In the context of the current coronavirus pandemic situation, hand hygiene is a key infection prevention measure to help combat transmission both in the healthcare setting and in the community [7]. Since the legal requirement concerning hand hygiene standards in China was instituted in 2009, compliance with appropriate hand hygiene practices in medical facilities has gradually increased [8], but still remains suboptimal [9,10], similar to other countries worldwide [11].
We consider that our findings can be considered as a true representative sample of the awareness of hand hygiene basic knowledge across the main three regions of China. The overall 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 WHO “My 5 moments for hand hygiene” concept revealed an accuracy rate above 91.96%, although the results of an 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 in China believe that wearing gloves can replace hand hygiene, as highlighted in a recent review [12], and this erroneous notion must be corrected rapidly. The correct response rate was poor for several other notions and suggests that a more in-depth evaluation is needed to understand and address the barriers to an awareness of these concepts.
The correct response rate was higher in Eastern and Central China than Western regions. Based on these data, differences of awareness of the importance of hand hygiene may help to trigger improvement at the hospital administrative level, particularly in the Western region. Staff awareness was best in primary care hospitals and showed that they have been attentive to the importance of hand hygiene in recent years, followed by non-registered and tertiary care hospitals, while awareness in secondary facilities was poor. This is unexpected and inconsistent with the research by Shen and colleagues [10] and slightly different from the results of Xu and colleagues and Qin and colleagues [4,9]. This finding is important and reveals that 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.
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 and particularly poor among nursing staff [13]. This was unexpected and did not correlate with previous reports [14]. 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. It is difficult to accept that infection control personnel were less knowledgeable, but this has already been documented elsewhere [15]. 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. Of note, the 2019 updated recommendations of the Ministry of Health address the shelf life duration of handrub/gel and other awareness points raised in our questionnaire [16]. WHO has proposed "Clean Care is Safer Care" as a priority initiative to improve medical quality in the 21st century, but this cannot be achieved if major efforts are not made to continue to improve the compliance of medical staff with optimal practices.
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, are not homogenous. Second, there is a lack of investigation of some other aspects of hand hygiene, e.g. surgical hand antisepsis and knowledge of multimodal intervention strategies. Third, there was heterogeneity across the different regions regarding the types of hospital and staff categories, with less primary care hospitals involved, particularly in Central and Western China.
In summary, large differences exist in the basic knowledge of hand hygiene in healthcare facilities in different regions in China and basic knowledge needs to be more extensively promoted in secondary hospitals and particularly in infection prevention and control units.