The global antimicrobial drug resistance situation remains extremely preoccupying and transmission by the hands of healthcare workers has been identified as a major cause of the rapid increase of multidrug-resistant bacteria[7]. Several studies have confirmed that improving the hand hygiene compliance rate among healthcare workers can effectively reduce the incidence of healthcare-associated infection[8, 9]. In addition, in the context of the current pandemic situation related to the spread of the new coronavirus (SARS-CoV-2), hand hygiene is a key infection prevention measure to help combat transmission both in the healthcare setting and in the community[10]. Since the legal requirement concerning hand hygiene standards in China was instituted in 2009, as well as the continuous development of hand hygiene promotion over the past decade, compliance with appropriate hand hygiene practices in medical facilities has gradually increased[11], but still remains suboptimal[12, 13], similar to other countries worldwide[14].
We consider that our survey results comprising 45,455 healthcare workers in the main three regions of China can be considered as a true reflection of the awareness of hand hygiene basic knowledge in the country to a large extent. These findings also provide national health authorities with valuable scientific data for the development of further targeted training on hand hygiene to improve the implementation rate of recommendations within facilities. The average correct response rate to all 10 questions was 81.55%. However, the overall accuracy of respondents to all 10 questions was only 26.53%.
The correct response rate to the question related to the knowledge and understanding of the “My 5 moments for hand hygiene” concept revealed an accuracy rate above 91.96%, although the results of the earlier national hand hygiene survey reported by Xu and colleagues were slightly lower for this specific hand hygiene knowledge point[4]. The misunderstanding related to this question may be that many healthcare workers believed that wearing gloves can replace hand hygiene. Indeed, the review of Sun and Gao highlighted that several studies revealed that appropriate hand hygiene practices had been replaced by glove use in China[15] and this erroneous notion must be corrected rapidly. Although the responses to questions 10, 8 and 7 (“My 5 moments for hand hygiene” concept, glove use and hand hygiene, and knowledge of materials used for hand hygiene) were approximately 90%, the question related to the indications and knowledge of other aspects of hand hygiene practices was relatively low (71.00%).
The highest correct response rate (96.25%) concerned the relationship between hand hygiene and the acquisition of healthcare-associated infection, whereas the response investigating awareness related to the actual concept of hand hygiene was only 65.20%. Another inconsistency of awareness related to microbiota on hands. The correct response to the question on the characteristics of resident flora on hands was high (96.35%). However, the correct response concerning the characteristics of transient flora on hands was only 84.60%, and the response concerning the effectiveness of alcohol-based handrub on transient flora even lower (81.21%). Only a mere 48.04% of participants responded correctly to the question on the effect of handrubbing on the number of microbiota on hands. Therefore, this suggests that a more in-depth evaluation is needed to understand and address the factors that have impeded an awareness of these notions.
Logistic analysis showed that the correct response rate was higher in Eastern and Central China than Western regions. In 2018, the number of healthcare workers per 1000 population in the Eastern, Central and Western regions of China was 7.2, 6.2 and 6.9, respectively, and the hospitalization rate of the population in 2018 was 16.5%, 18.7% and 20.3%, respectively[5]. Based on these data, differences of awareness of the importance of hand hygiene may help to act as a guide to drive improvement at the hospital administrative level, particularly in the Western region.
Our analysis of the basic knowledge of hand hygiene in different types of hospitals suggested that staff awareness was best in primary care hospitals, followed by non-registered and tertiary care hospitals, while awareness in secondary facilities were poor. This is unexpected and inconsistent with the research by Shen and colleagues[13] and slightly different from the results of Xu and colleagues and Qin and colleagues[4, 12]. This may be related to the number and scope of knowledge points on hand hygiene addressed in our questionnaire. Our survey results showed that primary care hospitals have been attentive to the spread of hand hygiene knowledge in recent years and, consequently, the awareness rate has greatly improved. Tertiary hospitals have more training opportunities, stricter management and a stronger sense of the importance of hand hygiene. The weakest link lies in secondary hospitals where training is not in place and the emphasis on prevention measures for healthcare-associated infection is insufficient. This must be the key target for hand hygiene education in the future in China.
Knowledge of hand hygiene was poorest among nurses compared to other healthcare categories. Interestingly, the awareness level of logistics personnel was greatly improved than previously observed, thus indicating that medical facilities have carried out effective strategies across all categories of healthcare workers to improve the weak medical knowledge of this profession in recent years. Although nurses and physicians have the most clinical interaction with patients, some aspects of their knowledge of the basic concepts surrounding hand hygiene were sadly lacking. This was unexpected and did not correlate with the previous reports by Deng and colleagues and Xiao and colleagues[16, 17] In terms of microbial knowledge of hand flora and correct hand hygiene practices[17], knowledge was rather poor, especially concerning the use of sterile gloves to replace hand hygiene, as previously reported[18].
Healthcare workers in the outpatient/emergency room performed best among the different departments, while those in gynaecology/obstetrics, paediatrics and infection control units performed poorly. For the gynaecology/obstetric departments where more clinical procedures occur, hand hygiene should be the focus of a specific intervention and awareness-raising strategy. It is difficult to accept that infection control personnel were less knowledgeable, but this has already been documented elsewhere [19]. Our data suggest also that it remains necessary to continue to strengthen hand hygiene training for infection prevention and control staff by developing an occupational license or a professional development programme integrated into the regular educational activities of the various departments, notably for clinical frontline medical staff. In particular, infection prevention and control services in hospitals need to heighten their profile with the full and visible support of the directorate in order to make all staff aware of the importance of their work and its translation into real practice. WHO has proposed "Clean Care is Safer Care" as a priority initiative to improve medical quality in the 21st century [20]. However, this cannot be achieved if major efforts are not made to continue to improve the compliance of medical staff with optimal practices.
Limitations
Our study has some limitations. First, the number of participants in the different regions, as well as the types of hospital, healthcare worker categories, gender and clinical departments, is not homogenous. Second, in terms of the study design, there are some limitations, such as a lack of investigation of some aspects of hand hygiene, e.g. surgical hand antisepsis and knowledge of multimodal intervention strategies for hand hygiene. Third, there was heterogeneity across the different regions regarding the types of hospital and staff categories (e.g. educational background, length of service) with less primary care hospitals involved, particularly in Central and Western China. Finally, the specific issue related to the limited duration of the shelf life of handrub/gel has been updated in the new edition of the CSHH (WS/T 313–2019)[21], and all other points of awareness in our questionnaire will also be included in the updated edition.