Last year, Nigeria observed how an existential threat from the Ebola pandemic reinforced people’s attitude towards hand hygiene – a strongly held idea and collective belief in our cultures and religions – drove forward improvement in hand hygiene by hand washing.
Nigerian cultures and religious beliefs have a great influence on their way of life, and yet many Nigerians prior to the outbreak of Ebola were negligent on hand hygiene practice until there was a real, credible and present threat.
The demand and usage of hand hygiene products such as alcohol sanitisers grew with rapid frenzy to be utilized as the major preventative approach against the disease.
Following the declaration by the World Health Organization deeming Nigeria ‘Ebola-free’ in October 2014, we observed that hand hygiene promotion and practice began to wane. This was not just in the general population but also in healthcare and amongst healthcare providers. These were the very people whose behaviour and performance should drive correct practice and promote hand hygiene as a routine public health practice for both patient safety and occupational health, based on scientific evidence.
While the determinants for implementing a successful hand hygiene improvement campaign and system are multi-factorial, we identified behaviour as the key reason people chose whether or not to increase their promotion and practice of hand hygiene. The real and clear threat of Ebola provided the incentive to promote and practice hand hygiene. When that threat was taken away, there was no further incentive and thus withdrawal from hygiene practices. Our experience on the field in general population and in healthcare, suggests a strong association between Ebola and hand hygiene which can provide a window of opportunity for behaviour change communication against possible threats. The challenge is to make ‘foreseeable’ illnesses perceived as ‘real, credible and present’.
The challenge is to make ‘foreseeable’ illnesses perceived as ‘real, credible and present’
We propose in this article that methods targeting behaviour change, which have been trialled in other parts of the world and resulted in an established or sustained measure of hand hygiene improvement. We also propose scientific studies on hand hygiene behavioural change, looking at linkages from real, credible and present threats for which health care-associated infections, antimicrobial resistance and climate change/disruptions may be very significant.
Behaviour change is the biggest driver to sustain hand hygiene promotion and practice in health care facilities in Nigeria. Establishing these changes as a basic preventive and protective principle in clinical practice will drive the demand and supply of the appropriate infrastructure and systems to support effective hand hygiene.
During the outbreaks of Ebola in Nigeria in 2014 there was a sharp and frenzied demand for hand sanitizers and Personal Protective Equipment (PPE) kits in Nigeria.
Health care facilities, as well as public and private organisations such as banks, schools, hotels, and restaurants believed that the use of hand sanitizers would prevent Ebola from spreading to their staff, students and visitors, and thus, diligently sought to ensure that they had sufficient supplies.
Their behaviour was influenced by fear from the threat of a dangerous infection. The meticulous practice of hand hygiene management lasted only for a short while (for the majority of people) during the active phase of Ebola pandemic. This short period ceded after the WHO declared Nigeria as Ebola-free. The impression was that Nigeria is ‘safe’ to go back to ‘business as usual’. This was obviously a missed opportunity for post-pandemic programming to strengthen infection prevention and control systems that had been relatively weak in Nigeria; and further weakened in many West African countries that were more strongly affected by Ebola.
Post-Ebola, we have observed indifference and near apathy to infection prevention and control.
Post-Ebola, we have observed indifference and near apathy to infection prevention and control. This is especially true of hand hygiene; the very fundamental of infection prevention measures in general population. Similar to this observation is the post-bird flu era in the US, Europe and Asia.
While it is human nature to sometimes forget a learned behaviour after a period of time, in this instance, the epidemic triggered a particular action or response that once removed, resulted in a return to previously held habits. In their 2005 paper, Trunnel and White¹ observed that: ‘Increasing awareness, and belief in ability to perform the behaviours, actually changing hand hygiene behaviours, as well as maintaining these behaviours over time are integral aspects of successful behaviour change programs in a variety of settings and with various individuals involved in caring for the health and welfare of others’.
This is in addition to divergent, but valid healthcare/service priorities within poorly-structured developing countries. Driving forward a culture and attitude (most especially in healthcare) of regular hand hygiene promotion is one of the biggest challenges. This would be a practice that would provide a much needed barrier to pathogen spread and resilience when pandemics arise.
