Knowledge, attitudes and practices of hand hygiene among final year medical and nursing students at the University of Sri Jayewardenepura

Abstract

Effective hand hygiene is essential for reducing healthcare associated infections. However, compliance of healthcare workers to hand hygiene guidelines are reportedly poor. It is important therefore to instill adequate knowledge and good attitudes and practices at the time of primary training of the healthcare workers. This study was done to identify gaps in knowledge, attitudes and practices to improve existing training programs and enhance good practices and working ethics in the future. A self-administered questionnaire based cross sectional study was done to compare the knowledge, attitudes, practices and satisfaction (KAPS) of facilities between final year medical and nursing students of the Faculty of Medical Sciences, University of Sri Jayewardenepura. Participants had moderate knowledge (77%) but attitudes, practices and satisfaction of facilities of all the participants was overall poor (<50%). However the nursing students had better knowledge (p=0.023), attitudes (p<0.001), practices (p<0.001) and satisfaction of facilities (p<0.001) compared with the medical students. The knowledge, attitudes, practices and satisfaction of facilities of medical and nursing students are unsatisfactory. The study shows the need for further improvement of the existing hand hygiene training programs to address the gaps in knowledge, attitudes and practices. Further, there is a need to improve the facilities available for hand hygiene and make them readily accessible for students at their training centers to enable them to engage in good practices which will be beneficial for them as doctors and nurses in the future. 16

Full text

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________________________________________
1 Department of Microbiology, Faculty of Medical Sciences, University of Sri Jayewardenepura, Gangodawila,
Nugegoda
2. Department of Anaesthesiology, Anuradhapura Teaching Hospital, Anuradhapura.
______________________________________________________________________________
Address for correspondence: Dr. TDCP Gunasekara. Department of Microbiology, Faculty of Medical
Sciences, University of Sri Jayewardenepura, Gangodawila, Nugegoda. Tel no.; +94112802026:
Fax no.; +94112802026 Email: chinthikaandbimal@yahoo.co.uk
Research Article
Knowledge, attitudes and practices of hand hygiene among final year medical
and nursing students at the University of Sri Jayewardenepura
MHJD Ariyaratne1, TDCP Gunasekara1, MM Weerasekara1, J Kottahachchi1,
BP Kudavidanage2, SSN Fernando1
Sri Lankan Journal of Infectious Diseases 2013 Vol.3(1);15-25
DOI: http://dx.doi.org/10.4038/sljid.v3i1.4761
Key words: Hand hygiene; Hospital acquired infections; medical students; nursing students; KAPS
Abstract
Effective hand hygiene is essential for reducing healthcare associated infections. However,
compliance of healthcare workers to hand hygiene guidelines are reportedly poor. It is important
therefore to instill adequate knowledge and good attitudes and practices at the time of primary
training of the healthcare workers. This study was done to identify gaps in knowledge, attitudes
and practices to improve existing training programs and enhance good practices and working
ethics in the future. A self-administered questionnaire based cross sectional study was done to
compare the knowledge, attitudes, practices and satisfaction (KAPS) of facilities between final
year medical and nursing students of the Faculty of Medical Sciences, University of Sri
Jayewardenepura. Participants had moderate knowledge (77%) but attitudes, practices and
satisfaction of facilities of all the participants was overall poor (<50%). However the nursing
students had better knowledge (p=0.023), attitudes (p<0.001), practices (p<0.001) and
satisfaction of facilities (p<0.001) compared with the medical students. The knowledge,
attitudes, practices and satisfaction of facilities of medical and nursing students are
unsatisfactory. The study shows the need for further improvement of the existing hand hygiene
training programs to address the gaps in knowledge, attitudes and practices. Further, there is a
need to improve the facilities available for hand hygiene and make them readily accessible for
students at their training centers to enable them to engage in good practices which will be
beneficial for them as doctors and nurses in the future.

