Background characteristics of the study participants
A total of 19 semi-structured and 18 key informant interviews were conducted. The majority, 40.5% (15/37) of the respondents were clinical officers, 43.2% (16/37) were aged between 35 and 44 years, more than a tenth, 18.9% (7/37) had between 6 and 10 years of experience in the delivery of healthcare services (Table 1).
Status of hand hygiene
An assessment of hand hygiene was conducted in 19 HCFs. About 73.6% (14/19) of the HCFs were at the level of health centre III, 68.4% (13/19) were public and more than half, 57.9% (11/19) were urban. Less than half, 47.4% (9/19) of the HCFs had sufficient hand hygiene infrastructure. More than a third, 36.8% (8/19) of the healthcare providers mentioned that their colleagues sufficiently complied with hand hygiene, 68.4% (13/19) knew the roles of the IPC committee, and more than half, 57.9% (11/19) mentioned that there was no compliance to hand hygiene during all the critical moments at their facility (Table 2).
Facilitators and deterrents to hand hygiene among healthcare providers
The facilitators and deterrents of hand hygiene have been classified based on the sub-components of the BCD model components (Environment, Brains, Body, Behavioural setting and interventions) (Figure 2).
Facilitators of hand hygiene among healthcare providers (Figure 3)
Physical environment determinants
Constant reminders such as mobile text messages, nudges and posters
Healthcare providers, mainly those in public HCFs mentioned that the presence of nudges and information, education and communication (IEC) materials such as posters acted as reminders and thus facilitated them to practice hand hygiene, especially hand washing during the critical moments of patient care.
“Yes, environmental cues are everywhere in the healthcare facility. These continuously remind us to adhere to hand washing during critical moments of patient care. The hand washing posters at the healthcare facility, especially in the wards also teach and remind us how and when we should wash hands during patient care since learning is a continuous process. The in-charge himself also always encourages us to wash hands and monitors us regularly.” (Enrolled midwife).
“Yes, it is practised. We have different posters at sinks which remind healthcare providers on hand washing.” (Clinical officer)
Partners such as the Uganda Virus Research Institute provided healthcare providers with posters that reminded them to practice hand hygiene during critical moments.
“Uganda Virus Research Institute sends us hand hygiene posters which we are supposed to pin at all strategic points. These posters act as reminders for practising hand hygiene, for instance when you are in the laboratory you are reminded to wash hands after taking off a sample, and so on.” (Enrolled Nurse).
Mobile text messages sent through the mTrac (a mobile phone-based health information system strengthening tool) platform also reminded healthcare providers and village health team members to practice hand hygiene thence fostering compliance during the critical moments.
“Through the mTrac platform, we receive messages from the district. These messages are sent to all healthcare providers who are registered on the platform, including VHTs. Since majority of the health providers are registered, we receive reminders on hand hygiene through the platform. Secondly, the other way we have been receiving reminders is through training.” (Enrolled nurse)
“There are some messages that are sent to our phones, I don’t know if they come from the ministry of health. What I know is that they come from a code 6767 on a daily basis, and they remind us to frequently wash our hands. Actually, even before we started chatting, I had received a message” (Nursing officer).
Social environment determinants
Existence of IPC Committees/ active focal persons
Almost all the HCFs had a committee or a focal person in charge of infection prevention and control. The IPC committee or focal persons were involved in routine monitoring and provision of feedback on hand hygiene, display of reminders on hand hygiene, conducting routine continuous medical education (CME), and ensuring availability of hand hygiene supplies at all points of care.
“The IPC committee reminds us and encourages us to clean our hands all the time. Each day, the focal person or any other person on the committee moves around to check and monitor hand hygiene in the different departments. In addition, they conduct CMEs at least every month and also carry out weekly supervisions. They also make duty plans for cleaners, and ensure that water and soap are available at hand washing stations.” (Senior Clinical Officer).
