Knowledge, Attitude, and Practice of Hand Hygiene among Healthcare Workers during the COVID-19 Pandemic in referral hospitals: A case study from Southern Iran

doi:10.21203/rs.3.rs-3128085/v1

Download PDF

Research Article

Knowledge, Attitude, and Practice of Hand Hygiene among Healthcare Workers during the COVID-19 Pandemic in referral hospitals: A case study from Southern Iran

https://doi.org/10.21203/rs.3.rs-3128085/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Background: Hand hygiene compliance is the simplest, the most important, and the most cost-effective way to prevent and reduce healthcare-associated infections. Its implementation requires adequate knowledge and awareness. This study aimed to assess the knowledge, attitude, and practice of hand hygiene among healthcare workers in referral hospitals of Bushehr province, southern Iran, in 2021.

Method: This is a cross-sectional descriptive-analytical survey of 205 medical staff. A stratified sampling technique was used to select the respondents. They completed the questionnaire, which included demographic information (age, gender, education, etc.) and questions in three sections to assess the level of knowledge, attitude, and practice of medical staff.

Results: The results showed that the mean age of the population studied was 34.18 ± 7.15 years. Of these, 63.9% were female, most of the participants (80.0%) were married, nurses (66.8%), had a bachelor's degree (70.2%), and worked in the COVID-19 wards (51.7%). The mean scores for staff knowledge, attitude, and practice of hand hygiene among the staff were 7.7 ± 2.4 (from 0-12), 69.7 ± 7.1 (from 19-95) and 56.8 ± 9.1 (from 14-70), respectively, indicating relatively adequate knowledge among medical staff. In the non-COVID-19 wards, staff compliance with hand hygiene was higher than in the COVID-19 wards (P<0.001).

There was a direct relationship between hand hygiene knowledge, attitude, and practice scores and education, gender, occupation, and type of employment (P value <0.05).

Conclusion: Due to staff shortages in hospitals and overcrowding in emergency departments and wards such as COVID-19, hand hygiene is usually not practiced because staff believe that their duties of caring for patients are more important than cleaning their hands, or that wearing gloves instead of washing their hands is sufficient. Ongoing infection control education programs for healthcare workers, especially medical staff, are essential.

knowledge

attitude

practice

hand hygiene

healthcare workers

COVID-19

Iran

Healthcare-associated infections occur as a result of hospitalization. They do not have an infection at the beginning of their hospital stay. Rather, patients become infected in hospital. Healthcare-associated infections occur at least 48 to 72 hours after the start of hospitalization. The risk of these infections occurs even in the best equipped and most modern hospitals in developed countries (1).

Healthcare-associated infections are undoubtedly one of the most important problems in the healthcare sector, with high economic and social costs. Understanding how infections are transmitted can help break the chain of infection. The five most common modes of microbial transmission are direct contact, droplet spread, airborne, vehicle-borne, and vector- borne, of which direct contact is the most important (2). In developed countries, 5–10% of hospitalized patients acquire healthcare-associated infections (HAIs), rising to around 25% in developing countries (3). Hands have the most contact with hospital surfaces, medical instruments, and patient's bodies (4).

The hand is therefore the most important route of infection transmission. For this reason, hand hygiene has been emphasized (5–8).

Hand contamination is a major contributor to healthcare-associated infections (9). Currently, the most effective and least expensive method of infection control, as recommended by the WHO, is hand hygiene, particularly hand washing before and after each patient contact (10).

Because of their constant contact with patients, staff, and instruments, nurses play an important role in identifying and controlling the sources of hospital-acquired infections (11).

Staphylococcus aurous carrier status, found in 21–91% of healthcare workers, is associated with outbreaks of this infection, particularly in intensive care units. Failure to wash hands has led to transmission of the bacteria (12). Nasiriani's study of the microbial contamination of the hands of Intensive Care Units workers found that 64% of them were infected with transient flora (13). Studies show that the willingness to wash hands is low in many healthcare settings (14, 15). It is also noted in many reports that, despite the availability of basic facilities, the willingness of workers to wash their hands was low (16). Studies have shown that hand hygiene performance is lower in ICUs (30 to 40 percent) than in other departments (50 to 60 percent), and the level of hand hygiene compliance is lower among physicians (32 percent) than among nurses (48 percent) (17). According to the World Health Organization, by 24October 2021, more than 243 million people worldwide will be infected with coronavirus and 4.9 million people will have died from the disease. This virus can survive for three days on surfaces in the form of secretions (18). Given the persistence of the Coronaviruses in the environment, preventive measures such as hand washing with soap and water or disinfectant solution can break the cycle of infection (19). Therefore, preventive behaviors are necessary to reduce the severity of complicated COVID-19 cases (20, 21).

