320) ported from a previous study in Ethiopia [24]. The Health centres 76.3 (60–125) 188.8 (115–260) causes of low utilization of alcohol based hand rub in Dispensaries 75 (55–145) 175 (100–247.5) Tanzania and Ethiopia were not evaluated; however, Overall median 80 (60–145 187.5 (112.5–260 studies in Kenya and China demonstrated that smell, HH score (IQR) skin irritation, dryness, unreliable availability, and heavy Wiedenmayer et al. Antimicrobial Resistance and Infection Control (2020) 9:80 Page 7 of 9 Fig. 3 Paired comparison of baseline and follow-up hand hygiene re-assessment in Dodoma region work load negatively affected hand hygiene practices where a baseline assessment was done followed by specific among health workers [25, 29]. In contrast to these fac- hand hygiene interventions, the re-assessment showed re- tors, in a busy hospital setting like an intensive care unit, markably increased hand hygiene compliance rate irre- alcohol based hand rub is preferred due to its conveni- spective of the health workers’ profession and hospital ence [30]. Therefore, assessment of specific individual, units [18, 24–26, 29]. Although the hand hygiene compli- institutional and government factors affecting hand hy- ance rate of ≥81% recommended by WHO was reported giene will be of interest in the future assessments in to be significantly lower in both types of health care facil- Dodoma region. ities assessed (MKAJI and non-MKAJI associated), the Regarding the self-reported hand hygiene compliance, overall compliance rate was higher among respondents good compliance was reported more frequently among from MKAJI units. Low compliance was also reported in clinicians and nurses, as opposed to other professional Kenya (28% pre-intervention to 38% post-intervention, re- cadres. Of note, none of the medical attendants had spectively) as opposed to higher compliance (48–88%) in achieved the WHO recommended rate of ≥81.0%. The China connoting similar epidemiological and infrastruc- compliance rate in this study was low compared to the tural predisposition in Tanzania and Kenya [24, 25, 29]. baseline compliance rates reported in Kenya (28%), These findings emphasize that specific interventions, Ethiopia (22.0%), China (66.3%), Switzerland (61.4%) and when carefully designed, can have a significant positive in a systematic review involving 96 studies (40%) [18, 24– impact, which in turn can improve patients’ health care 26]. However, variable compliance has been previously re- services. Therefore, similar programs should be rolled out ported in six ICU in Italy ranging from 3 to 100% [27]. to increase coverage not only in Dodoma but also in other Variability in the hand hygiene compliance rates across regions in Tanzania. countries may be related to individual, institutional and This assessment did not evaluate all health facilities in government differences with regard to hand hygiene prac- Dodoma region. Nevertheless, over three quarters of tices, resource availability and reinforcement modalities health care facilities were assessed allowing for extrapo- available in each setting. Interestingly, in other countries lation of the findings to the rest of the facilities in this Wiedenmayer et al. Antimicrobial Resistance and Infection Control (2020) 9:80 Page 8 of 9 region. The hand hygiene compliance was self reported Ethics approval and consent to participate Ethical approval was provided by the Joint CUHAS/BMC Research and Ethics and subjectivity elements cannot be ruled out. However, Committee (CREC/358/2019) and the National Institute for Medical Research audit files were used for verification purposes. This study (NIMR/HQ/R.8a/Vol. IX/3116). Permission to conduct this comparative study could not link the impacts of hand hygiene levels/scores was also sought and granted by relevant government authorities and in- charge of the respective health facilities in Dodoma region. A voluntary writ- to AMR rates and patients’ outcomes, and these parame- ten informed consent was requested from every participant prior to involve- ters should be studied in future investigations. ment in the assessment. Conclusions Consent for publication Not applicable. The overall hand hygiene level in healthcare facilities in Dodoma region increased from inadequate level in March Competing interests 2018 to basic level in June 2019. Hand hygiene practice The authors declare that they have no competing interests. All authors have was significantly higher in hospitals compared with health read and approved this manuscript. centres and dispensaries. There was significantly higher Author details hand hygiene score and hand hygiene compliance rate in Health Promotion and System Strengthening/Tuimarishe Afya Project, 7th health care facilities associated with the MKAJI interven- Road, ACT Building, P.O. Box 29, Dodoma, Tanzania. Swiss Centre for tional project. However, the recommended WHO compli- International Health at Swiss Tropical and Public Health Institute, Socinstrasse 57, P.O. Box 4002, Basel, Switzerland. University of Basel, P.O. Box, CH-4003, ance rate of ≥81% was widely missed by both MKAJI and Basel, Switzerland. Dodoma Regional Medical Officer’s Office, P.O. Box 914, non-MKAJI units. Most health facilities had a continuous Dodoma, Tanzania. Department of Microbiology and Immunology, Weill supply of water but only one third of facilities provided Bugando School of Medicine, Catholic University of Health and Allied Sciences, P. O. Box 1464, Mwanza, Bugando, Tanzania. alcohol-based hand rub. Future assessments should maintain regular region- Received: 24 February 2020 Accepted: 29 May 2020 wide hand hygiene evaluation. Programs similar to MKAJI should be rolled out to increase the coverage not only in Dodoma but also in other regions in Tanzania. References 1. Nejad SB, Allegranzi B, Syed SB, Ellis B, Pittet D. Health-care-associated Ascertaining the implication of the hand hygiene scores/ infection in Africa: a systematic review. Bull World Health Organ. 