“Yes, we have an IPC committee and its role is to ensure that people wash their hands. The committee holds meetings regularly, ensures that hand washing supplies are available and also conducts evaluations to ascertain the gaps in hand hygiene, that is, are people washing hands or not, and what should be done to improve hand washing.” (Nursing Officer).
“The IPC committee does monthly assessments in each department. Like when we go to the theatre, we have to assess whether it is thoroughly cleaned, well dusted, equipment well sterilized and then we score. We score and give them feedback at the end of the day. Also, before we start our other duties, we move around to ensure that waste is properly segregated and hand hygiene is adhered to. We have to ensure that supplies like water and soap are in place. That is what we always do daily.” (IPC committee member/theatre assistant).
In some HCFs, the IPC committee had someone in charge of enforcing infection prevention and control including hand hygiene and availing hand hygiene supplies to the different departments. The IPC committee provided support supervision, during which they reminded the different staff to practice hand hygiene during the critical moments.
“We have an IPC committee which sits regularly and there is someone appointed for hand hygiene. This person makes sure that there are enough supplies for washing hands. We have enough hand washing facilities available for everyone to use. Also, we have a water tank donated by water aid for rainwater harvesting and in addition to national water connection. We have sinks in every room and sanitation stations in every corner. The clients are always reminded to wash their hands by the IPC focal person “(Healthcare facility in-charge).
“Like the maternity people, we encourage them to wash hands in these scenarios; before touching a mother, after touching a mother and putting on and off gloves in between examinations of different clients. The mid wives working with pregnant mothers, some of them wash hands but many prefer using the sanitiser especially after examining different clients because it dries easily. We make sure each clinical and injection room has water, sanitiser and jelly so that they keep on washing hands after working on every client.” (Healthcare facility in-charge).
We have a committee on IPC, and we identified someone responsible for enforcing infection prevention and control in each department. Everyone is encouraged to wash their hands!’’ (Healthcare facility in-charge).
Good leadership in the healthcare facility
The study revealed that good leadership by the healthcare facility in-charges and administration portrayed through ensuring a constant and reliable supply of hand hygiene infrastructure and supplies motivated healthcare providers to adhere to hand hygiene during all the critical moments.
“At times we may need hand washing facilities in the different departments. When we identify the need, we tell the in-charge and he quickly comes in and provides them. He also ensures that water is available all the time.” (HCF Deputy Manager).
“The administration has provided IPC infrastructure, for example, every clinical room has soap and water. We are encouraged every after a procedure to wash hands or even before touching a client.” (Key informant).
Biological environment determinants
Frequency of patient contact and nature of clinical work
Healthcare providers who were frequently involved in the physical examination of patients practised hand hygiene more than their counterparts who did not physically examine patients. Healthcare providers working in the maternity ward, theatre and laboratory were more likely to practice hand hygiene compared to their counterparts at the outpatient department (OPD), pharmacy, and other prescription or dispensing stations.
“The fact that my duties in the maternity ward require a lot of examining and constant touching of the patients motivates me to wash hands. I wash my hands more frequently because most of the time we don’t wear gloves, especially during antenatal yet the patients always sweat.” (Enrolled midwife)
“Yes, for example, maternity and lab healthcare providers may practice hand hygiene more than people at OPD or pharmacy, where touching the patient is not necessary.” (Assistant Nursing Officer).
“Healthcare providers in maternity and those in lab practice hand washing more frequently than their counterparts at OPD yet we all have similar hand washing stations. I think it’s because we (healthcare providers at maternity and OPD) get into more contact with the patients.” (Enrolled midwife)
“The roles these people (healthcare providers) play influence the frequency of hand hygiene. For instance, someone in the pharmacy department may not wash hands as frequently as someone in theatre or maternity. For some people, it is their culture to wash hands and others are not used to hand washing.” (Registered midwife)
Executive brain determinants
Knowledge of health risks associated with the work environment
Healthcare providers became knowledgeable of the health risks their work environment posed, and the benefits of hand hygiene through the continuous training provided by the district health office, partner organizations, healthcare facility in-charges and IPC committees. These built their capacity on hand hygiene, disinfection, waste management, and donning and doffing protective gears. Some respondents mentioned that one of the aims of these trainings was to make sure that healthcare staff adhered to hand hygiene during all the critical moments of patient care.
