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Cover page of the Journal of Health Sciences

 Table of Contents  
Year : 2021  |  Volume : 14  |  Issue : 2  |  Page : 249-253

Mobile application-assisted observation of hand hygiene practices among nurses in a tertiary care center: A cross-sectional study

1 Department of Microbiology, Indira Gandhi Medical College and Research Institute, Puducherry, India
2 Indira Gandhi Medical College and Research Institute, Puducherry, India

Date of Submission29-Jan-2021
Date of Acceptance08-Apr-2021
Date of Web Publication31-May-2021

Correspondence Address:
Dr. A Malini
Department of Microbiology, Indira Gandhi Medical College and Research Institute (Governement of Puducherry Institution), Kadirkammam, Puducherry - 605 009
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kleuhsj.kleuhsj_17_21

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BACKGROUND: Improper hand hygiene (HH) practices are responsible for nearly 40% of health care-associated infections (HCAIs). Good HH measures are the most cost-effective means of reducing its incidence. Health-care workers (HCWs) play an important role in reducing HCAI by adhering to HH and intensive care unit protocols.
OBJECTIVES: The objectives of the study are to assess the knowledge regarding HH among nurses using a questionnaire and to assess compliance to the WHO's “My five moments of hand hygiene” among nurses using a mobile application (App).
MATERIALS AND METHODS: This was an observational cross-sectional study in a tertiary care center conducted among 100 nurses willing to participate. Their knowledge on hand hygiene was assessed using the WHO questionnaire, and compliance to the WHO's “My five moments of hand hygiene” was assessed by direct observation and documentation using a mobile App (Speedy Audit™, freely downloadable, developed by Handy Metrics Corporation). The data on compliance were entered into the mobile App which saves it as a MS Excel sheet. The knowledge and compliance rate were then calculated using proportions.
RESULTS: Of 100 nurses who participated in the study, 72% had good knowledge about HH practices. Overall compliance to “My five moments of hand hygiene” was 73.6%, with 100% compliance for “after body fluid exposure” and “after touching a patient” and 50% for “after contact with patient surroundings.”
CONCLUSIONS: Our study has shown that nurses not only have good knowledge about HH practices but have also implemented it. Periodic awareness programs on HH and the provision of adequate hand washing facilities can facilitate better practices.

Keywords: Behavior observation techniques, guideline adherence, hand hygiene, health knowledge, mobile applications

How to cite this article:
Malini A, Bhuvaneshwari B. Mobile application-assisted observation of hand hygiene practices among nurses in a tertiary care center: A cross-sectional study. Indian J Health Sci Biomed Res 2021;14:249-53

How to cite this URL:
Malini A, Bhuvaneshwari B. Mobile application-assisted observation of hand hygiene practices among nurses in a tertiary care center: A cross-sectional study. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 Jun 17];14:249-53. Available from: https://www.ijournalhs.org/text.asp?2021/14/2/249/317397

  Introduction Top

Health care-associated infections (HCAI) are the serious consequences of patient care. Implementation of hand hygiene (HH) practices is not only the primary measure but also a very cost-effective measure to reduce HCAI.[1] Hands are the main vehicle for transmission of microorganisms during health care. The hands of the health-care workers (HCWs) are usually colonized with pathogens from the environment and other patients of the hospital.[2]

HH is a general term used for hand washing with soap and water, antiseptic hand rub, or surgical hand antisepsis. Routine hand antisepsis may be practiced by alcohol-based hand rubs, the optimum duration is 20–30 s. When hands are visibly contaminated with body fluids, it has to be washed with soap and water for an optimum duration of 40–60 s.[2],[3],[4] Although the procedure is simple, compliance to HH among HCWs is only about 40%.[5],[6]

To improve the HH practices among HCWs, in 2005, WHO Patient Safety launched global campaigns and introduced slogans such as “Clean Care is Safer Care,” “Save Lives: Clean Your Hands.” These slogans reinforce the “My Five Moments of Hand Hygiene” endorsed by WHO. The five moments include (a) before touching a patient, (b) before clean/aseptic procedures, (c) after body fluid exposure/risk, (d) after touching a patient, and (e) after touching patient surroundings.[1]

Some studies showed a 6.0%–44% reduction in respiratory diseases with proper hand washing practices.[7],[8] Studies have also shown that there is a significant reduction of bloodstream infections in a neonatal intensive care unit with improved HH practices.[9]

HH compliance can be measured by direct observation or indirectly by the consumption of hand rubs/soaps. Direct observation of HH compliance by a validated observer is currently considered as the gold standard method in monitoring.[2],[3]

Technology-assisted direct HH observation methods using mobile devices such as iPods, iPads, and cell phones and electronic monitoring devices to document HH adherence have been studied.[10] Very little literature is available regarding technology-assisted HH observation in India.[11]

Monitoring the knowledge and practices of HCWs regarding HH becomes an important component in reducing HCAI. Hence, this study was taken up to assess the knowledge regarding HH practices among nurses using a questionnaire and to observe their compliance to HH using a mobile application (App).