2011; levels and its compliance in relation to the incidence of 89(10):757–65. HCAIs and AMR rates would be of interest in future 2. Peleg AY, Hooper DC. Hospital-acquired infections due to gram-negative bacteria. N Engl J Med. 2010;362(19):1804–13. studies in order to translate these figures directly into 3. WHO: Antimicrobial resistance: global report on surveillance: World Health patients’ care and health systems’ performance. Organization; 2014. 4. Seni J, Moremi N, Matee M, van der Meer F, DeVinney R, Mshana SE, JD DP: Abbreviations Preliminary insights into the occurrence of similar clones of extended- AMR: Antimicrobial resistance; EF: Evaluation and feedback; HCAIs: Health spectrum beta-lactamase-producing bacteria in humans, animals and the care associated infections; IPC: Infection prevention and control; environment in Tanzania: a systematic review and meta-analysis between IQR: Interquartile range; ISC: Institutional safety climate; MDR: Multidrug 2005 and 2016. Zoonoses Public Health 2018 Feb;65(1):1–10. doi: 10.1111/ resistance; MKAJI: “Maji kwa Afya ya Jamii” (a Swahili phrase: “Water for zph.12387.. Healthier Community”); RW: Reminders in the work place; SC: System 5. Mpogoro FJ, Mshana SE, Mirambo MM, Kidenya BR, Gumodoka B, change; TE: Training and education; WASH: Water, hygiene and sanitation; Imirzalioglu C. Incidence and predictors of surgical site infections following WHO: World Health Organization caesarean sections at Bugando medical Centre, Mwanza, Tanzania. Antimicrob Resist Infect Control. 2014;3:25. Acknowledgements 6. De Nardo P, Gentilotti E, Nguhuni B, Vairo F, Chaula Z, Nicastri E, Nassoro We are grateful to the City/District Medical Officers, In-charges from various MM, Bevilacqua N, Ismail A, Savoldi A, et al. Post-caesarean section surgical health care facilities, Council Health Management Teams, research assistants site infections at a Tanzanian tertiary hospital: a prospective observational and study participants in various health care facilities in Dodoma region. We study. J Hosp Infect. 2016;93(4):355–9. are very thankful to Mr. Hussein Chanzi for his excellent support on data 7. Blomberg B, Manji KP, Urassa WK, Tamim BS, Mwakagile DS, Jureen R, quality control. We are grateful to MKAJI project programme manager, Thea Msangi V, Tellevik MG, Holberg-Petersen M, Harthug S, et al. Antimicrobial Bongertman for her technical support throughout this assessment. resistance predicts death in Tanzanian children with bloodstream infections: a prospective cohort study. BMC Infect Dis. 2007;7:43. Authors’ contributions 8. Seni J, Mwakyoma AA, Mashuda F, Marando R, Ahmed M, DeVinney R, Conceived and designed the study: KW, VM, FC, JCK and JS. Executed the Pitout JDD, Mshana SE. Deciphering risk factors for blood stream infections, study: VM, FC, JCK and JS. Analyzed the data: JS. Wrote the initial draft of the bacteria species and antimicrobial resistance profiles among children under manuscript: JS; Critical review of the manuscript’s drafts: KW, FC, JCK and JS. five years of age in North-Western Tanzania: a multicentre study in a The authors read and approved the final manuscript. cascade of referral health care system. BMC Pediatr. 2019;19(1):32. 9. Moremi N, Mshana SE, Kamugisha E, Kataraihya J, Tappe D, Vogel U, Funding Lyamuya EF, Claus H. Predominance of methicillin resistant Staphylococcus This project was funded by the Swiss Agency for Development and aureus -ST88 and new ST1797 causing wound infection and abscesses. J Cooperation (SDC), Government of Switzerland. The funder had no any role Infect Dev Countries. 2012;6(8):620–5. in the design of the study and collection, analysis, and interpretation of data 10. Mshana SE, Hain T, Domann E, Lyamuya EF, Chakraborty T, Imirzalioglu C. and in writing the manuscript. Predominance of Klebsiella pneumoniae ST14 carrying CTX-M-15 causing neonatal sepsis in Tanzania. BMC Infect Dis. 2013;13:466. Availability of data and materials 11. Marando R, Seni J, Mirambo MM, Falgenhauer L, Moremi N, Mushi MF, The datasets used and/or analysed during the current study are available Kayange N, Manyama F, Imirzalioglu C, Chakraborty T, et al. Predictors of the and can be accessed from the corresponding author on reasonable request. extended-spectrum-beta lactamases producing Enterobacteriaceae neonatal Wiedenmayer et al. Antimicrobial Resistance and Infection Control (2020) 9:80 Page 9 of 9 sepsis at a tertiary hospital, Tanzania. Int J Med Microbiol. 2018;308(7):803– 12. JHPIEGO.: The United Republic of Tanzania Ministry of Health and Social Welfare National Infection Prevention and Control Standards for Hospitals in Tanzania Standards- Standards-Based Management and Recognition for Improving Infection Prevention And Control Practices – An Assessment Tool June 2012. 2012. 