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Introduction
Effective hand hygiene can lower the prevalence of healthcare associated infections.
Unfortunately, the prevalence of these infections continues to rise and poses a challenge to
healthcare providers. Healthcare associated infections due to poor hand hygiene has been linked
to an unacceptably high level of morbidity, mortality and healthcare costs.1 In developing
countries it’s prevalence is found to be as high as 19%.2
Previous studies have shown that hand hygiene compliance among healthcare workers is
generally low.3 Further increase in compliance is difficult to sustain, although the World Health
Organization (WHO) has compiled guidelines in this regard in order to reduce the prevalence of
health care associated infections.3 Furthermore, many studies done to assess the knowledge,
attitudes, compliance and reasons for non-adherence to hand hygiene guidelines have found that
compliance with hand hygiene protocols by health care workers (HCW) is poor4,5,6 due to several
constraints, including heavy work load, high number of clinical procedures and skin conditions
of the HCW.7,8 An alarming revelation was that compliance was found to be worst before high-
risk procedures.5,9
In Asia there is a paucity of studies10,11,12 exploring this subject, although the prevalence of
health care associated infections is high in this region. In Sri Lanka, a study13 conducted at the
National Hospital of Sri Lanka (NHSL), showed that more than 60% of the nursing staff had
substandard practices when it came to aseptic techniques including hand washing. It was also
shown that nursing students, less experienced nurses and those who had recently got their
knowledge updated were more likely to have better compliance with aseptic techniques. Work
overload at NHSL and shortage of equipment were the main problems which were identified. In
Anuradhapura Teaching Hospital,14 although ICU staff had adequate knowledge, the majority of
them had poor attitudes and practices regarding hand hygiene. In this study, the majority were
dissatisfied with the facilities available for hand hygiene.
Most of these studies have explored the knowledge, attitudes and practices of doctors and nurses
with only a few including nursing students. The primary training of these groups is the
responsibility of the faculty and the hospital where they receive their initial training. We believe
a much needed study would be to explore the effectiveness of undergraduate training programs.
This would be useful in identifying gaps in knowledge, poor attitudes and substandard practices
to improve existing training programs and enhance good practices and work ethics in the future.
Method
Setting and Study Population
Medical and nursing students from the Faculty of Medical Sciences, University of Sri
Jayewardenepura who had started clinical training at the Colombo South Teaching Hospital and
Sri Jayewardenepura General Hospital were enrolled in this study. The investigator visited
groups of students and explained the nature of the study. Verbal consent was obtained from
those who volunteered to participate.

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Study Design
This was a questionnaire based cross sectional study. Ethical clearance for the study was
obtained from the Ethical Review Committee of the University of Sri Jayewardenepura. A self
administered questionnaire was used which consisted of 5 parts; demographic information,
assessment of knowledge, attitudes, practices and availability of facilities. Knowledge was
assessed using 25 questions which included multiple choice and “yes” or “no” questions.
Attitudes were measured using 10 questions where the respondents were given the option to
select on a 1 to 7 point scale between strongly agree and strongly disagree. Practices and
facilities were assessed in a similar way using 6 and 8 questions respectively.
A scoring system was used where 1 point was given for each correct response to knowledge,
positive attitudes, good practices and satisfaction with facilities. 0 was given for incorrect
knowledge, negative attitudes, poor practices and dissatisfaction with facilities. A score of more
than 75% was considered good, 50-74% moderate and less than 50% poor. Different Knowledge
Attitudes and Practices (KAPs) studies have used different analytic methods. In our study we
used descriptive statistics by use of percentages for each of the responses given. The cut off
values to determine good, moderate and poor levels were taken from previously published
studies with some modification to suit our purpose.14,15 Data was analyzed using Microsoft
EXEL 2010 software. The two sample equal variance T-test was used to check for statistically
significant differences between the two study populations, namely medical and nursing students,
assuming that both groups had equal variance. A p value less than 0.05 was considered
significant.
Results
There were a total of 289 study participants (196 medical students and 93 nursing students).
When considering the total study group, a majority (81%, 232 out of 289) had claimed to have
received formal training in hand washing. A significant difference (p<0.001) was observed
between medical (142 of 196, 72.4%) and nursing (90 of 93, 96.7%) students who had received
formal training in hand hygiene. However, when asked about the correct technique of hand
washing, 187 of 196 medical students (95.5%) and 92 of 93 nursing students (98.9%) said they
knew the correct technique of hand washing.
Knowledge on hand hygiene
The knowledge on hand hygiene was moderate (224 of 289, 77%) among the total study
population. Only 9% of participants (26 of 289) had good knowledge regarding hand hygiene.
Nursing students had significantly better knowledge than medical students. (p= 0.023) [Figure 1
A] The percentages of correct responses of the two groups of students to the individual
questions on hand hygiene knowledge are given in Table 1.

