title: Barriers to hand hygiene in ophthalmic outpatients in Uganda: a mixed methods approach.
abstract: BACKGROUND
  Healthcare-associated infection rates are high in low-income countries and are associated with significant morbidity. There is a paucity of published data on infection control practice, attitudes or resources in these settings, particularly in ophthalmology. The aim of this study is to understand current hand washing practices, barriers to hand washing and facilities available in two Ugandan specialist eye hospitals. This study was undertaken through non-participant observations of healthcare worker hand washing practices, documentation of hand hygiene facilities and semi-strucutured interviews with clinical staff.
  
  
  RESULTS
  Eighty percent of the WHO opportunities for hand washing were missed through lack of attempted hand hygiene measures. Facilities for hand hygiene were inadequate with some key clinical areas having no provisions for hand hygiene. Training on effective hand hygiene varied widely with some staff reporting no training at all. The staff did not perceive the lack of facilities to be a barrier to hand washing but reported forgetfulness, lack of time and a belief that they could predict when transmission might occur and therefore did not wash hands as often as recommended.
  
  
  CONCLUSIONS
  Hand hygiene at the two observed sites did not comply with WHO-recommended standards. The lack of facilities, variable training and staff perceptions were observable barriers to effective hand hygiene. Simple, low-cost interventions to improve hand hygiene could include increased provision of hand towels and running water and improved staff education to challenge their views and perceived barriers to hand hygiene.
authors.affiliation: International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
authors.forename: Rachel
authors.initials: R
authors.lastname: Mearkle
authors.affiliation: Department of Infection, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UKᅟ. rebecca.houghton@uhs.nhs.uk.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Houghton
authors.affiliation: Eye Unit, Mengo Hospital, Plot 396, Albert Cook Road, PO Box 7161, Kampala, Uganda.
authors.forename: Dan
authors.initials: D
authors.lastname: Bwonya
authors.affiliation: International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
authors.forename: Robert
authors.initials: R
authors.lastname: Lindfield