13. URT: United Republic of Tanzania. National Communication Strategy for Infection Prevention and Control 2012-2017. . 2012. 14. URT: United Republic of Tanzania. National Infection Control Guidelines. Draft for consultation. 2016. 15. Jones M, Gower S, Whitfield A, Thomas S. Evaluation of practice change in Tanzanian health professionals 12 months after participation in an infection prevention and management course. J Infect Prev. 2015;16(5):200–6. 16. Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect. 2009;73(4):305–15. 17. WHO: A guide to the implementation of the WHO Multimodal Hand Hygiene Improvement Strategy. who/iep/psp/2009.2. 2009. 18. Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, van Beeck EF. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol. 2010;31(3):283–94. 19. WHO: WHO guidelines on hand hygiene in health care. First global patient safety challenge. Clean care is safer care. 2009. 20. WHO & UNICEF: WASH in health care facilities: global baseline report 2019. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2019. Licence: CC BY-NC-SA 3.0 IGO. 2019. 21. UNDP: United Nations Development Programme. Sustainable Development Goals. Available at http://www.un.org/sustainabledevelopment/news/ communications-material/. New York, NY 10017 USA. 2016. 22. URT: The National Action Plan on Antimicrobial Resistance (2017–2022). 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Sustained improvement in hand hygiene compliance using a multimodal improvement program at a Swiss multisite regional hospital. J Hosp Infect. 2018;100(2):176–82. 27. Musu M, Lai A, Mereu NM, Galletta M, Campagna M, Tidore M, Piazza MF, Spada L, Massidda MV, Colombo S, et al. Assessing hand hygiene compliance among healthcare workers in six intensive care units. J Prev Med Hyg. 2017;58(3):E231–7. 28. Sharma R, Sharma M, Koushal V. Compliance to hand hygiene world health organization guidelines in hospital care. Int J Prev Med. 2014;5(1):127–8. 29. Ndegwa L, Hatfield KM, Sinkowitz-Cochran R, D'Iorio E, Gupta N, Kimotho J, Woodard T, Chaves SS, Ellingson K. Evaluation of a program to improve hand hygiene in Kenyan hospitals through production and promotion of alcohol- based Handrub - 2012-2014. Antimicrob Resist Infect Control. 2019;8:2. 30. Saito H, Kilpatrick C, Pittet D. The 2018 World Health Organization SAVE LIVES: clean your hands campaign targets sepsis in health care. Intensive Care Med. 2018;44(4):499–501. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Antimicrobial Resistance & Infection Control Springer Journals

Impact of hand hygiene intervention: a comparative study in health care facilities in Dodoma region, Tanzania using WHO methodology

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Abstract

Background: Compliance with guidelines on hand hygiene (HH) is pivotal to prevent and control health-care associated infections and contributes to mitigating antimicrobial resistance. A baseline assessment in Dodoma region, Tanzania in March 2018 showed inadequate HH levels across health care facilities. We evaluated the impact of training in HH as part of a water, sanitation and hygiene (WASH) interventions of “Maji kwa Afya ya Jamii” (MKAJI) project. Methods: A comparative HH assessment was conducted in June 2019 involving health care facilities under MKAJI project (n = 87 from which 98 units were assessed) vs non-MKAJI facilities (n = 85 from which 99 units were assessed). Irrespective of MKAJI interventional status, baseline assessment in March 2018 were compared to re- assessment in June 2019 in all health care facility units (unpaired comparison: 261 vs 236 units, respectively), and in facilities assessed in both surveys (paired comparison: 191 versus 191 units, respectively). The ‘WHO HH Self- Assessment Framework Tool, 2010’ with five indicators each counting 100 points was used. The cumulative scores stratified each health facility’s unit into inadequate (0–125), basic (126–250), intermediate (251–375) or advanced (376–500) HH level (score). The HH compliance rates were also assessed and compared. Results: The overall post-intervention median HH score [interquartile range (IQR)] was 187.5 (112.5–260). MKAJI health facilities had significantly higher median HH scores (IQR) [190 (120–262.5)] compared with non-MKAJI facilities [165 (95–230); p = 0.038]. Similarly, the HH compliance rate of ≥51% was significantly higher in MKAJI than non-MKAJI facilities [56.1% versus 30.3%; chi2 = 13.39, p < 0.001]. However, the recommended WHO compliance rate of ≥81% was only reached by 6.1 and 3.0% units of MKAJI and non-MKAJI facilities, respectively. Both paired and unpaired comparisons during baseline and re-assessment surveys showed increase in HH level from inadequate to basic level. (Continued on next page) * Correspondence: senijj80@gmail.com Department of Microbiology and Immunology, Weill Bugando School of Medicine, Catholic University of Health and Allied Sciences, P. O. Box 1464, Mwanza, Bugando, Tanzania Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Wiedenmayer et al. Antimicrobial Resistance and Infection Control (2020) 9:80 Page 2 of 9 (Continued from previous page) Conclusion: The overall HH level after the combined WASH and training intervention was at basic level. Higher median HH scores (IQR) and HH compliance rates were evident in health facilities of the MKAJI project, underscoring the impact of the intervention and the potential value of a national