There are a number of reasons why hand hygiene may not be performed properly, including lack of awareness, the misconception that gloves eliminate the need for hand hygiene, lack of motivation, lack of equipment, and cultural issues (22, 23).

Therefore, improving hand hygiene is the key factor in preventing HAIs (8). Despite the increase in hand hygiene protocols in order to reduce the rate of infection, hand hygiene remains weak in some medical groups (17). Therefore, this study aimed to investigate the knowledge, attitude, and practice of hand hygiene among healthcare workers of referral hospitals of Bushehr Province in 2021during the COVID-19 pandemic.

This descriptive-analytical cross-sectional study was conducted to determine hand hygiene knowledge, attitude, and performance of among healthcare workers of Bushehr referral hospitals during the COVID-19 pandemic in 2021. Using a stratified sampling method, 205 healthcare workers were recruited to complete the valid and reliable questionnaire. There are two referral hospitals in the center of Bushehr province. Both of them were included in the study (Shohadaye-khalije-Fars center and coronary center).

According to the study by Najafi et al. (24), the correlation coefficient between performance score and hand hygiene attitude was 0.2, so a sample size of 198 was calculated, taking into account a type 1 error probability of 0.05 and a type 2 error probability of 0.2.

Taking into account a drop-out rate of 10%, the questionnaire was distributed to 218 employees. The data collection instrument used in this study was a questionnaire that consisting of two parts; A checklist of demographic and occupational characteristics (including age, gender, marital status, level of education, employment status, years of service, type of employment, job title, and department of service) and the second part was the questionnaire measuring staff knowledge, attitude, and performance of hand hygiene among the staff in five situations (immediately before touching a patient, before performing an aseptic task, after risk of exposure to body fluids, after touching a patient or their immediate environment, and after touching the patient environment) (25).

Knowledge questions consist of 12 items with 4 options, where the correct option is worth 1 point and the incorrect option is worth 0 points (scoring range 0–12). Attitude questions consist of 19 items based on a 5-point Likert scale ranging from strongly disagree = 1 to strongly agree = 5 (scoring range 19–95). Performance questions consist of 14 items with a 5-point Likert scale (never = 1, rarely = 2, sometimes = 3, usually = 4, always = 5) (range is 14–70).

To measure hand hygiene knowledge, attitude, and performance, an average score is calculated and a higher average score indicates better hand hygiene knowledge, attitude, and performance.

The study by Najafi Qazaljeh et al. (24) confirmed the validity and reliability of the questionnaire. The Cronbach's alpha of the total hand hygiene questionnaire was 0.83 and the Cronbach's alpha of the knowledge, attitude, and performance questionnaire were 0.83, 0.87 and 0.91 respectively. The objectives and procedure of the study were explained to the hospital authorities. Staff were then asked to complete the questionnaires carefully. The questionnaire was also designed in electronic form due to the conditions of the Covid-19 epidemic. Descriptive statistics (absolute and relative frequency, mean and standard deviation) and analytical statistics (T-test, ANOVA, and Pearson correlation coefficient) were used to analyze the data using SPSS software version 22.

Ethics:

This study was approved by the Ethics Committee of Bushehr University of Medical Sciences with the ethical code: IR.BPUMS.REC.1400.062. Participants in the study were assured that their information would remain completely confidential. Informed consent was also obtained. All the participants were performed in accordance with relevant guidelines and regulations.

A total of 205 staff completed the questionnaires (The response rate was 94%). The demographic information of the participants is shown in Table 1.

