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The Global Handwashing Partnership

How policy, training practice, and learning work together to improve hand hygiene

Published: April 16, 2019

Chedly Azzouz is a Paramedical Professor, an infection prevention control master trainer with the World Health Organization, and a policy advisor. He works with health workers, health system leaders, and policy makers to improve hand hygiene to prevent infections.

Chedly began his career as a registered nurse in Tunsia, and went on to receive a master’s degree as a certified nurse educator and a Paramedical Professor later, among several other trainings and certifications. His Master’s degree had a concentration in hospital hygiene, including infection prevention and control (IPC). He also participated in multiple World Health Organization (WHO) trainings, including on IPC. Chedly first worked in IPC through his nursing practice in Tunisia and Saudi Arabia, and later went to be a teacher and academic researcher in health sciences and care to expand IPC to others. He shared his experiences and advice for how to work with health sciences students (doctors, nurses, midwives, etc.), health workers, and health policy makers to improve hand hygiene.

Developing hand hygiene habits through clinical education

As a nurse educator, Chedly works with nurses to develop their skills, practices, and commitment to infection prevention and control (IPC). In most settings, it is very common for all health staff to have some training on hand hygiene. This is typically didactic training, for example through a supervisor or trainer informing staff of the critical times to wash their hands. However, Chedly says, “This alone will not change things.” The evidence base also shows that simply providing information is typically not enough to ensure good hand hygiene behavior.

Chedly has worked with hundreds of nurses in his career and has found two key things to be most effective: evidence and role modeling. There is clear evidence that good hand hygiene contributes to lower infection rates. Using real examples where improved hand hygiene showed lower rates of infection motivates nurses to realize the power of their own behavior. Chedly uses examples from the literature, showing how facilities and even countries have been able to reduce infections through better hand hygiene. He pairs this with his firsthand experience as a scrub nurse, when he and his team saw fewer surgical site infections when they improved hand hygiene.

Chedly reinforces this by modeling good IPC behavior to be a model for students and hospital staff. He champions the ‘dual benefits’ of handwashing as an important way to protect oneself and others at the same time. He has found that health workers often have misconceptions around hand hygiene. For example, some staff think that if they wear gloves for a task, they are protecting themselves and their patients. However, staff may contaminate their gloves by taking care of multiple patients, doing a cleaning or administrative task, without removing or changing gloves. Chedly says that guidelines and education need to be clear that good hand hygiene is in place to protect both staff and patients.

Finally, he encourages all educators and health facility leaders to develop a staff culture where quality of care is important, and patient and health worker safety are respected as part of that. He reminds his students that “If you accepted to be a healthcare provider, you are ethically and legally obligated to give care that is with a quality that will not harm the patient.”

Focusing on hand hygiene in outbreaks

Hand hygiene is one of the best ways to prevent the spread of infection. In infectious disease outbreaks, hand hygiene compliance becomes even more urgent to keep health workers, patients, and communities safe and contain the spread of disease.

In March 2014, the World Health Organization identified an outbreak of Ebola in Guinea, which tragically spread to include nearly 30,000 cases in Guinea, Liberia, and Sierra Leone over two years. In 2014, Chedly joined the World Health Organization response in Guinea. During the outbreak, there were complex standard precautions in place in Ebola treatment units, coupled with challenging workloads and health worker shortages. He coached staff to remember the importance of consistent good hand hygiene, saying, “Focus on hand hygiene, and you will see how you can improve the quality of care and the safety of patients.”

It had been difficult to convince officials, health professionals and the community of the role that hand hygiene can play in the prevention of and protection against Ebola Virus Disease. But with time, and as numbers of cases reduced, an awareness was gained of the importance of hand hygiene in the response. Handwashing was promoted in communities as well as in healthcare settings, and handwashing stations were put up in many public spaces. Over time, Chedly observed a change in behavior, with handwashing becoming prevalent all levels in schools, mosques, churches, hospitals, markets, and other public places. However, as the epidemic decreased, he noticed that this change in behavior was not always sustained.

Beyond the individual practice, Chedly and his colleagues wanted to be sure that hand hygiene was part of the staff culture at Ignace Deen Hospital, a University teaching hospital in Conakry, Guinea, where he was working in 2015. As the 5th of May approached, they saw an opportunity to reinforce the importance of hand hygiene. The 5th of May is Hand Hygiene Day, a World Health Organization day dedicated to advocating for good hand hygiene practices in all healthcare settings. At first, staff were reluctant to get involved in the Day, given the extremely demanding workload they were facing. However, the Director of the hospital saw the importance of observing the day as a key moment to establish the importance of hand hygiene. With leadership on board, the hospital installed new handwashing stations and hosted an event. The Minister of Health attended and spoke about importance of hand hygiene for everyone to save lives.