roll-out. Keywords: Hand hygiene, Health care facilities, Tanzania Introduction services, with 55% availability in least developed coun- Healthcare-associated infections (HCAIs) are challenging tries. One out of six health care facilities (16%) world- health care facilities across the world [1]. The burden of wide is estimated to have no hygiene services at all, HCAIs is further complicated by a particularly high translating into 896 million people with no access to hy- prevalence of multi-drug resistant (MDR) pathogens in giene services in their health care facilities. Of note, hospitals, resulting in significant morbidity, mortality availability of water services was estimated to be three and extra health-care expenditure [2–4]. In the United times less in the rural health care facilities compared Republic of Tanzania (Tanzania hereinafter), MDR infec- with those in urban settings [20]. This situation poses a tions are higher among patients admitted in hospitals wide-reaching challenge to the Sustainable Development than those with community-associated infections. Goals (SDGs) outlined in the Agenda 2030 on Sustain- Reports from Mwanza city and Dodoma – Tanzania’s able Development – above all – SDG 3 (‘to ensure capital city showed that the proportions of women de- healthy lives and promote well-being for all at all ages’) veloping surgical site infections post-caesarean section and SDG 6 (‘to ensure availability and sustainable man- were 11 and 48%, respectively [5, 6]. Moreover, children agement of water and sanitation for all’)[21]. under 5 years of age, specifically neonates with sepsis re- In April 2017, Tanzania launched its National Action main also vulnerable to MDR infections [7, 8]. Plan on AMR (2017–2022) in response to the global ac- The clonal spread of these pathogens suggests a com- tion plan on combating AMR [22, 23]. In this national mon source [9–11]; however, delineation of the ultimate plan, the Priority Area 6 is focusing on IPC in health source remains to be explored. Various reports on infec- care systems with hand hygiene being a critical compo- tion prevention and control (IPC) in Tanzania have stip- nent [22]. In this context, health centres and dispenas- ulated specific guidelines, standard procedures and ries in Dodoma region received support for WASH communication strategies to ensures IPC and ultimate interventions by the ‘Maji kwa Afya ya Jamii’ (MKAJI) patient safety [12–14]. Nevertheless, there are a number project aiming to upgrade water supply and sanitation in of challenges to address and overcome, including scar- these primary health facilities (https://www.eda.ad- city of material resources/items required for IPC, a lack min.ch/dam/countries/countries-content/tanzania/en/ of technical know-how by medical personnel, adminis- 601.0-00_Factsheet _SDC_MKAJI_EN.pdf). The MKAJI trative, logistical and financial constraints [12–15]. project covered a total of 90 health care facilities be- Despite the fact that adherence to hand hygiene prac- tween 2014/15 and 2018/19; with activities ongoing in tices was shown to be pivotal in reducing carriage of four additional health care facilities. WASH infrastruc- MDR pathogens by healthcare workers’ hands and sub- ture and capacity development/training among health sequent transmission to patients, compliance has plat- care workers was provided by the project. A baseline as- eaued at around 40% in a multi-centre studies across the sessment on hand hygiene among health care facilities in world [16–18]. To ensure uniformity and objective as- Dodoma region in March 2018 demonstrated inadequate sessment of hand hygiene practices, the ‘WHO Hand levels of hand hygiene calling for a more refined strategy Hygiene Self-Assessment Framework Tool (2010)’ was to address this low compliance, notably in dispensaries introduced to promote hand hygiene [17, 19]. This and health centres (Wiedenmayer & Seni., 2018, unpub- multimodal strategy has been designed to take into ac- lished data available at http://hssrc.tamisemi.go.tz/stor- count individuals as well as system related factors in as- age/app/uploads/public/5bf/a92/34c/ certaining the healthcare workers compliance with the 5bfa9234cb9f1296356496.pdf). IPC measures when providing routine care to the pa- To explore whether the capacity building and WASH tients in health facilities, irrespective of the level of training provided within MKAJI had an effect on hand health facilities or economic status [17]. hygiene, the Swiss-funded Health Promotion and System An extensive global assessment on water, hygiene and Strengthening (HPSS) project planned to conduct a sanitation (WASH) conducted jointly by the WHO and comparative study between those health care facilities UNICEF in 2016 showed that globally approximately under the MKAJI interventional project and non-MKAJI three quarters of health care facilities have basic water facilities to guide future IPC measures. Moreover, a Wiedenmayer et al. Antimicrobial Resistance and Infection Control (2020) 9:80 Page 3 of 9 comparison between the baseline level of hand hygiene Committee (CREC/358/2019)] and the National Institute obtained in March 2018 and the re-assessment in June for Medical Research (NIMR/HQ/R.8a/Vol. IX/3116). 