“We had training on how to wash hands, which solutions to use for hand hygiene, and dilution and mixing of these solutions. So, the training was conducted mainly to make sure that people (healthcare providers) adhere to hand washing during all the critical moments, and also to learn how to mix the chlorine solutions” (Clinical Officer).
“We received training from the district health office. Our in-charge and the IPC focal person also train us during the CMEs, which happen every two weeks. We have been trained in hand washing, waste segregation, general cleanliness of the ward, how to mix chlorine powder or JIK (brand name of a chlorine solution on the market), how to decontaminate surfaces, and how to don and doff PPE. All our staffs were trained in these especially those on duty” (Enrolled nurse, public HC III).
“We orient new staff and tell them where to wash their hands from. We show them where the sink is located and where to always find soap and gloves.” We tell them everything! And if they forget, we remind them” (Enrolled Nurse, HC III).
“These days AMREF has come up to teach us about the 7 steps of hand hygiene. We used to wash our hands normally but when we were taught about the 7 steps, it became a part of us” (Clinical officer).
Knowledge of infection prevention and control guidelines, policies and standards
Knowledge of some IPC guidelines, policies and standards among healthcare providers facilitated hand hygiene in the healthcare facility. Although no guidelines were seen in majority of the HCFs, most respondents were aware of some contents of the guidelines such as the hand hygiene technique, critical moments of hand hygiene in a healthcare setting and how to mix chlorine for purposes of disinfection. Respondents pointed out that these guidelines reminded them of the benefits of hand hygiene and the dangers of hand hygiene non-compliance. These guidelines were enforced by the IPC committees at the respective HCFs.
“We have Continuous Medical Education sessions where we integrate Infection Prevention and control. We also have infection prevention and control committee members who enforce these guidelines in the different departments.” (Healthcare facility in-charge).
“The guidelines usually remind us of the importance of hand washing and the danger of cross-infection in the facility. They remind us of having the IPC committee that should be functional with meetings that discuss issues of IPC.” (Healthcare facility in-charge).
Knowledge on hand hygiene was derived from training which was conducted by the Ministry of Health and partners like the Infectious Diseases Institute (IDI), GIZ, AMREF and UNICEF.
“AMREF and GIZ have sensitized us about the steps of hand hygiene. We used to wash our hands normally but when we were taught the steps, it became a part of us.” (Clinical officer).
“IDI trained us on the five critical moments of hand hygiene in a healthcare setting. The Ministry of Health has also provided us with brochures talking about hand hygiene.” (Enrolled midwife).
“IDI has trained us. We have so far received two trainings within two months. IDI taught us about mixing JIK (brand name for a chlorine solution on the market) to improve hand hygiene and disinfection of medical instruments, and waste segregation.” (Registered midwife).
While knowledge of some aspects of the guidelines facilitated hand hygiene, it was evident that the knowledge of the policies, guidelines and standards was sub-optimal. For example, some respondents confused the five moments of hand hygiene with the hand hygiene technique.
There is a policy with the five steps of hand hygiene, the policy of washing hands during all the critical moments, the policy of washing hands at the entry and exit of the health facility and the policy of washing hands after handling medical wastes. (Healthcare facility in-charge).
We have the 5 steps of hand hygiene and also the procedure of mixing JIK. The five steps are never followed but the rest are followed. There are no repercussions but we supply the health care provider with whatever they need to practice hand hygiene. (Enrolled midwife).
Whereas some healthcare providers had knowledge of which aspects of hand hygiene were covered in the infection prevention and control guidelines, others, particularly those in private-not-for profit HCFs were not.