Lessons from the 2014- 2016 outbreak are coming up again in the current Ebola outbreak in the Democratic Republic of the Congo. One major lesson from Chedly is to include all areas where healthcare is performed, including outside traditional healthcare facilities. In Beni, the center of the outbreak, it is common for people to also seek care from traditional or private health clinics. The World Health Organization is providing IPC training for people who are providing health care, to limit the risks of infection and prevent transmission of Ebola. This is expected to be one contributing factor to why there were no new cases notified during the month of February.

Changing policies to improve hand hygiene

Now, Chedly uses his experience as a nurse educator, Paramedical Professor, and IPC expert to support Ministries of Health to improve IPC through policy change. Passing strong policies helps to create accountability, ensure resources are dedicated to hand hygiene, and reinforce the importance of hand hygiene. Chedly works with Ministries to convince governments of the importance of IPC, and to develop IPC policies which cover standard precautions with a major focus on hand hygiene.

Reflecting on what works for hand hygiene advocacy, he stressed the importance of sharing experiences and consistent results from improved hand hygiene. It is vital to convince Ministries of the importance of hand hygiene, but this is not always easy to do. Frequently, policy makers may underestimate the need for a policy on hand hygiene. Some think that hand hygiene is already a ‘solved problem’, and others are simply unaware of the impact it has on healthcare associated infections and other health outcomes. Policy makers are often thinking of new technologies or approaches, and “water and soap don’t seem so revolutionary.”

The role of hand hygiene advocates it to make sure the issue remains at the top of the policy agenda. Like with individual health workers, it helps to include examples where other countries have reduced healthcare associated infections through hand hygiene. By giving examples where other countries have seen better health outcomes when hand hygiene improved, he can show how “Even if it looks like a minor thing, it is one of the things that gives the most benefit for the health system.” Chedly emphasizes these improvements in his advocacy work, while keeping the context that hand hygiene is truly a global challenge that no country has solved. As he says, “Even with hand hygiene, we are not going to cut all HCAIS, but we can limit them.”

He also stressed the importance of being sure that hand hygiene is reflected in micro-plans and budgets. In his words, “If we are spending the money and the time now, we will be earning in the future.”

Challenges and opportunities in sustainability

While there have been some great successes in improving hand hygiene, sustainability is a major challenge. Availability of water and soap are a consistent challenge in many facilities, with over 60% of health facilities in low and middle income countries lacking soap and piped water for handwashing.

However, there are examples where simple tools have led to sustainable behavior change. Chedly gave an example from Togo. In 2017, he and colleagues from CDC Atlanta conducted an assessment of WASH and IPC in 265 health facilities. The publication is available here.

Three facilities were selected to participate in the WASH FIT process. WASH FIT stands for the Water, Sanitation, and Hygiene Facility Improvement Tool. The tool provides a step-by-step process and set of tools for health facilities to plan, implement, and monitor improvements in WASH. It focuses on making incremental improvements that can be managed by the health facility. In Togo, the three pilot facilities received some training and the WASH FIT tool but were not provided any materials or funds outside their normal facility budgets. All facilities reported an improvement in hand hygiene.

In follow up assessments two years later, staff consistently reported that when they improved handwashing, they noticed a change. The most common example was that fewer women returned to a facility with postpartum infections. Some facilities even reported that “patients are happy to see them wash their hands, and are even asking them to wash their hands.” In most of the facilities that participated in WASH FIT, more than 60% of facilities are still observing hand hygiene and other components of WASH FIT. Based on the success of this, Togo is looking into how they can scale WASH FIT nationally.

In Chedly’s opinion, policy is one key to sustainability. He says, “In the health system, if there is a directory or a law from the ministry of health that says you have to wash your hands, written very clearly, people will do it.” Many countries still need to develop an official policy documenting the key moments. This presents a challenge for trainers, because trainers can provide information and examples, but if nothing obligates health workers it is difficult to sustain the behavior over time.

Finally, health facility directors have to be role models and provide examples. Chedly advises, “If you are the director and you are not doing your best to make water and soap available, and give the example by washing your hands correctly, the health care workers will not do it.” When directors of facilities adhere to the practices and start talking loudly about the importance of handwashing / using hand rub, they consistently see results.

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