2019 post-intervention was conducted. Data management Sources of data Methodology Data were collected from in-charges of health facility’s Assessment design and settings units via interviews and observations using the ‘WHO This was a comparative study which involved MKAJI Hand Hygiene Self-Assessment Framework 2010 Tool’. and non-MKAJI health care facilities in Dodoma region This tool is divided into five components containing 27 in June 2019. Dodoma region hosts the capital city of indicators. The five components are i) system change Tanzania and is located in the central zone of the coun- (SC); ii) training and education (TE); iii) evaluation and try. It has a population of 2,083,588 as per National feedback (EF); iv) reminders in the work place (RW); Housing and Population Census, 2012. Dodoma region and v) institutional safety climate (ISC). Each of these is divided into 8 district councils (DC) with 8 hospitals, components has a subtotal score of 100, amounting to 30 health centres and 284 dispensaries. The district an overall maximum hand hygiene score of 500 [19]. councils are Dodoma City Council, Chamwino DC, Kon- doa DC, Kondoa Town Council, Bahi DC, Chemba DC, Preparation for data collection Mpwapwa DC and Kongwa DC. However, in the analysis The project assessment team underwent a 5-day training Kondoa DC and Kondoa Town Council were combined session on the general principles of hand hygiene in the together. context of IPC, the assessment protocol and pre-testing of the data collection tool in six dispensaries in Dodoma Study population, sampling strategy and sample size city council. This was followed up by a feedback session, A total of 236 participants (out of 242 eligible partici- where questions, inquiries and concerns were addressed pants) from 7 hospitals, 16 health centres and 155 dis- ensuring that all research assistants would be conversant pensaries were recruited in June 2019. Of these, 87 were with the data collection tool. The same research assis- MKAJI health care facilities (seven health centres and 80 tants deployed in the baseline assessment in March dispensaries from which 98 units were assessed) and 85 2018, were involved in the re-assessment in June 2019. non-MKAJI health care facilities (9 health centres and 75 dispensaries from which 99 units were assessed). One Data quality checks unit was included for assessment for dispensaries (i.e. Research assistants were divided into three groups each labour wards/rooms), 3 units were included in health with a team lead. The later was tasked to oversee the centres (i.e. labour wards/rooms, theatre and outpatient) data quality at the end of each day, and do the necessary and 6 units were included in hospitals (i.e. labour ward, corrective actions. Then, filled data collection tools were theatre, outpatient, laboratory, pharmacy and surgical sent to the data quality officer on weekly basis. The final wards). Individuals who were in-charge of a health facil- data quality assessment was done by the co-investigators ity’s unit and who gave their consent to be involved in and the principal investigator. the study were included (i.e. all 236 participants from 236 units were included). Health care facility units under Data analysis MKAJI were compared to units not under MKAJI inter- Data collected was entered into an Excel sheet for clean- ventional project based on the hand hygiene scores, ing and consistency checks and then exported to levels and compliance. Furthermore and irrespective of STATA version 13.0 software (StataCorp®, College Sta- MKAJI interventional status, baseline hand hygiene tion, Texas, USA) for analysis. Cumulative scores of five scores and their corresponding levels (obtained in March indicators stratified each health facility’s unit into inad- 2018) were compared with those obtained in this post- equate (0–125), basic (126–250), intermediate (251–375) interventional re-assessment i.e. in June 2019. In the or advanced (376–500) hand hygiene (score) level. Cat- later, unpaired comparison included all health care facil- egorical variables such as type of professional cadre, ity units assessed (261 units in March 2018 versus 236 health care facilities levels (i.e. dispensary, health centre units in June 2019), and paired comparison involved or hospital) and hand hygiene levels were described as only health care facility units which were both involved proportions and compared using a Chi-squared (Chi2) in the baseline and re-assessment (191 versus 191 units, test. Participants’ ages were presented as mean ± stand- respectively). ard deviation, whereas the hand hygiene scores were This project was approved by institutional board [the presented by median scores (interquartile range). Com- Joint Catholic University of Health and Allied Sciences/ parison of median hand hygiene scores in various vari- Bugando Medical Centre Research and Ethics ables such as district councils, health facility ranks, Wiedenmayer et al. Antimicrobial Resistance and Infection Control (2020) 9:80 Page 4 of 9 health facility units and MKAJI project status was done dispensaries [175 (100–247.5); p = 0.0136]. Although not sta- using a two-sample Wilcoxon rank-sum (Mann-Whit- tistically significant, median hand hygiene score (IQR) was ney) test. The significance cut off was set at p < 0.05 for also higher in health centre units [188.8 (115–260)] than in associations between hand hygiene level/score and other dispensaries [175 (100–247.5); p = 0.458]. All health care fa- variables. cility units had basic hand hygiene levels, except surgical units which had an intermediate hand hygiene level (Table Results 1). All seven city/district councils in Dodoma region had Demographic information of participants and health care basic hand hygiene level, except Bahi district council which facilities had inadequate hand hygiene level with median hand hy- The majority of participants were female (60.2%) and giene score (IQR) of [90 (70–130)]. 