“I have not heard about the national policy, guidelines or standards on hand hygiene and I have not heard of regulations about hand hygiene. What I can say is that in the medical setting we use hand hygiene to control infections.” (KI-PNFP).
A positive healthcare provider attitude towards hand hygiene
A positive healthcare worker attitude was reported by a few respondents as a facilitator of hand hygiene during critical moments.
“The attitude of health providers is key. I have been involved in training health providers here and they are positive about hand hygiene. They do practice it not because I am around but do it in good faith.” (Enrolled midwife)
Motivated brain determinants
Recognition and reward of compliant healthcare providers
Some healthcare providers pointed out that the recognition of best performing departments and staff facilitated hand hygiene compliance during the critical moments of patient care. Respondents mentioned that departments that were viewed as non-compliant during recognitions were motivated to improve their hand hygiene behaviour to be proclaimed as best performers.
“Of course, when you’re viewed as a department that is non-compliant, then you get the urge to improve. There is no penalty, however, the next time, you would also want to be recognized as the best performer in relation to hand hygiene. So, they (management) majorly do recognitions to motivate compliant departments and healthcare providers.” (Enrolled nurse).
“We have an infection prevention and control focal person who monitors and keeps track of healthcare providers who practice hand hygiene, and we reward them at the end of the year. Every year, we keep records of the people that comply to hand hygiene” (Manager).
Fear of healthcare-associated infections
The fear of contracting healthcare-associated infections such as COVID-19 motivated healthcare providers in this study to practice hand hygiene at all possible opportunities. Respondents mentioned that working in a risky environment that is prone to infections instils fear among them, hence they comply in order to protect themselves and their families.
“Before COVID 19, hand hygiene was not taken seriously now it is. It is practised continuously with soap and water or sanitisers due to fear of contracting the infection. So yes, being that we are in an environment prone to infections, we have to practice hand hygiene to protect ourselves and our families.” (Assistant Nursing Officer, Wakiso district)
“It’s due to fear of infection. You can see there is that in-built fear among the people especially when this corona virus emerged. Hand washing is always practised now. So yes, fear of infections can motivate health providers to wash hands.” (Clinical Officer)
“This COVID-19 pandemic has also facilitated hand washing because when they are aware that COVID-19 exists, then they have to wash hands. It’s like the fear of spreading the pathogens gets people to wash their hands. And also, regarding keeping yourself safe, for example, if you want yourself and your patient to be safe, then you are motivated to practice hand washing.” (Clinical Officer)
Besides the fear of contracting healthcare-associated infections such as COVID-19, some HCWs were knowledgeable of the health risks their work environment posed, and the role hand hygiene played in controlling and reducing the risk of acquiring infections. They acknowledged that they are exposed to both visible and non-visible dirt, hence the need to practice hand washing.
“We know that we are supposed to practice hand washing since this is not a safe or clean environment. We are exposed to visible and non-visible dirt every day, so we have to wash our hands. During the COVID-19 pandemic, we know that through hand washing, we can prevent further infections.” (Clinical Officer)
“They are knowledgeable of hand hygiene as one of the ways of controlling and reducing the risk of infection in a healthcare setting.” (Clinical Officer).
“Awareness has been created; we have been sensitizing healthcare providers on the dangers of not adhering to hand washing. So, they practice hand washing to prevent these risks.” (Clinical Officer).
Behavioural setting- Roles’ determinants
Availability of a budget for hand hygiene supplies
It was pointed out that having a budget for infection prevention and control facilitated hand hygiene compliance. Availability of a budget facilitated procurement, and thus the availability of hand hygiene supplies at the HCF.
“We have a budget which supports the procurement of hand hygiene supplies such as soap and sanitisers. It is a sufficient budget and as an in charge, I make sure that hand hygiene supplies and equipment are provided on time.” (Manager, Hospital).
“Our budget is enough to “foot” (cater for) the supplies for practising hand hygiene. The budget for medicine also includes hand washing supplies, so they are ever enough.” (Key informant, PNFP).