Table 1

Distribution of demographic and occupational characteristics of medical personnel working in the referral hospitals in Bushehr province
Variable		Frequency	Percent
Gender	Female	131	63.9
Gender	Male	74	36.1
Job	physician	17	8.3
	nurse	137	66.8
	Health care personnel	21	10.2
	midwife	13	6.3
	Operating Room Technician	17	8.3
Marital status	Single	41	20.0
Marital status	Married	164	80.0
Degree	diploma	15	7.3
	Associate Degree	4	2.0
	bachelor	144	70.2
	Master's degree	25	12.2
	PhD and above	17	8.3
Department of service	ICU and CCU	41	20.0
	Sections	107	52.2
	Operating room	16	7.8
	emergency	35	17.1
	Other sections	6	2.9
Type of employment	commitment	24	11.7
	contractual	54	26.3
	Recruited personnel	36	17.6
	formal	85	41.5
	Other employment	6	2.9
Total		205	100

The results showed that the mean age of the population studied was 34.18 ± 7.15 years. There were 131 females (63.9%) and 74 males (36.1%), and most participants (80.0%) were married. Most of the staff were nurses (66.8%) and most of them had a bachelor's degree (70.2%). The majority had less than 8 years of work experience and the average work experience was 7.33 years. By ward, 51.7% worked in COVID-19 wards and 48.3% in the non-COVID-19 wards.

Table 1: Distribution of demographic and occupational characteristics of medical personnel working in the referral hospitals in Bushehr province

The results showed that although 10.7% used alcohol-based hand rubs alone and 3.4% used hand washing alone, most study participants (85.9%) used both methods for hand hygiene.

The mean scores for staff knowledge, attitude, and practice of hand hygiene among the staff were 7.7 ± 2.4 (out of 0–12), 69.7 ± 7.1 (out of 19–95), and 56.8 ± 9.1 (out of 14–70) respectively, indicating relatively adequate knowledge among medical staff. The majority of respondents had knowledge (61.4% above the mean), favorable attitudes (52.4% above the mean) and good hand hygiene practices (53.1% above the mean) about hand hygiene during the COVID-19 pandemic.

Although the level of knowledge in the COVID-19 wards was above the average at 51.1%, it was 74.7% in the non-COVID-19 wards. Although, the attitude rate of 36.0% in the COVID-19 wards was above the average, this rate was 71.1% in the non-COVID-19 wards. Although, the practice rate of 35.7%, was above the mean in the COVID-19 wards, this rate was 69.3% in the non-COVID-19 wards. The results of the Pearson correlation coefficient test are presented in Table 2.

Table 2

Relationship between knowledge and attitude and performance of medical personnel
Variables	Pearson Correlation	P-value
Knowledge and attitude	0.485	< 0.001
Knowledge and performance	0.028	0.716
Attitude and performance	0.399	< 0.001

Table 2: Relationship between knowledge and attitude and performance of medical personnel

According to the results, there is a meaningful and significant relationship between knowledge and attitude (P-value < 0.001). This means that as people's knowledge score increases, so does their attitude score. There is also a statistically significant relationship between attitude and performance (P value < 0.001). This means that as people's attitude increases, so does their performance.

Table 3 shows the relationship between individual and demographic variables with knowledge, attitude, and performance. There was a significant relationship between the mean knowledge, attitude, and performance scores of the study participants according to their level of education (P < 0.05). The knowledge, attitude and performance scores of the participants with doctoral degrees were higher than those of the other educational groups. There was a significant relationship between gender and staff performance, with women performing better than men (P value = 0.003). There was a significant relationship between age and staff attitudes. That is, the higher the age, the higher the reported attitude score (P value < 0.001). There was also a significant relationship between marriage and staff attitude. The attitude score was higher for married people (P value = 0.042).

Table 3

The relationship between individual and demographic variables with knowledge, attitude and performance
Variable		Knowledge		attitude		performance
Variable		mean ± Standard deviation	P-value	mean ± Standard deviation	P-value	mean ± Standard deviation	P-value
gender	Female	7.80 ± 2.28	0.615	7/21 ± 70/00	0.499	58.19 ± 8.60	0.003
gender	Male	7.61 ± 2.51	0.615	7/20 ± 69/26	0.499	54.08 ± 9.43	0.003
Marital status	Single	7.61 ± 2.42	0.757	67.61 ± 6.73	0.042	55.85 ± 9.22	0.553
Marital status	Married	7.75 ± 2.37	0.757	70.21 ± 7.13	0.042	56.87 ± 9.088	0.553
Degree	diploma	5.53 ± 1.76	0.002	60.58 ± 4.87	< 0.001	47.28 ± 11.50	< 0.001
	Associate Degree	6.00 ± 2.44		7/39 ± 62/00		47.50 ± 15.45
	bachelor	7.88 ± 2.32		69.59 ± 6.51		56.90 ± 8.47
	Master's degree	7.85 ± 1.92		72.92 ± 6.87		60.28 ± 6.79
	PhD and above	80.90 ± 2.87		75.00 ± 6.047		60.85 ± 6.150
Age (correlation coefficient)		r = 0.093	0.226	r = 0.291	< 0.001	r = 0.107	0.146