  Materials and Methods Top

This was a cross-sectional study done in a tertiary care center, Puducherry, India. The study was conducted in a period of 4 months from January to April 2019. Ethical clearance for the study was obtained from the Institute ethics committee (No. 6/152/IEC//PP/2018 dated November 17, 2018). The study was conducted among the nursing staff working in the hospital. The purpose and nature of the study were explained to them, and written consent was obtained. Confidentiality and anonymity of participants were assured.

Sample size calculation showed a requirement for 90 staff nurses (expecting a compliance rate of 60% to hand washing among HCWs similar to a study in Pune[12]), however, 100 staff nurses were included in the study keeping in mind dropouts or nonrespondents.

Inclusion criteria

Nursing staff working in the institute for a minimum period of 6 months who were willing to participate in the study were included in the study. Study participants were 100 nurses working in various departments, chosen by simple random sampling.

Study tool

The knowledge and attitude of the study participants were assessed using a standard questionnaire designed by WHO.[2] This questionnaire consisted of nine questions which included both open-ended and closed type questions. Marks were allotted to only 6 questions, so the maximum score would be 6. A score of more than 75% was considered good, 50%–74% moderate, and <50% poor.

Compliance to HH was tested by direct observation for the WHO's “My Five Moments of Hand Hygiene,” using an android mobile phone App called Speedy Audit™ (freely downloadable, developed by Handy Metrics Corporation, version 87.0, updated on January 04, 2019). Using this App, the trained observer could enter the compliance data “real time” and upload it to a secure database and analyze it later. The trained observer was the student investigator.

Data collection technique

The data were collected separately for each individual using the mobile App. The trained observer makes entry into the App directly for each individual under observation, on the opportunities of HH, he/she had and how many were performed. The data entered into the App by the observer will be saved into an MS Excel sheet which can later be used for analysis. The App software is customized to location and profession. The identity details of the individual were not collected. The factors for noncompliance were also observed and recorded by the student on a case-to-case basis.

Data analysis technique

The data collected in the mobile App was saved as a backup in an MS Excel sheet as per the App software. The percentage of compliance was calculated with the help of an Excel sheet. Knowledge was assessed based on the answers obtained for the questionnaire. Proportions were used for the calculation of compliance and knowledge.

  Results Top

All the 100 staff nurses included in the study responded to the questionnaire. Ninety-six percent of the participants responded that they had received formal training in HH. Among the participants, 92 were females and 8 were males. [Table 1] shows the questionnaire that was used and the percentage of participants who answered correctly.
Table 1: Questionnaire used and the response obtained in the study

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The knowledge on HH was good among 72% of the total study population and moderate among 28% of the study population.

Compliance to HH – compliance for HH was measured for the “My Five Moments of Hand Hygiene.” Direct observation was done and the data were fed into the mobile App. The compliance rate was calculated using MS Excel 2010. [Figure 1] shows the compliance rate for the five moments.
Figure 1: Graph representing the compliance of the study participants for the “My 5 Moments of Hand Hygiene” (%)

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Compliance rate = (Number of performances × 100)/number of opportunities

The participants showed 100% compliance to HH after contact with the patient's body fluids and after patient contact. The overall/total compliance rate was also found to be around 73%.

  Discussion Top

HH is an effective tool in reducing HCAI. Nursing staff forms the backbone of any hospital as they render important services in patient care activities. Knowledge and HH practices of nursing staff, therefore, assume priority.

In this study, knowledge assessed by a standard set of the questionnaire showed that it was good (score of >75%) in 72% of the participants, and the overall HH compliance was 73.6%, which are good compared to other studies, both serving as good indicators. It was also observed that the compliance for the “After moments” was better than the “Before moments.”

A study in a tertiary care center in Pune also showed similar results with 85% of HCWs having good knowledge of HH and a compliance rate of 91%.[12]

In contrast to our findings, a study in a medical college hospital in Nepal showed that only 9% of the nursing staff among the study participants had good knowledge of HH.[6] Another study in a tertiary care center in Odisha also showed that 31% of the nursing staff had HH knowledge.[13]

Increased workload, time factor, and shortage of hand washing facilities were some of the factors mentioned for noncompliance in this study, which is similar to others.[6],[14]

Direct observation of HH is considered the gold standard for monitoring compliance.[15] Direct observation by a trained observer and manual entry of observations into a standard form are the traditional method. Given the large number of opportunities to which a HCW is exposed, manual entry of all the opportunities is not only time-consuming but also may not be practically possible. This can be overcome by directly recording the observations in a mobile-based App which also helps in reducing the paperwork.

Newer technologies such as electronic HH systems with sensors are also used in a few set-ups, where not only compliance is recorded but also promotes HH. However, such systems are limited only to few hospitals as they are quite expensive and also need maintenance.[16]

To our knowledge, this is the second study on observation of HH compliance using a mobile-based App that is being reported in India. The advantage of the App is that it is freely downloadable, user-friendly and has an automatic data backup. Infection preventionists or observers can be trained, and HH audit can be obtained on a regularly.