112 (47.5%) were nurses. Other professional cadres were clinicians 23.7% (medical specialists, medical doctors, as- Evaluation of hand hygiene indicators in health facility sistant medical doctors, clinical officers and clinical as- units sistants), medical attendants 19.1%, laboratory staff 5.5%, Post-intervention evaluation of the five hand hygiene in- pharmacy staff 2.5%, and others 1.7%. The mean age ± dicators in 236 units across various health care facilities SD of participants was 34.4 ± 9.8 years, ranging from 20 in Dodoma region showed that the respective median years to 60 years. hand hygiene score (IQR) were SC [45 (35–55)] and EF The overall distribution of the 236 health facility units [50 (25–67.5). These indicators were relatively higher across seven district councils was similar (range: 27 to compared to TE [25 (5–55)], RW [30 (5–50)] and ISC 33 per council), with exception of Dodoma city council [37.5 (20–60)]. Continuous supply of clean and running which accounted for 20.7% of all units. The majority of water was observed in approximately 90.3% (213/236), units involved were labour wards/rooms (75.0%) whereas the presence of alcohol hand rub was observed followed by outpatient units (10.2%) (Table 1). in 30.9% (73/236) of the health care facility units. It was reported that TE among health care workers on hand Hand hygiene scores and levels across health care hygiene had never been received in approximately 44.1% facilities in Dodoma region (n = 104), whereas in 37.7% (n = 89), training has been Hand hygiene scores and levels by health care facility units received only once. On the other hand, approximately and district councils 14.8% (n = 35) and 3.0% (n = 8) have regular and The overall post-intervention median hand hygiene score mandatory training in their workplaces, respectively. (IQR) across 236 health care facility units in Dodoma region The compliance rates were relatively higher among cli- was 187.5 (112.5–260), with the minimum and maximum nicians and nurses, compared to medical attendants and scores being 25 and 425, respectively. The distribution of other professional cadres (Fig. 1). The compliance rates hand hygiene levels across health care facility units post- above 50% and the WHO recommended rate of ≥81.0% intervention were inadequate 31.4% (n = 74), basic 40.3% specific to each professional cadres were found to be as (n = 95), intermediate 25.4% (n = 60), and advanced 3.0% follows; clinicians 48.2% (n = 27) and 7.2% (n = 7), nurses (n = 7). The median hand hygiene score (IQR) was signifi- 45.5% (n = 51) and 7.1% (n = 8), medical attendants cantly higher in hospital units [235 (147.5–320) than in 42.2% (n = 19) and 0.0%(n = 0) and others 30.5% (n =7) and 4.4% (n = 1), respectively (Fig. 1). Comparison of hand hygiene scores between MKAJI Table 1 Post-interventional hand hygiene scores and levels by health care facilities and non-MKAJI facilities health facility units in Dodoma region Of the 236 health care facility units, 197 units from health Health facility unit Median hand hygiene score Hand hygiene centres and dispensaries were subjected to a sub-analysis. (IQR) level Those health care facility units involved in the MKAJI inter- Labour ward (n = 182.5 (105–250) Basic vention project had significantly higher median hand hygiene 177) scores (IQR) [190 (120–262.5)] compared with non-MKAJI Outpatient (n = 24) 205 (143.8–272.5) Basic facilities [165 (95–230); p = 0.038]. The overall median hand Theatre (n = 14) 185 (115–250) Basic hygiene scores (IQR) were also higher among MKAJI health Laboratory (n = 8) 197.5 (111.3–307.5) Basic care facilities compared with non-MKAJI facilities in both Pharmacy (n = 7) 180 (115–195) Basic labour wards [190 (120–265) versus 166.3 (90–230)]; and Surgical ward (n = 327.5 (235–347.5) Intermediate outpatient units [178.8 (155–243.8) versus 147.5 (127.5– 6) 260)]. The median hand hygiene scores (IQR) differences Total (N = 236) between the two groups were also evident in all district IQR Interquartile range councils. The hand hygiene scores (IQR) for indicators which Wiedenmayer et al. Antimicrobial Resistance and Infection Control (2020) 9:80 Page 5 of 9 Fig. 1 Self-reported hand hygiene compliance using WHO tool (or similar techniques) among health workers by professional cadres demonstrated significant differences between MKAJI versus baseline [median score (IQR): 80 (60–145], it increased to non-MKAJI units were TE [32.5 (5–55) versus 10 (0–40), basic level after the re-assessment in 2019 [median score p < 0.001); and EF [55 (25–70) versus 40 (20–60), p = 0.043]. (IQR): 187.5 (112.5–260; p<0.001] (Table 2). On the other hand, the remaining three indicators did not show significant differences: SC [45 (35–50) versus 40 (30– Paired comparison of hand hygiene among facilities 50), p = 0.288]; RW [22.5 (5–50) versus 26.3 (5–47.5), p = sampled at the baseline and during re-assessment in 0.877), and ISC [35 (20–60) versus 35 (15–55), p = 0.408)]. Dodoma region There was no statistical difference on the