Behavioural setting - Props and infrastructural determinants
Availability of functional hand hygiene infrastructure and supplies
Some healthcare providers mentioned that the provision and availability of hand hygiene infrastructure and supplies such as soap, water, sinks, jerry cans and alcohol-based hand rub/sanitiser at every point of care and working station facilitated adherence to hand hygiene during the critical moments. Hand hygiene supplies were often provided by the Ministry of Health and partners such as UNICEF, AMREF and Water Aid Uganda. Some healthcare providers also mentioned that the management of their HCFs often ensured continuous supply and availability of hand hygiene supplies which eases hand hygiene compliance during critical moments. Availability of hand hygiene supplies was more common in private not for profit HCFs compared to public HCFs.
“First of all, hand hygiene supplies are always available. For instance, after using the toilet, you will be looking at the sink so you can’t pass by it without washing your hands. In case you are going to touch a patient, definitely, the sanitiser or alcohol-based hand rub will be there. If you are done attending to a patient, you wash your hands because the sinks are available.” (Enrolled Nurse)
“They (management) provide us with the supplies we need to practice hand hygiene such as soap and water. Water is always available at the sink. This eases the process of hand washing during the critical moments.” (Enrolled midwife PNFP).
“Yes, the management makes sure that there are enough hand washing facilities, water and soap. Hand sanitisers are provided to every health worker and the in-charge supervises to make sure these items are always in place.” (Assistant Nursing Officer).
“The healthcare facility in-charge motivates us by providing liquid soap. Each healthcare worker is also provided with 3 bars of soap for personal use. The IPC focal person makes sure that the hand washing stations are filled with water and also makes it a point that hand hygiene supplies are available. The water is always available and we have a water harvesting tank in addition to the national water supplies!” (Enrolled midwife).
“Yes, UNICEF and Water Aid provided us with hand washing facilities. UNICEF provided the powdered JIK, soap and sanitiser to support in hand washing.” (Assistant Nursing Officer)
The role of healthcare providers and other support staff was also evident in ensuring the functionality of hand hygiene infrastructure, safety and availability of hand hygiene supplies. The functionality of hand hygiene infrastructure was facilitated by regular notification of healthcare facility management (i.e., to the in-charge or IPC focal person) about break-downs, and immediate replacement of non-functional parts such as taps and sinks. Healthcare providers and other support staff collaboratively worked together in ensuring that hand washing stations at all points of care had water and soap. The cleaning staff also ensured the safety of the hand hygiene stations through regular cleaning, which in the end attracted healthcare providers.
“We work as a team, in that if the water can does not have water, you cannot just look on. As an individual, you have to ensure that there is water in the hand washing facility. If your colleagues are busy, then you take up the initiative to refill the hand washing facility. The support staff as well as fellow clinical staff often ensure that there is a constant supply of soap. In case it’s exhausted, one can just cut a piece and make a replacement. It’s not an individual but team effort.” (Enrolled nurse).
“The lady who cleans makes sure that the sink is clean. She makes sure soap and water are available. We also make sure we refill the jerry can every single time.” (Enrolled nurse).
“We have trained the cleaners to ensure that break down of hand hygiene infrastructure is reported to management. For example, when the tap is broken, we buy new ones for immediate replacement. We want to ensure that there aren’t any excuses from people like, “I should not wash my hands because the tap is not functioning.” (Senior clinical officer)
“The in-charge and IPC focal person take care of the maintenance of hand hygiene infrastructure. If there is a breakdown of the hand hygiene infrastructure, we report to the focal person who in turn reports to the healthcare facility in-charge. I can also report to the in-charge directly.” (Enrolled nurse)
Besides the availability of hand hygiene supplies and infrastructure, the strict enforcement of hand hygiene before entry and during other critical moments among healthcare providers further reinforced the practice.