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Figure 1: Comparison of knowledge, attitudes, practices and satisfaction with facilities
between medical and nursing students
Medical Students Nursing Students Medical Students Nursing Students
*P=0.023
Good Moderate Poor
2
Attitudes on hand hygiene
When assessed for attitudes, overall the results were disappointing as the majority of students
had poor attitudes. However nursing students had significantly (p<0.05) better attitudes (52%)
compared to medical students (16%) as shown in Figure 1 B. The percentages of correct
responses of the two groups of students to the individual questions on hand hygiene attitudes are
given in Table 2.
A-Knowledge (p=0.023) *, B- Attitudes (p=7.47 x 10-8)**, C- Practices (P=4.6 x 10-20)**, D- Satisfaction with facilities
(P=0.0002)**. Significance (p value) calculated using students t Test. Significant difference between medical and nursing
students (P<0.05) is indicated by *, or highly significant difference ( P<0.001) is indicated by **.
A
B
C
p=0.023 *
P<0.001 **
P<0.001 **
P<0.001 **

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Table 1: Comparison of knowledge in medical and nursing students on each question
Medical students
n=196
Nursing students
n=93
P value
K1
Which of the following is the main route of transmission of potentially
harmful germs between patients (Health care workers hands when
not clean)
142
72.4%
68
73.1%
NS
K2
What is the most frequent source of germs responsible for health
care associated infections? (Germs already present on or within the
patient)
89
45.4%
25
26.9%
** 0.0025
Hand hygiene actions that prevent transmission of germs to the patient?
K3
Before touching a patient(yes)
183
93.3%
92
98.9%
NS
K4
Immediately after risk of body fluid exposure(yes)
158
80.6%
78
83.8%
NS
K5
After exposure to immediate surroundings of a patient(no)
57
29.1%
28
30.1%
NS
K6
Immediately before a clean/aseptic procedure(yes)
166
84.7%
84
90.3%
NS
Which of the following hand hygiene actions prevents transmission of germs to the health care worker?
K7
After touching a patient(yes)
185
94.4%
93
100%
*0.02
K8
Immediately after a risk of body fluid exposure(yes)
176
89.7%
85
91.4%
NS
K9
Immediately before a clean/aseptic procedure(no)
96
48.9%
57
61.3%
*0.05
K10
After exposure to the immediate surroundings of a patient(yes)
151
77.0%
76
81.7%
NS
Which of the following statements on alcohol-based hand rub and hand washing with soap and water are true ?
K11
Hand rubbing is more rapid for hand cleansing than handwashing
(true)
143
72.9%
76
81.7%
NS
K12
Handrubbing causes skin dryness more than handwashing (false)
62
31.6%
19
20.4%
NS
K13
Handrubbing is more effective against germs than handwashing
(false)
90
45.9%
32
34.4%
*0.01
K14
Handwashing and handrubbing are recommended to be performed in
sequence (false)
71
36.2%
13
14.0%
NS
K15
What is the minimal time needed for alcohol based hand rub to kill
most germs on your hands ?(20 seconds)
68
34.6%
23
24.7%
NS
Which type of hand hygiene method is required in the following situations ?
K16
Before palpation of the abdomen rubbing
53
27.0%
36
38.7%
*0.02
K17
Before giving an injection rubbing
47
23.9%
28
30.1%
NS
K18
After emptying a bed pan washing
134
68.4%
74
79.5%
*0.02
K19
After removing examination gloves rubbing/washing
136
69.4%
77
82.7%
NS
K20
After making a patients bed rubbing
60
30.6%
12
12.9%
**0.0005
K21
After visible exposure to blood washing
92
46.9%
54
58.0%
*0.03
Which of the following should be avoided, as associated with increased likelihood of colonization of hands with harmful germs ?
K22
Wearing jewellery (yes)
153
78.0%
90
96.8%
**0.0001
K23
Damaged skin (yes)
184
93.8%
86
92.4%
NS
K24
Artificial fingernails (yes)
158
80.6%
84
90.3%
*0.04
K25
Regular use of a hand cream (no)
116
59.1%
67
72%
NS
Correct answer to each response is given within brackets. Significance calculated using student T-test
*p<0.05 (Significant), **p<0.001 (highly significant), NS (Not significant)

