Healthcare-associated infections(HCAIs) are a global problem and a major source of preventable morbidity and mortality worldwide, but particularly so in low and middle income countries. A recent review estimated the pooled prevalence of HCAI in developing countries (defined as Organisation Economic Co-operation Development (OECD) low or middle income countries) to be 15.5 per 100 patients, and highlighted the need to improve infection control practices. Rates of surgical site infection have been reported to range from 12 to 39% in developing countries compared to 2 to 5% in developed countries and rates of HCAI in neonates have been found to be 12 times higher in developing countries. Mortality due to such infections in developing countries is found to greatly exceed that in developed countries.
There is, however, evidence from quasi experimental research that concerted and sometimes low-cost interventions are able to greatly reduce the hospital transmission and prevalence of multi-drug resistant organisms (MDROs), resulting in improved patient outcomes. Improved hand hygiene(HH) is widely believed to be the single most effective intervention. However a 2010 Cochrane review has highlighted the lack of methodologically sound research evaluating interventions to improve HH: only four studies met the minimum inclusion criteria and only one such study came from a lower or middle income country (a randomised trial of an educational intervention for nurses in China). Moreover, a recent review has identified a need for stronger evidence linking improved HH compliance with reductions in HCAIs (currently such evidence is based only on observational studies).
While there are comprehensive hospital infection control guidelines at the proposed study site, Sappasithiprasong hospitals, a recent observational study our team carried out at this hospital has indicated poor HH compliance, below 5% for all health-care workers(HCWs) (manuscript in preparation). Previous data collected by our team has suggested hospital infection control guidelines may not have been implemented consistently due, in part, to resource constraints[5]. More recent qualitative research we have carried out at Sappasithiprasong hospital into the causes of poor hand hygiene compliance has identified several obstacles, and highlighted in particular a lack of knowledge about appropriate hand hygiene behaviour.
Available evidence suggests that hand hygiene promotion (HHP) with a multimodal intervention will be the most effective approach to improve HCW hand hygiene compliance[6]. While formal evaluation of such an intervention using a strong study design in lower and middle income countries is lacking, such interventions are relatively inexpensive and thought likely to be cost-effective (and potentially cost-saving as a result of reduced infections rates). Again, however, formal economic evaluations outside high income countries are lacking.
This approach promoted by the WHO guidelines identifies five moments for HH (before patient contact, before aseptic procedure, after body fluid exposure, after touching a patient, after touching a patient's surroundings). These guidelines aim to encourage good HH compliance in the real world and recommend a multimodal HHP strategy making use of up to five components: 1) system change (for example, changing systems to ensure that alcohol-based hand-rub is readily available wherever and whenever needed), 2) training and education, 3) observation and feedback, 4) reminders in the hospital, and 5) a hospital safety climate.
Adapting these guidelines to local conditions is important, and will make use of our initial qualitative research. This has identified important local barriers to achieving high levels of HH compliance.
Another major issue for improving HH behaviour in hospital HCWs is sustainability. While many studies have reported immediate improvements in HH following interventions, sustaining such improvements is much more challenging and another area where research has been very limited.
In conclusion, there is a need for methodologically rigorous research to evaluate the impact of a multimodal intervention based on the WHO recommendations both in the short and longer-term considering as outcomes both HH compliance, and preventable HCAIs. The need for such research is greatest in resource-constrained settings in lower and middle income countries where the burden of disease due to healthcare associated infections is the greatest. Findings from this research can also inform economic evaluations which are needed to determine the conditions under which such interventions are cost-effective.