“Currently, we have made it mandatory for healthcare providers to wash their hands at the gate and to put on a face mask, which safe guards us and the clients. When a healthcare provider is entering the gate, he/she needs to put on a face mask, undergo temperature screening and wash hands using soap and water. In addition, if one is a health worker, he/she must put on gloves, and properly segregate medical wastes.” (In-charge, Public HC IV).
Proximity to hand hygiene infrastructure and supplies
The majority of the healthcare providers, particularly those working in public HCFs pointed out that hand hygiene during the critical moments was possible due to the proximity to equipment and supplies such as soap and sinks, water, and jerry cans. Respondents mentioned that having these supplies close to their working stations and points of care motivated them to practice hand hygiene. They further highlighted that the flexibility of movable hand washing cans also eases hand washing.
“They are motivated because of the proximity and the availability of hand washing materials like sanitisers, soap and water. They are too close because every department has a hand washing facility with soap and water. For example, there’s a station both in and out of the laboratories, at OPD, clerking room, theatre and also in the maternity. Even in this room, there is a provision of an in-built sink that you can see with flowing water and soap.” (Clinical Officer)
“The hand washing stations are very close to us. We don’t need to move long distances to access them. This motivates us to wash hands during all the critical moments.” (Assistant Nursing Officer).
“We have stations at each critical point of care in the ward for example the antenatal, examination, delivery room, postnatal room and also at the entrances. Of course, the movable hand washing stations have also improved hand hygiene among health providers because you can place them wherever you want or wherever you’re seated. In case you want it closer, you can just pull it.” (Enrolled midwife).
Deterrents to hand hygiene compliance among healthcare providers (Figure 4)
Biological environment deterrents
Heavy workload
The heavy workload was cited by healthcare providers as one of the deterrents to compliance with hand hygiene during the critical moments of patient care, particularly among those working in health centre IIIs. Healthcare providers in HC IIIs pointed out that the shortage of staff left healthcare providers on duty exhausted after performing their roles, and consequently, they neglected hand washing.
“Due to the nature of HC IIIs, there is one nurse and a mid-wife who performs all the duties. So as the day goes by, they become tired and might neglect hand washing.” (Enrolled midwife, HC III)
“They just forget to wash hands. At times, they tell you that they were so busy to an extent that they didn’t find time to practice hand hygiene during the critical moments.” (Healthcare facility in charge, private not for profit HC III).
Executive brain deterrents
Negative healthcare provider attitude towards hand hygiene
A negative attitude towards hand hygiene coupled with unfavourable beliefs and perceptions hindered hand hygiene during the critical moments of patient care. Some healthcare providers in both public and private not for profit HCFs believed that hand washing wasn’t necessary when they did not get into contact with a patient’s body and for procedures performed while wearing gloves, whereas others believed that gloves offered adequate protection and eliminated the need to perform hand hygiene after patient care.
“Sometimes people’s attitudes hinder them from practising hand hygiene during the critical moments of patient care. There are those health providers who have the belief that hand washing isn’t necessary when you perform a procedure while putting on gloves. They think it’s okay and safe because she has protected herself with gloves. Yet, if I touch you and then others, am transferring infections.” (Senior Clinical Officer).
“So, for the ART clinic, they (healthcare providers) rarely examine patients. As you have observed, when they are seeing their patients, they only do refills of ARVs, and when they are dispensing their patients, it’s less interaction with the patient’s body. They think it’s safe yet one of the moments for hand washing is after touching the patients surrounding. (Clinical officer).
Furthermore, some healthcare providers, most especially those in public and private-not-for profit lower-level HCFs such as HC IIIs, believed that some clients were not infectious, because they didn’t appear so, hence the reluctance to practice hand hygiene.
“Some (healthcare providers) believe that their clients are not infectious. The appearance of the clients influences the healthcare providers’ tendency to wash hands, while others are just lazy to wash hands.” (Enrolled midwife)
Body- Traits, physiology and senses deterrents
The smell of hand hygiene supplies
A few healthcare providers cited the smell of hand hygiene supplies, particularly chlorine as a hindrance to practising hand hygiene during all the critical moments of patient care. These healthcare providers mentioned that the sharp pungent smell of chlorine discouraged them from practising hand washing during the critical moments of patient care. A few healthcare providers also pointed out that the use of chlorine made their skins rough.