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Table 2: Comparison of attitudes among medical and nursing students on each question.
Significance calculated using student T-test
*p<0.05 (Significant), **p<0.001 (highly significant), NS (Not significant)
Practices of hand hygiene
When assessed for hand hygiene practices, we found that only 5.53% had good practices, while
26.9% had moderate practices and the majority (67%) had poor hand hygiene practices. Nursing
students had better practices than medical students and the difference was statistically significant
(p<0.05).[Figure 1, C] The percentages of correct responses of the two groups of students to the
individual questions on hand hygiene practices are given in Table 3.
Satisfaction regarding facilities available for hand hygiene.
The satisfaction of medical students and nursing students regarding the overall facilities available
for hand hygiene was reported as poor by 76% medical students and 61% nursing students.
However the nursing students had more significant satisfaction with the facilities than the
medical students.(P=0.0002). [Figure 1, D] The percentages of responses of the two groups of
students to the questions regarding satisfaction with facilities are given in Table 4.
Medical students
n=196
Nursing students
n=93
P value
A1
I adhere to correct hand hygiene practices at all times
41
20.9%
58
62.4%
**<0.001
A2
I have sufficient knowledge about hand hygiene
70
35.7%
69
74.1%
**<0.001
A3
Sometime I have more important things to do than hand
hygiene
41
20.9%
33
35.5%
*0.004
A4
Emergencies and other priorities make hygiene more
difficult at times
16
8.1%
5
5.4%
NS
A5
Wearing gloves reduce the need for hand hygiene
50
25.5%
36
38.7%
*0.01
A6
I feel frustrated when others omit hand hygiene
54
27.5%
51
54.8%
**<0.001
A7
I am reluctant to ask others to engage in hand hygiene
39
19.8%
14
15. 0%
NS
A8
Newly qualified staff has not been properly instructed
in hand hygiene in their training
52
26.5%
46
49.5%
**<0.001
A9
I feel guilty if I omit hand hygiene
77
39.3%
64
68.8%
**<0.001
A10
Adhering to hand hygiene practices is easy in the
current setup
53
27%
43
46.2%
*0.008