Table 3: The relationship between individual and demographic variables with knowledge, attitude and performance

Table 4 shows the relationship between job variables and hand hygiene knowledge, attitude, and performance. Based on the results, there was a significant difference between the mean knowledge, attitude, and performance scores of the study participants according to their job and type of employment (P value < 0.05). There was a significant difference between the mean knowledge, attitude, and performance scores of the study participants according to the COVID-19 wards (P < 0.001). In such a way that the score in the non-COVID-19 wards was higher than in the COVID-19 wards, indicating the low commitment to hand hygiene in the COVID-19 wards.

Table 4

The relationship between job variables and knowledge, attitude and performance
Variable		Knowledge		attitude		performance
		mean ± Standard deviation	P-value	mean ± Standard deviation	P-value	mean ± Standard deviation	P-value
Job	physician	8.90 ± 2.87	< 0.001	06/04 ± 75/00	< 0.001	60.85 ± 6.15	< 0.001
	nurse	7.99 ± 2.23		69.80 ± 6.58		56.44 ± 8.39
	Health care personnel	5.44 ± 1.63		60.39 ± 4.63		48.78 ± 12.43
	midwife	7.07 ± 2.81		73.15 ± 8.36		62.41 ± 6.84
	Operating Room Technician	8.33 ± 1.37		71.06 ± 4.89		61.41 ± 5.76
type of employment	commitment	7.94 ± 2.15	0.010	68.50 ± 24.6		55.10 ± 9.50	0.040
	contractual	6.93 ± 2.54		67.55 ± 7.10		54.38 ± 8.51
	Recruited personnel	7.25 ± 2.30		67.66 ± 6.68		55.35 ± 10.15
	formal	8.42 ± 2.19		19/7 ± 07/72		58.77 ± 8.58
	Other employment	7.40 ± 2.07		71.50 ± 2.58		60.66 ± 9.09
Center	Shohadaye-Khalije Fars	7.34 ± 2.40	< 0.001	68.84 ± 7.49		56.22 ± 9.88	0. 116
Center	Coronary	9.00 ± 1.72	< 0.001	72.97 ± 4.41		58.66 ± 5.63	0. 116
Department	ICU and CCU	8.26 ± 2.58	< 0.001	70.66 ± 5.28		6/27 ± 58/09	0.046
	Sections	7.43 ± 2.27		08/02 ± 68/69		56.27 ± 8.99
	Operating Room	9.09 ± 2.77		72.20 ± 5.94		60.60 ± 5.72
	emergency	7.25 ± 2.17		66.13 ± 6.54		51.41 ± 11.43
	Other sections	7.00 ± 1.73		70.50 ± 3.93		67.16 ± 1.16
COVID-19 department	Yes	7.11 ± 2.59	< 0.001	66.78 ± 6.64		53.07 ± 9.88	< 0.001
COVID-19 department	No	8.43 ± 1.92	< 0.001	73.16 ± 6.27		60.23 ± 6.17	< 0.001
Hand Disinfection	hand rub	7.65 ± 2.13	< 0.001	64.60 ± 5.70		9/18 ± 47/75	< 0.001
	hand wash	3.25 ± 0.95		9/23 ± 61/00		54.50 ± 15.21
	Both of them	7.85 ± 2.31		70.75 ± 6.69		57.96 ± 8.27
work experience (correlation coefficient)		r = 0.010	0.899	r = 0.181	0.013	r = 0.328	< 0.001

Although health workers with more work experience had higher mean scores for attitude and performance (P value < 0.05), there was no significant relationship between work experience and knowledge (P value = 0.899).

Table 4: The relationship between job variables and knowledge, attitude and performance

In the non-COVID-19 areas, staff compliance with hand hygiene was higher than in the COVID-19 areas (P < 0.001).

There was a direct relationship between hand hygiene knowledge, attitude, and practice scores with education, gender, occupation, and type of employment (P value < 0.05).

This study aimed to determine staff knowledge, attitude, and performance in relation to hand hygiene compliance during the coronavirus pandemic.

After the prevalence of COVID-19 in Bushehr Province, the policy makers decided to divide hospital wards into COVID-19 and non-COVID-19. There is an interesting result in this study in the referral hospital.