“Yes, something like chlorine, it has a pungent smell. The hands also feel rough after use and the smell is sharp. So, such sensitivities sometimes deter health providers from doing hand hygiene.” (Enrolled nurse).
Behavioural setting- Props and infrastructural deterrents
Inadequate hand hygiene supplies
Healthcare providers failed to practice hand hygiene during the critical moments due to a lack of supplies such as water, soap and sanitisers. The large number of healthcare providers which included healthcare facility staff, students and volunteers for example made it difficult for each of them to own sanitisers. Due to the failure to access hand hygiene supplies, some healthcare providers were forced not to practice hand hygiene or to wash hands with only water till supplies were availed. Water scarcity, especially during the dry season was also reported as a significant barrier to hand hygiene not only among the public but also in private not for profit HCFs.
“There are times when we have a scarcity of hand hygiene supplies. We get our supplies from NMS (National Medical Stores) periodically. So, when our supplies get used up, there isn’t any other option but to do without them or to improvise by supporting each other to have these materials. As of today, sanitisers are out of stock. You are aware that it’s very important for every health worker to have a pocket sanitiser. However, this may not be feasible for everyone because we have students and volunteers, you know! You cannot start buying for everybody. Even if you decide to buy for yourself, it does not help.” (Clinical Officer).
“Water is inadequate and we fetch it off the facility premises. Now, in the dry seasons, we have to resort to fetching water from the borehole which is very far away from this facility. The potters make sure that they collect water and fill all the jerry cans and the hand washing stations because it’s their duty. However, some wards like the labour ward don’t have a hand washing station. So, from the labour and post-natal ward, you have to come here to the centre to wash your hands. So that’s the challenge. There are also those times when there is no soap. It’s kept in the stores, and if the person who has the store keys is not around, you go without it.” (Nursing Officer).
Long-distance to hand washing equipment/ station
The distance to a hand washing station or equipment discouraged some healthcare providers in both private not for profit and public HCFs from practising hand hygiene during the critical moments of patient care. Healthcare providers mentioned that hand hygiene stations such as hand washing basins and sinks, and jerry cans were located far away from the users’ workstations, which made it inconvenient for them to practice hand hygiene during the critical moments of patient care.
“Hand washing stations are far away from some healthcare providers’ workstations. You may find that in some departments, the hand washing facility is several meters away which can affect hand hygiene during critical moments. At times they find it difficult to move from one room to the other just to wash their hands. As my colleagues at that clinic, their hand washing facility is a bit far from them. They move from room to room.” (Clinical Officer).
“There is limited space in the antenatal room, and no sink as well. So, one has to move to the wash rooms to clean their hands. The lab also lacks a sink and they have to move out. In a nutshell, the hand washing stations are not close to the points of care. This makes people reluctant to wash hands.” (Enrolled midwife)
“There are places in the healthcare facility that lack hand washing stations, like the clerking room in the OPD. If you don’t have a sanitiser, it becomes so difficult to move to another room to practice hand hygiene.” (Clinical Officer).
Non-functionality of hand hygiene infrastructure
Non-functional or faulty hand washing stations hindered healthcare providers from performing hand hygiene during critical moments of patient care. Healthcare providers noted that taps usually break down due to misuse on busy immunization days, which discourages them from adhering to hand washing. Furthermore, they highlighted that hand washing stations are often stolen due to their temporary nature, which also hinders them from complying with the practice.
“Another thing is that some hand washing stations are faulty or non-functional. Every time we have an immunization clinic, taps get broken. So, at times, breakdowns hinder us from practising hand hygiene during the critical moments of patient care. They are also not permanent like you see, so they get stolen since the healthcare facility is not fenced.” (Senior Clinical Officer).