availability of con- Of the 236 health care facility units involved in the tinuous supply of water in units associated with MKAJI ver- current study, only 191 (80.9%) were enrolled in the sus non-MKAJI units [90.8% (89/98) versus 88.9% (88/99); baseline assessment in March 2018 and therefore, the chi2 = 0.201; p = 0.654]. Similarly, no statistical difference was later allowed for a specific sub-analysis to assess a observed on the availability of alcohol hand rub in MKAJI change in trend. While the overall hand hygiene level units [29.6% (29/98) versus 23.2% (23/99); chi2 = 1.025; p = was inadequate at baseline [IQR of 90 (60–165)], the 0.311]. Hand hygiene compliance rate of ≥51% was signifi- level of those same 191 units had increased to basic level cantly higher in MKAJI units than non-MKAJI units [56.1% by the time of the re-assessment [IQR of 190 (120–260); (55/98) versus 30.3% (30/99); chi2 = 13.39; p < 0.001]. How- (p < 0.001)] (Fig. 3). ever, the recommended WHO compliance rate of ≥81% was only reported in 6.1 and 3.0% for MKAJI and non-MKAJI Discussion units, respectively (Fig. 2). Approximately 90% of the health care facilities involved in this study were dispensaries, whereas the remaining Baseline hand hygiene versus hand hygiene re- facilities being either health centres or hospitals, and the assessment in Dodoma region irrespective of MKAJI majority (75.0%) of units were labor wards. This higher intervention status proportion of labor wards is because this unit is present Overall baseline and re-assessment hand hygiene score in all three levels of health care facilities i.e. dispensaries, across health care facilities heath centres and hospitals. Previous studies in various While the overall hand hygiene level among the 261 units in units in Ethiopia, China and Switzerland have reiterated Dodoma region was found to be inadequate during the the need for a wide coverage of units to allow Wiedenmayer et al. Antimicrobial Resistance and Infection Control (2020) 9:80 Page 6 of 9 Fig. 2 Comparison of self-reported hand hygiene compliance using WHO tool (or similar techniques) among health workers by MKAJI status generalization of the findings in the context of patients to health centres and dispensaries may relate to the fact care services [24–26]. Similar to previous work in that most hospitals are better equipped with material re- Ethiopia, China and Italy, the current study showed a sources, have higher staff numbers and better access to in- predominance of females and nurses [24, 25, 27]. This formation regarding hand hygiene. The significant may be related to the fact that the nursing profession is improvement since the baseline assessment may be attrib- a predominant health cadre in Tanzania irrespective of uted to the on-going MKAJI project interventional mea- the rank of the health care facilities. sures, post-baseline assessment sensitization sessions and The overall post-intervention hand hygiene level was provision of hand hygiene tools to various health care fa- basic with a median score of 187.5, and was higher than cilities by the HPSS project and in collaboration with the the inadequate level reported in the baseline assessment council health management teams. In this regard, in March 2018 (both in paired and unpaired compari- strengthening of hand hygiene activities in health centres sons). This is comparable to a similar study in India which and dispensaries should be emphasized so as to have com- reported a hand hygiene score of 225 [28]. Similar to the prehensive coverage and subsequently reduce potential baseline assessment, the hand hygiene score was higher in HCAIs in all ranks/tiers of health care facilities in Dodoma hospitals than in health centres and dispensaries. The rela- region and other areas in Tanzania with similar epidemio- tively higher level of performance in hospitals as opposed logical predisposition [1, 16]. It was evident that continuous supply of clean water Table 2 Comparison of baseline and hand hygiene re- through conventional or improvised sinks was remark- assessment in health care facility units in Dodoma region ably high (90.3%), in contrast to the presence of alcohol- Health care Baseline median HH Re-assessment median HH based hand rub which was observed in only one third of facilities score (IQR) (n = 261 score (IQR) (n = 236 units) the health care facilities’ units. Nevertheless, our finding units) on alcohol based hand rub was higher than the 11.5% re- Hospitals 107 (80–182.5) 235 (147.5–320) ported from a previous study in Ethiopia [24]. The Health centres 76.3 (60–125) 188.8 (115–260) causes of low utilization of alcohol based hand rub in Dispensaries 75 (55–145) 175 (100–247.5) Tanzania and Ethiopia were not evaluated; however, Overall median 80 (60–145 187.5 (112.5–260 studies in Kenya and China demonstrated that smell, HH score (IQR) skin irritation, dryness, unreliable availability, and heavy Wiedenmayer et al. Antimicrobial Resistance and Infection Control (2020) 9:80 Page 7 of 9 Fig. 3 Paired comparison of baseline and follow-up hand hygiene re-assessment in Dodoma region work load negatively affected hand hygiene practices where a baseline assessment was done followed by specific among health workers [25, 29]. In contrast to these fac- hand hygiene interventions, the re-assessment showed re- tors, in a busy hospital setting like an intensive care unit, markably increased hand