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Table 3: Comparison of the correct responses to hand hygiene practices of medical and
nursing students.
Significance calculated using student T-test
*p<0.05 (Significant), **p<0.001 (highly significant), NS (Not significant)
Table 4: Comparison of satisfaction of facilities between medical and nursing students.
Medical students
n=196
Nursing students
n=93
P value
F1
Are you satisfied with the facilities available for hand hygiene
*yes
113
57.6%
57
61.3%
NS
Satisfaction with the availability of
F2
Infection prevention notices
40
20.4%
43
46.2%
**<0.001
F3
Soap/antiseptic and water for hand washing
48
24.5%
44
47.3%
**<0.001
F4
Alcohol rub
29
14.8%
24
25.8%
*0.01
F5
Paper/clothes for drying hands
23
11.7%
23
24.7%
*0.002
F6
Availability of gloves
64
32.6%
27
29%
NS
F7
Number of sinks with running water
64
32.6%
38
40.8%
NS
F8
Training programmes on hand Hygiene conducted by the hospital
19
9.7%
29
31.2%
* <0.001
Significance calculated using student T-test
*p<0.05 (Significant), **p<0.001 (highly significant), *p<0.05, NS (Not significant)
Discussion
Compliance of health care workers to adhere to correct hand hygiene are reported to be poor in
Sri Lanka as well as other countries.1,13,14 However hand hygiene is a single most effective
preventive measure against hospital acquired infections, and can contribute to shorter hospital
stay, reduction in patient morbidity and health care costs.1 It is important to carry out training
programmes on hand hygiene regularly for health care workers as it has been associated with
increased compliance to hand hygiene practices and reduction of infection.16,17 Our study group
consisted of final year medical and nursing students undergoing primary training. It is important
Medical students
(n=196)
Nursing students
(n=93)
P value
P1
Sometime I miss out hand hygiene simply because I forget it
32
16.3%
43
46.2%
**<0.001
P2
Hand hygiene is an essential part of my role
92
46.9%
78
83.8%
**<0.001
P3
The frequency of hand hygiene required makes it difficult for me to
carry it out as often as necessary
12
6.1%
26
27.9%
**<0.001
P4
Infection prevention team have a positive influence on my hand hygiene
41
20.9%
51
54.8%
**<0.001
P5
Infection prevention notice boards remind me to do hand hygiene
52
26.5%
49
52.7%
**<0.001
P6
It is difficult for me to attend hand hygiene courses due to time
pressure
22
11.2%
28
30.1%
**<0.001

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to instill correct hand hygiene practices, good attitudes and correct knowledge regarding hand
hygiene during the primary training..
In our study, both study groups had moderate knowledge on hand hygiene, which was a positive
finding. However it is important to address the gaps of knowledge with regard to sources and
transmission of germs and appropriate methods of hand hygiene during their training. Seventy
two percent of all participants knew that unhygienic hands of HCWs were the main route of
transmission in a health care facility (HCF). However, only 45% of medical students and 27% of
nursing students were aware that the main source of germs in a HCF was from patients, with
medical students having significantly better knowledge in this aspect.
Use of alcoholic hand rub solutions or gels has been shown to be effective for hand antisepsis.19
However the availability of hand rub solutions in hospitals are still unsatisfactory. In our study,
75% were aware that hand rubbing is more rapid for hand cleansing. Knowledge about hand
washing as a more effective method was found to be significantly better among medical students
when compared to the nursing students. An unexpected finding was that only few medical and
nursing students (35% and 25% respectively) knew that 20 seconds is the minimum time
required for effective hand hygiene as documented in the WHO guideline.3 Both groups had poor
knowledge regarding the correct method of use prior to palpation of abdomen (31%), giving an
injection (26%) and after making a patient’s bed (25%). It is important to address this during
future clinical training sessions. Both medical and nursing students had a good knowledge (69%,
83% respectively) of the proper method of hygiene following removal of examination gloves.
However the overall correct responses regarding appropriate use of hand rub and hand washing
was unsatisfactory and there were several gaps in their knowledge with regard to the accurate
procedure. One of the reasons may be due to unavailability of hand rub solution in the hospital
for medical and nursing students as shown in Table 4. It has been shown that increased
compliance to hand hygiene can be achieved by making the hand rub solutions available at the
bedside of patient.16
In our study, nursing students showed better attitudes towards hand hygiene than medical
students. A majority (74%) of nursing students thought they had sufficient knowledge about
hand hygiene compared to just 35% of medical students. This shows the need to conduct hand
hygiene sessions for medical students regularly. Further, a significantly higher percentage of
nurses (62.4%) reported adhering to correct hand hygiene methods compared to just 20% of
medical students. In our study, 26% medical students and 39% nursing students thought that
wearing gloves could replace hand hygiene. More nursing students (69%) claimed that they felt
guilty about omitting hand hygiene as compared with medical students (39%) as shown in [Table
2. Although these nursing students had a better overall attitudes regarding hand hygiene, they did
not recognize important practical aspects such as the importance of hand hygiene after preparing
a patient’s beds. The nursing students also were more satisfied with the facilities available. It
may be hypothesized that nursing students have better access to facilities than medical students.
Dissatisfaction with facilities available for hand hygiene was high among the study group. Only
a few of the respondents (27% medical students and 46% nursing students) felt that adhering to
hand hygiene practices in current practice was easy. In order for the students to develop good

