Is your well-being in a health professional’s (clean) hands?

The world marks Global Handwashing Day every year on October 15. This year, let us bring the spotlight on to a group that we turn to keep us healthy, prevent and treat our ailments: health providers.

India continues to battle pressing health problems such as deaths among new mothers and new born, infectious diseases like tuberculosis, and vector borne diseases like dengue and Chikungunya. As the sick throng health centres seeking relief and cure, quality health care is what determines recovery. Equitable, inclusive, and sustainable water, sanitation, and hygiene (WASH) services available to everyone irrespective of caste, class, and gender, constitute a crucial component of quality health care. Closely intertwined with WASH facilities is hand hygiene practices by doctors, nurses and others involved in patient care. Inadequate WASH in clinics, nursing homes and hospitals fuels infections, complicating and delaying treatment.

Hand hygiene is an underrated behaviour; it is in fact, a simple and cost-effective intervention that can play a critical role in improving patient health. We may take for granted that doctors and nurses have infection free hands. Worryingly, evidence suggests otherwise, as hand hygiene behaviours among health care providers across the world is abysmally low. Poor hand hygiene contributes to health care associated infections (HCAI) and anti-microbial resistance (AMR), two rapidly emerging health care related concerns, that lead to chronic health conditions, lengthy hospitalisation, and high treatment costs for patients, their families, and the public health system. HCAIs result from unsafe, unhygienic patient care, with evidence suggesting that at least 10 per cent of patients acquire such infections^[1]. HCAIs are also among the leading risk factors for AMR^[2], a deadly threat predicted to cause 10 million deaths every year, and cumulatively cost over USD 100 trillion in terms of lost global production by 2050.^[3] If we want to curb the spread of such infections and drug resistant diseases among vulnerable patients, especially new mothers and their babies, we must include water, sanitation and hygiene services and encourage hand hygiene compliance in health care facilities as critical interventions. Such services must include:

• An improved source of water, including safe drinking water.
• Improved sanitation facilities, particularly functional toilet facilities for patients, health care providers, caregivers, and those with limited mobility.
• Hand hygiene facilities, including a sink with water and soap, or alcohol based hand rubs, conveniently placed near critical points of patient care and close to a toilet.
• Appropriate solid, liquid and biomedical waste management.
• Appropriate disinfecting routine of facilities.
• Behavioural interventions for hand hygiene compliance

While India is slowly taking action to improve WASH in hospitals, evidence calls for urgent action to encourage hand hygiene among health care providers as well. A systematic review pooled together evidence from 96 studies conducted in high income countries and concluded that hand hygiene compliance rate was as low as 40 per cent among health professionals^[4]. In low and middle income countries such as India, the compliance rates are even lower given the numerous constraints faced. When WaterAid India examined WASH conditions in 343 health care facilities across 12 districts in the country, the organisation noted low hand hygiene scores in assessed facilities across four districts in Uttar Pradesh.

Health professionals are supposed to be aware of the importance of hand hygiene. So what prevents them from actually washing their hands? One major reasons is that they just don’t have facilities to do so. Water coverage in health facilities in India was estimated to be 72 per cent and sanitation coverage lower, at 59 per cent according to a WHO and UNICEF report. WaterAid India’s facility assessments found similar trends, and noted several striking gaps such as broken and dysfunctional sinks and taps, lack of water and soap at handwashing stations, absence of alcohol based hand rubs in patient care areas, and the lack of communication materials on appropriate handwashing. Compounding these issues are varied levels of awareness on critical times for handwashing in health care settings among care providers. Heavy workload, high inflow of patients, and resultant time constraints are other factors complicating this seemingly simple act. Further, an increase in usage of gloves could well be instilling a false sense of hygiene, negating the need for handwashing among health professionals.

The barriers are significant, yet action is imperative to protect patients from preventable hospital acquired infections and unnecessary treatment costs. For this, health facilities must have sufficient functional and accessible WASH facilities. To inculcate hand hygiene as an essential part of health care among providers, medical education and in-service training must repeatedly stress the significance of hand hygiene at critical points of care, linking it with health outcomes. In health facilities, simple behaviour change interventions such as the WHO-5 (a multi-component strategy comprising system change, training and education, observation and feedback, reminders in the hospital, and a hospital safety climate) coupled with goal setting and reward incentives can engender and sustain compliance.

[1] Alegranzi B., Nejad SB, Combescure C, Graafmas W, Attar H, Donaldson L et at (2011). ‘Burden of endemic health-care associated infection in developing countries: systematic review and meta analysis’. Lancet, 377: 228-241.

[2] Holmes A, Moore L, Sundsfjord M, Regmi S, Karkey A, Guerin P and L Piddock (2016). Understanding the mechanisms and drivers of antimicrobial resistance. The Lancet, 387: 10015, 176-187.

[3] O’Neill J. (2016) Tackling Drug-Resistant Infections Globally: Final Report and Recommendations.

[4] Erasmus V, et al., Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol. 2010; 31(3):283-294. doi:10.1086/650451.

Arundati Muralidharan is Manager - Policy (WASH in Health & Nutrition, WASH in Schools) at WaterAid India. She Tweets as @arundati_md