hygiene compliance rate irre- alcohol based hand rub is preferred due to its conveni- spective of the health workers’ profession and hospital ence [30]. Therefore, assessment of specific individual, units [18, 24–26, 29]. Although the hand hygiene compli- institutional and government factors affecting hand hy- ance rate of ≥81% recommended by WHO was reported giene will be of interest in the future assessments in to be significantly lower in both types of health care facil- Dodoma region. ities assessed (MKAJI and non-MKAJI associated), the Regarding the self-reported hand hygiene compliance, overall compliance rate was higher among respondents good compliance was reported more frequently among from MKAJI units. Low compliance was also reported in clinicians and nurses, as opposed to other professional Kenya (28% pre-intervention to 38% post-intervention, re- cadres. Of note, none of the medical attendants had spectively) as opposed to higher compliance (48–88%) in achieved the WHO recommended rate of ≥81.0%. The China connoting similar epidemiological and infrastruc- compliance rate in this study was low compared to the tural predisposition in Tanzania and Kenya [24, 25, 29]. baseline compliance rates reported in Kenya (28%), These findings emphasize that specific interventions, Ethiopia (22.0%), China (66.3%), Switzerland (61.4%) and when carefully designed, can have a significant positive in a systematic review involving 96 studies (40%) [18, 24– impact, which in turn can improve patients’ health care 26]. However, variable compliance has been previously re- services. Therefore, similar programs should be rolled out ported in six ICU in Italy ranging from 3 to 100% [27]. to increase coverage not only in Dodoma but also in other Variability in the hand hygiene compliance rates across regions in Tanzania. countries may be related to individual, institutional and This assessment did not evaluate all health facilities in government differences with regard to hand hygiene prac- Dodoma region. Nevertheless, over three quarters of tices, resource availability and reinforcement modalities health care facilities were assessed allowing for extrapo- available in each setting. Interestingly, in other countries lation of the findings to the rest of the facilities in this Wiedenmayer et al. Antimicrobial Resistance and Infection Control (2020) 9:80 Page 8 of 9 region. The hand hygiene compliance was self reported Ethics approval and consent to participate Ethical approval was provided by the Joint CUHAS/BMC Research and Ethics and subjectivity elements cannot be ruled out. However, Committee (CREC/358/2019) and the National Institute for Medical Research audit files were used for verification purposes. This study (NIMR/HQ/R.8a/Vol. IX/3116). Permission to conduct this comparative study could not link the impacts of hand hygiene levels/scores was also sought and granted by relevant government authorities and in- charge of the respective health facilities in Dodoma region. A voluntary writ- to AMR rates and patients’ outcomes, and these parame- ten informed consent was requested from every participant prior to involve- ters should be studied in future investigations. ment in the assessment. Conclusions Consent for publication Not applicable. The overall hand hygiene level in healthcare facilities in Dodoma region increased from inadequate level in March Competing interests 2018 to basic level in June 2019. Hand hygiene practice The authors declare that they have no competing interests. All authors have was significantly higher in hospitals compared with health read and approved this manuscript. centres and dispensaries. There was significantly higher Author details hand hygiene score and hand hygiene compliance rate in Health Promotion and System Strengthening/Tuimarishe Afya Project, 7th health care facilities associated with the MKAJI interven- Road, ACT Building, P.O. Box 29, Dodoma, Tanzania. Swiss Centre for tional project. However, the recommended WHO compli- International Health at Swiss Tropical and Public Health Institute, Socinstrasse 57, P.O. Box 4002, Basel, Switzerland. University of Basel, P.O. Box, CH-4003, ance rate of ≥81% was widely missed by both MKAJI and Basel, Switzerland. Dodoma Regional Medical Officer’s Office, P.O. Box 914, non-MKAJI units. Most health facilities had a continuous Dodoma, Tanzania. Department of Microbiology and Immunology, Weill supply of water but only one third of facilities provided Bugando School of Medicine, Catholic University of Health and Allied Sciences, P. O. Box 1464, Mwanza, Bugando, Tanzania. alcohol-based hand rub. Future assessments should maintain regular region- Received: 24 February 2020 Accepted: 29 May 2020 wide hand hygiene evaluation. Programs similar to MKAJI should be rolled out to increase the coverage not only in Dodoma but also in other regions in Tanzania. References 1. Nejad SB, Allegranzi B, Syed SB, Ellis B, Pittet D. Health-care-associated Ascertaining the implication of the hand hygiene scores/ infection in Africa: a systematic review. Bull World Health Organ. 2011; levels and its compliance in relation to the incidence of 89(10):757–65. HCAIs and AMR rates would be of interest in future 2. 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Intensive Care Med. 2018;44(4):499–501. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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