Good knowledge and compliance for HH in our study can be attributed to the training programs conducted regularly for the nurses on infection control measures as well as observing “World Hand Hygiene day” every year as a motivational program, in our hospital. Other studies have also shown that training sessions improve HH knowledge and compliance.[17]


Observation of compliance using mobile App was done after informing them about the study, and hence, the Hawthorne effect would have come into play, which was unavoidable and also that the study was limited to nurses and could not involve other HCWs such as interns and residents.

  Conclusions Top

HH is key to the prevention of HCAI. Periodic educational programs to HCWs on HH play important role in reinforcing the concepts and in motivating them for better practices. The administration also needs to be supportive by providing adequate HH facilities, and a multifaceted approach to tackle barriers such as workload and poor attitude is needed. Regular auditing of HH practices is necessary to identify shortcomings and to take corrective actions.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Save Lives Clean Your Hands. guide to the Implementation of the WHO Multimodal Hand Hygiene Strategy. Available from: http://whqlibdoc.who.int/hq/2009/WHO_IER_PSP_2 009.07_eng.pdf. [Last accessed on 2019 Jan 12].  Back to cited text no. 1
World Health Organization & WHO Patient Safety. Hand Hygiene Technical Reference Manual: To Be Used by Health-Care Workers, Trainers, and Observers of Hand Hygiene Practices. World Health Organization; 2009. Available from: https://apps.who.int/iris/handle/10665/44196. [Last accessed on 2019 Jan 10].  Back to cited text no. 2
Allegranzi B, Pittet D. Hand hygiene. In: Fraise A, Maillard J, Sattar S. editors. Russell, Hugo &Ayliffe's Principles and Practice of Disinfection, Preservation & Sterilization. 5th ed. New Jersey: Wiley-Blackwell Publishing Ltd; 2013. p. 418-44.  Back to cited text no. 3
Damani NN. Manual of Infection Control Procedures. 2nd ed. Cambridge, UK: Cambridge University Press; 2004. p. 227.  Back to cited text no. 4
Smiddy M, Donlon S. Hand hygiene observation audit: Standard operating procedure. R Coll Physicians Ireland 2014;3:17-29.  Back to cited text no. 5
Yadav SK, Giri A. Assessment of hand hygiene knowledge among residents and nursing staffs at nobel medical college teaching hospital, Biratnagar. J Nepal Paediatr Soc 2018;38:69-73.  Back to cited text no. 6
Hand Washing Reducing the Risk of Common Infections, 2011. Hamilton: Canadian Center for Occupational Health and Safety. International Scientific Forum on Home Hygiene (ISFHH); 2008.  Back to cited text no. 7
Healthcare – Associated Infections. Fact Sheet. WHO. Available from: https://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf?ua=1. [Lastaccessed on 2019 Dec 16].  Back to cited text no. 8
Helder OK, van Goudoever JB, Hop WC, Brug J, Kornelisse RF. Hand disinfection in a neonatal intensive care unit: Continuous electronic monitoring over a one-year period. BMC Infect Dis 2012;12:248.  Back to cited text no. 9
Technology – Assisted Direct Observation Methods for Hand Hygiene. Duke Infection Control Outreach Network (dicon), Infection Prevention News; May 2015: Volume 10, No 5.  Back to cited text no. 10
Tyagi M, Hanson C, Schellenberg J, Chamarty S, Singh S. Hand hygiene in hospitals: An observational study in hospitals from two southern states of India. BMC Public Health 2018;18:1299.  Back to cited text no. 11
Anargh V, Singh H, Kulkarni A, Kotwal A, Mahen A. Hand hygiene practices among health care workers (HCWs) in a tertiary care facility in Pune. Med J Armed Forces India 2013;69:54-6.  Back to cited text no. 12
Nanda S, Mohanty B, Routray SS. Awareness of Hand Hygiene Practices among Healthcare workers in intensive care unit of a tertiary care Hospital of Odisha. Sch J App Med Sci 2017;5:418-21.  Back to cited text no. 13
Kupfer TR, Wyles KJ, Watson F, La Ragione RM, Chambers MA, Macdonald AS. Determinants of hand hygiene behavior based on the Theory of Interpersonal Behaviour. J Infect Prev 2019;20:232-7.  Back to cited text no. 14
Hand Hygiene Monitoring and Feedback. Available from: https://www.who.int/gpsc/5may/monitoring_feedback/en/. [Last accessed on 2019 Sep 23].  Back to cited text no. 15
Marra AR, Edmond MB. New technologies to monitor healthcare worker hand hygiene. Clin Microbiol Infect 2014;20:29-33.  Back to cited text no. 16
Ansari SK, Gupta P, Jais M, Nangia S, Gogoi S, Satia S, et al. Assessment of the knowledge, attitude and practices regarding hand hygiene amongst the healthcare workers in a tertiary health care centre. Int J Pharm Res Health Sci 2015;3:720-6.  Back to cited text no. 17


  [Figure 1]

  [Table 1]


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