There was a significant relationship between the mean hand hygiene knowledge, attitude, and performance scores of participants according to the wards (COVID-19 vs. Non-COVID-19 wards). The knowledge, attitude, and performance scores of the participants in the non-COVID-19 wards were higher than those in the COVID-19 wards, indicating that staff compliance with hand hygiene is lower in the COVID-19 wards. Hospitals with low staffing levels and overcrowding in emergency departments and wards such as COVID-19 tend to disregard hand hygiene compliance because the time required to perform patient care duties interferes with the time required to wash hands. They felt that patient care was more important than hands washing (26). They seem to think that wearing gloves is enough, rather than washing their hands. Ongoing training programs for healthcare works, especially medical staff in infection control, are essential.

There was a significant relationship between ward and staff knowledge and performance, with the more sensitive and specializes wards (ICU and the Operating Room), reporting high scores. In the study by Nasimfar et al. (27), the level of hand hygiene performance among students was higher in the ICU and Operating Room than in other wards. Also, in the study by Zia Sheikhul-Islami (38), the level of hand hygiene compliance among healthcare workers in the ICU was 44.5%, which is consistent with the results of the present study.

The results of the present study showed that the participants had a good level of awareness, attitude, and performance in the area of hand hygiene. The studies conducted in this area have found different results in different settings. In the study by Nasimfar et al., the average awareness of hand hygiene among medical students was found to be 47% (27). Similarly, in the study by Adalatdoust etal, 52.3% of the healthcare workers in ICUs had good and very good awareness and the average attitude was 41.37% (28), which is consistent with the results of the present study. Najafi et al. found that the knowledge and practice of hand hygiene among nurses in different setting was low (24). The study by Nair et al investigating hand hygiene knowledge among medical students showed that only 9% of participants had good knowledge of hand hygiene (29), which is not consistent with the results of the present study. It appears that the specific conditions of COVID-19 disease may have affected the level of knowledge, attitude, and performance of the participants.

The results show that there is a statistically significant relationship between knowledge and attitude, and between attitude and performance. There was also a significant difference between the average scores of participants according to their education and type of employment. For example, the knowledge and attitude scores of physicians and formally employed participants were higher than those of other groups. Operating room technicians and midwives also performed better than other occupations. In the study by Awazah et al (30), no significant relationship was found between knowledge and attitude, performance and attitude towards hand hygiene among nurses .There was a positive and significant relationship between knowledge and attitude in the study by Adalatdoust et al. (28), which is consistent with the results of the present study.

In some studies, knowledge levels are often high but their performance is low (31). In an intervention study, Baghai et al concluded that increasing the knowledge of nursing students did not change their behavior (32), which is consistent with this study. In some studies, healthcare workers perceive physicians as role models, but physicians do not see themselves as such (33).

Previous studies mentioned some reasons for low compliance with hand washing guidelines which are presented as follows. Having a role model can also be very effective. Lack of access to equipment, as well as the presence of poor quality equipment, and as a result, skin damage are other reasons that have been mentioned in studies (33). In addition to these cases, the availability and easy access to materials (such as handrails) as well as the necessary equipment can play an effective role in the prevention and control of hospital infections (34). In study by Esfandiari et al. (35) examined the challenges faced by the Iranian healthcare system in addressing the issues related to the prevention and control of HAIs. These include governance and stewardship, resources, safety culture, surveillance and monitoring systems, and inappropriate prescription of antibiotics.

In order to maintain hand hygiene in today's world, there are modern systems for the use of gloves by staff that can improve hand hygiene. These systems include automatic dispensers that provide the right amount of hand rub to people, or they can be dispensed based on video viewing. However, the use of these new systems should be piloted and monitored, and the benefits and cost-effectiveness of these new tools should be carefully evaluated. Advanced systems can also evaluate and provide feedback to staff (36).

According to the results of the present study, the use of towels and the frequency of hand washing with soap and water alone were low but most of the study participants used both methods for hand disinfection. In the study by Salmani et al (37) evaluating the performance of nursing students, hand washing with soap and water was the most commonly used method. Similarly, in the study by Forrester et al. (38), 89.5% of workers preferred washing with soap and water to the use of a sieve solution. However, in the study by Zia Sheikh Al-Islami et al. (39), hand hygiene with an alcohol solution was more common than washing with soap and water.