Over the last 12 months, WHO has requested support from all health care facilities in the global campaign; ‘Save Lives, Clean Your Hands.’ This is done by having healthcare workers assess/audit their hand hygiene status, using the WHO Hand Hygiene Assessment Framework (HHAF) tool³:
‘The Framework is a tool with which to obtain a situation analysis of hand hygiene promotion and practices within an individual healthcare facility, according to a set of indicators. It also acts as a diagnostic tool, identifying key issues requiring attention and improvement. Repeated use of the Framework will allow documentation of progress with time.’
The WHO intends to gather data globally to demonstrate the degrees of adoption of hand hygiene practices in different countries. This will be done with ratings ranging from inadequate, basic, intermediate/consolidated, advanced and leadership, and will be based on the establishment and/or practice of the components and indicators/elements of the WHO Multimodal Hand Hygiene Improvement Strategy ².
We have worked with a number of facilities especially in the last quarter to 2015, almost 1 year since the Ebola pandemic ended in Nigeria to assess their hand hygiene status by completing the HHAF questionnaire.
Summary of Observations:
- Majority of facilities (including large tertiary health centres and small private owned establishments) show inadequate to basic levels of hand hygiene promotion and compliance with limited levels of knowledge and motivation/desire to make the transition.
- Areas showing significant gaps included: training and education; evaluation and feedback; and reminders in the workplace. Unfortunately, these are all necessary components of the hand hygiene improvement strategy.
The WHO Multi-modal Hand Hygiene Strategy² includes system change; training & education; evaluation & feedback; work place reminders; and institutional safety climate. It is instrumental that 3 out of these 5 strategies introduce and sustain hand hygiene at point of care, educating health care workers in understanding the WHAT and the WHY of hand hygiene. To start, interactive training helps to identify the need for behaviour change. Then training, observation, workplace reminders, monitoring and evaluation will maintain and reinforce these new behaviours to sustain and promote practice.
All levels need to adopt key preventive, patient safety and occupational health measures to improve health outcomes
Putting hand hygiene at the forefront of health programming priorities is a crucial step that healthcare authorities at federal, state and local government levels (led by the Federal Ministry of Health in Nigeria). All levels need to adopt key preventive, patient safety and occupational health measures to improve health outcomes.
Hand hygiene promotion and practice are simple measures to prevent the many cases of morbidity and mortality in Nigeria, as a result of preventable infections. Hand hygiene also makes common sense as healthcare quality issues constantly challenge national assets and resources. Healthcare quality issues are a large burden to the National Health Insurance Scheme (NHIS), Nigeria’s major health insurance for social protection. Hand hygiene improvement makes compelling economic sense.
Perhaps even more serious is the high-level threat of antimicrobial resistance in Nigeria, and globally. With climate change and climate disruptions and the increasing risk of infectious diseases, simple infection prevention and control measures such as hand hygiene improvement, are a critical element to preventing routine infections and slowing down the evolution of ‘superbugs’. This will therefore reduce the need for prescribing, distributing and misuse of antimicrobial agents that is so freely available (due to weak regulatory enforcement) in Nigeria.
It seems quite apparent that changes to hand hygiene practices can be implemented if the compelling case for improvement is built on real, credible and present evidence. This includes both its healthcare outcomes, as well as its economic benefit. The conversation ought to begin right now with the need for follow through on supporting tools and incentives.
We believe that the most effective policies and campaigns to sustain hand hygiene culture especially in health care are:
- Government supported health and environmental social marketing and programming (centrally and locally); with clear targets and peer comparisons to health facility levels at the grassroots or community.
- Well-publicised awareness campaigns using clever ways to take the message to the community and create support.
- Measurable – for example, we ought to be able to identify a hospital that takes hand hygiene seriously not just by how many non-functioning hand-washing basins and empty dispenser units grace their walls, but by the policies, processes, and recurrent activities that staff and management in that facility engage in to ensure there is regular and sustained compliance.
- Trunnel E.P, White G.- Using Behavior Change Theories to Enhance Hand Hygiene Behavior (Education for Health, Vol. 18, No. 1, March 2005, 80 – 84))
- http://www.who.int/gpsc/5may/tools/en/ , accessed 10/12/2015
- http://www.who.int/gpsc/5may/hhsa_framework/en/ , accessed 10/12/15
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