23
practices regarding hand hygiene, it is important to make proper hand hygiene facilities
available. When these students are facing situations requiring urgent patient care, they are more
likely to omit hand hygiene practices when facilities are not easily accessible to them. Increasing
the supplies necessary for hand washing and institutional support is essential in combating
substandard practices in hand hygiene. We propose that a quantitative measure of hand hygiene
facilities be done to better assess the available resources. An ideal follow-up of this study would
be to implement certain interventions and reassess the same groups to look for an improvement.
On the other hand, it is also important to improve the current training programmes targeting
hand hygiene practices in medical and nursing students. Previous studies have shown that self
reported compliance of hand hygiene is higher than the actual compliance during the working
shift. However, having regular hand hygiene campaigns, displaying posters and encouraging
peers to remind colleagues of hand hygiene has been shown to improve the compliance of HCWs
significantly.16 Our findings are in agreement with previous observational studies which found
that nurses had better hand hygiene practices than doctors.7,17 Being a doctor rather than a nurse
is an observed risk in non-adherence to hand hygiene.3 For nursing students, infection control is
taught in the first year of their nursing curriculum at Sri Jayewardenepura University.
Furthermore these students’ start their ward training in the first year and they may be getting
better exposure to correct hand hygiene techniques regularly from a very early stage. This may
be the reason that nursing students fared better than medical students in most areas, including
better attitudes and practices which is a positive finding towards proper nursing practices in the
future.
Our study highlights that it is important to improve the current training programs targeting hand
hygiene practices among medical and nursing students. Hand hygiene training sessions may need
to be conducted more frequently for medical students with continuous monitoring and
performance feedback to encourage them to follow correct hand hygiene practices. As doctors
and nurses are the two key players in the health care team, it is important to provide the best
appropriate knowledge and proper training regarding preventive practices of infectious diseases.
It has been shown that physician compliance with proper hand hygiene practices can be
improved by personal encounters, direct meetings with the infectious disease physician and
videotaped presentations.18 We recommend that the infection prevention team of the hospitals
get more involved with student training and the updating of infection prevention notices.
Conclusion
The students had moderate knowledge on hand hygiene. However, attitudes, practices and
satisfaction of facilities of medical and nursing students were unsatisfactory. The study shows
the need for further improvement of the existing hand hygiene training programs to address the
gaps in knowledge, attitudes and practices. Further display of infection prevention notices, easy
access to hand hygiene facilities at the training centers and active involvement of staff to
emphasize the importance of correct hand hygiene as well as encouraging students to follow
good hand hygiene practices will be useful in increasing hand hygiene compliance among these
students. This will improve hand hygiene practices of fully qualified doctors and nurses in the
future.

24
Acknowledgements
We wish to thank all our study participants for volunteering, Miss Sujatha Senevirathne
(Coordinator, B. Sc. Nursing) and other staff members of the BSc. Nursing Program, Faculty of
Medical Sciences, University of Sri Jayewardenepura, and Dr. Dulnie Wijeweera for their kind
cooperation and support.
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