In the present study, there was an association between gender and hand hygiene performance, with women performing better than men. In the study by Niknejad et al. (40) and Polak et al. (41), women performed hand hygiene better than men.

People with more work experience had a significant difference in terms of average attitude and performance compared to people with less experience and had a higher average score of attitude and performance score, which is consistent with the findings of Hosseinialhashemi's study (42).

It is believed that in order to create desirable effects, all three areas - knowledge, attitude, and performance- need to be strengthened to achieve the desired effects. Awareness alone will not lead to good performance, but attitudes also need to be changed to achieve good performance. Indeed, measures should be taken to improve the attitudes of health workers. A positive attitude should be instilled in staff, which can lead to good and appropriate infection control practice and ultimately improve patient safety. Although the level of staff knowledge, attitude, and performance of staff in relation to hand hygiene is good, it is necessary to provide ongoing training to increase knowledge, reinforce positive attitudes, and correct some poor practices. For example, in the Corona departments, we found that hand disinfection was performed less frequently. This was because they thought they didn't need to disinfect if they wore gloves.

The results of most HAIs studies show that although nurses and other healthcare workers are aware of need and importance of hand washing before and after patient care, and have positive attitudes towards it, their performance in some areas is not good. Ongoing programs should be considered to improve their performance. Control and prevention of infections in developing countries require a comprehensive approach based on improving the structure of care, effective guidelines, behavioral change, and more effective use of equipment (43).

A study by Esfandiari et al. (44) identified stakeholders’ views on HAI control measures in Iran. They explored four main interdisciplinary strategies to control HAIs, including strengthening governance and stewardship; strengthening human resources policies; appropriate prescription and use of antibiotics, and environmental and personal hygiene.

According to the researchers' search, the present study is one of the first studies conducted in Iran and some other countries conducted to investigate staff knowledge, attitude, and performance in relation to hand hygiene compliance during the COVID-19 pandemic. Although most similar studies have been conducted in the country to determine staff knowledge, attitude, and performance regarding hand hygiene, we did not find any study during the COVID-19 pandemic. In addition, an unexpected finding was that staff compliance with hand hygiene was higher in the non-COVID-19 wards than in the COVID-19 wards. One of the limitations of this research was the completion of the questionnaire due to busy work during the pandemic, so we also designed an electronic form.

The results of the study showed that the hospital staff have a good level of awareness, attitude, and performance in hand hygiene, but considering the importance of preventing and controlling HAI infections, it seems necessary to provide training to improve and promote hand hygiene and to correct some misconceptions.

Acknowledgments

We thank the Deputy of Research and Technology of Bushehr University of Medical Sciences for approving and funding this research. The authors would like to thank all the health workers in the teaching hospitals of Bushehr University of Medical Sciences who gave their valuable time to participate in this study. We also thank the Clinical Research Development Center of the Shohadaye-Khalije-Fars Hospital, Bushehr University of Medical Sciences, Bushehr, Iran, for their assistance.

Authors’ contributions

A.E. contributed to the design, implementation, data analysis, interpretation, and writing of the manuscript M.M. contributed to the design, data analysis, interpretation, and writing of the manuscript. A.S. contributed to the implementation, and writing of the manuscript. H.S. (Corresponding Author) contributed to the design, implementation, data analysis, interpretation, and writing of the manuscript. All the authors read and approved the final manuscript.

Funding

This study was approved and funded by the Deputy of Research and Technology of Bushehr University of Medical Sciences with approval code: 1504 and ethical code: IR.BPUMS.REC.1400.062

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Ethics approval and consent to participate

This study has been approved by the Ethics Committee of Bushehr University of Medical Sciences with the ethical code: IR.BPUMS.REC.1400.062. Written informed consent was obtained from all participants and their anonymity was guaranteed. . Participants were informed that their participation was completely voluntary and that they could withdraw at any time. All the participants were performed in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

No conflicts of interest are declared by the authors.

Author details

Atefeh Esfandiari¹, Marzieh Mahmoodi², Asma Seddigh³, Hedayat Salari¹*

1. Department of Health Policy and Management, School of Medicine, Bushehr University of Medical Sciences, Bushehr, Iran

2. Department of Biostatistics and Epidemiology, School of Health and Nutrition, Bushehr University of Medical Sciences, Bushehr, Iran

3. Student Research Center, Bushehr University of Medical Sciences, Bushehr, Iran

Gruda A, Sopjani I. The knowledge, attitudes and practices of nurses toward management of hospital-acquired infections in the university clinical center of Kosovo. Materia socio-medica. 2017;29(2):84.
Viderman D, Khamzina Y, Kaligozhin Z, Khudaibergenova M, Zhumadilov A, Crape B, et al. An observational case study of hospital associated infections in a critical care unit in Astana, Kazakhstan. Antimicrobial Resistance & Infection Control. 2018;7(1):1-9.
Mahfoozpour S, Mosadegh Rad A, Bahadori Monfared A, Torab Jahromi L. Effect of implementation “Nosocomial Infection Management Model” on reduction of nosocomial infections at Hospital of Jahrom: An action research study. Journal of Health Promotion Management (Jhpm). 2015;5(1).
Alaedini M, Paghe AS, Fakhar M, Nasiri E. Implementing infection control principles in medical teaching hospitals of Mazandaran University of Medical Sciences, 2011. Journal of Mazandaran University of Medical Sciences. 2013;23(98):274-80.
Jayasree T, Afzal M. Implementation of infection control practices to manage hospital acquired infections. Journal of Pure and Applied Microbiology. 2019;13(1):591-7.
Saleem Z, Godman B, Hassali MA, Hashmi FK, Azhar F, Rehman IU. Point prevalence surveys of health-care-associated infections: a systematic review. Pathogens and global health. 2019;113(4):191-205.
Chi X, Guo J, Niu X, He R, Wu L, Xu H. Prevention of central line-associated bloodstream infections: a survey of ICU nurses’ knowledge and practice in China. Antimicrobial Resistance & Infection Control. 2020;9(1):1-9.
Alene M, Tamiru D, Bazie GW, Mebratu W, Kebede N. Hand hygiene compliance and its associated factors among health care providers in primary hospitals of Waghimira Zone, Northeast Ethiopia: a mixed study design. Antimicrobial Resistance & Infection Control. 2022;11(1):1-9.
Sureshkumar M, Suriyapraba R, Priyadharsini RI. A Study on Microbial Flora on Skin of Health Care Providers in a Tertiary Care Hospital in Southern India. Journal of Clinical & Diagnostic Research. 2018;12(11).
Demmler-Harrison GJ. Healthcare-associated viral infections: considerations for nosocomial transmission and infection control. Healthcare-associated Infections in Children: Springer; 2019. p. 229-57.
Ahmed J, Malik F, Memon ZA, Arif TB, Ali A, Nasim S, et al. Compliance and knowledge of healthcare workers regarding hand hygiene and use of disinfectants: a study based in Karachi. Cureus. 2020;12(2).
Sticchi C, Alberti M, Artioli S, Assensi M, Baldelli I, Battistini A, et al. Regional point prevalence study of healthcare-associated infections and antimicrobial use in acute care hospitals in Liguria, Italy. Journal of Hospital Infection. 2018;99(1):8-16.
Nasiriani K, Noorishadkam M, Ayatollahi J, Dehghani A, Zandi H. Investigating bacterial contamination of nurses’ hands in icu regarding their using of jewellery. SSU_Journals. 2013;20(6):709-15.
King REC, Berba RP. Effect of a multifaceted intervention on hand hygiene compliance among healthcare workers at the medicine wards and icu in a tertiary hospital setting. Acta Medica Philippina. 2018;52(1).
Ngugi SK, Murila FV, Musoke RN. Hand hygiene practices among healthcare workers in a newborn unit of a tertiary referral hospital in Kenya. Journal of Infection Prevention. 2019;20(3):132-8.
FitzGerald G, Moore G, Wilson A. Hand hygiene after touching a patient's surroundings: the opportunities most commonly missed. Journal of Hospital Infection. 2013;84(1):27-31.
Allegranzi B, Conway L, Larson E, Pittet D. Status of the implementation of the World Health Organization multimodal hand hygiene strategy in United States of America health care facilities. American journal of infection control. 2014;42(3):224-30.
Van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. New England journal of medicine. 2020;382(16):1564-7.
Khan N, Fahad S, Naushad M, Muhammad A. Climate impact on corona virus in the world. Available at SSRN 3561155. 2020.
Nasirzadeh M, Aligol M. Assessmentof knowledge, attitude, and factors associated with the preventive behaviors of COVID-19 in Qom, Iran, in 2020. Qom University of Medical Sciences Journal. 2020;14(7):50-7.
Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. Journal of autoimmunity. 2020;109:102433.
Tubbs‐Cooley HL, Pickler RH, Younger JB, Mark BA. A descriptive study of nurse‐reported missed care in neonatal intensive care units. Journal of advanced nursing. 2015;71(4):813-24.
Pincock T, Bernstein P, Warthman S, Holst E. Bundling hand hygiene interventions and measurement to decrease health care–associated infections. American journal of infection control. 2012;40(4):S18-S27.
Najafi Ghezeljeh T, Abbasnejad Z, Rafii F, Haghani H. Nurses’ knowledge, beliefs and practices towards hand hygiene. Hayat Journal. 2015;21(1):79-93.
van de Mortel T, Bourke R, McLoughlin J, Nonu M, Reis M. Gender influences handwashing rates in the critical care unit. American journal of infection control. 2001;29(6):395-9.
Chagpar A, Banez C, Lopez R, Cafazzo JA. Challenges of hand hygiene in healthcare: the development of a tool kit to create supportive processes and environments. Healthcare Quarterly. 2010;13(2010):59-66.
Nasimfar A, Sadeghi E, Bahrami N, Ghazavi A. Knowledge, Attitude, And Practice Of Hand Hygiene Among Medical Students In Urmia University Of Medical Sciences. Studies in Medical Sciences. 2020;31(9):700-11.
Edalatdoust Y, Bahraminejad N, Hanifi N, Faghihzadeh S. Health Care Workers› Knowledge and Attitude Towards Hand Hygiene in Educational Hospitals of Zanjann in 2014. Military Caring Sciences. 2018;5(1):46-53.
Nair SS, Hanumantappa R, Hiremath SG, Siraj MA, Raghunath P. Knowledge, attitude, and practice of hand hygiene among medical and nursing students at a tertiary health care centre in Raichur, India. International Scholarly Research Notices. 2014;2014.
Avazeh M, Babaei N, Moradi-Asl E, Gholizadeh B, Kalteh EA, Farhoudi S. Knowledge, Attitude and Practice (KAP) Study of Nurses Working at Meshgin Valiasr Hospital Regarding Hand Hygiene in 2018. Journal of Health. 2021;12(1):25-36.
Joshi S, Diwan V, Tamhankar A, Joshi R, Shah H, Sharma M, et al. Qualitative study on perceptions of hand hygiene among hospital staff in a rural teaching hospital in India. Journal of Hospital Infection. 2012;80(4):340-4.
Baghaei R, Sharifian E, Kamran A. Can theoretical intervention improve hand hygiene behavior among nurses? Psychology research and behavior management. 2016;9:133.
Jang T-H, Wu S, Kirzner D, Moore C, Youssef G, Tong A, et al. Focus group study of hand hygiene practice among healthcare workers in a teaching hospital in Toronto, Canada. Infection Control & Hospital Epidemiology. 2010;31(2):144-50.
Zingg W, Holmes A, Dettenkofer M, Goetting T, Secci F, Clack L, et al. Hospital organisation, management, and structure for prevention of health-care-associated infection: a systematic review and expert consensus. The Lancet Infectious Diseases. 2015;15(2):212-24.
Esfandiari A, Rashidian A, Asl HM, Foroushani AR, Salari H, Sari AA. Prevention and control of health care–associated infections in Iran: A qualitative study to explore challenges and barriers. American journal of infection control. 2016 Oct 1; 44(10):1149-53.
Dettenkofer M, Ammon A, Astagneau P, Dancer S, Gastmeier P, Harbarth S, et al. Infection control–a European research perspective for the next decade. Journal of Hospital Infection. 2011;77(1):7-10.
salmani f, darvishian m, fotokian z. Evaluating the performance of nursing students in observing hand hygiene in hospital internship units. Journal of Caspian Health and Aging. 2021;6(2):13-21.
Forrester L, Bryce E, Mediaa A. Clean Hands for Life™: results of a large, multicentre, multifaceted, social marketing hand-hygiene campaign. Journal of hospital infection. 2010;74(3):225-31.
Ziasheikholeslami N, Razavian F, Vafaei K, Esmkhani S. Evaluation of the level of hand hygiene in intensive care unit personnel of kamkar education, research and treatment center of Qom in 2014, Iran. Qom Univ Med Sci J. 2016;10(3):64-9.
Jalali AN, Setoodeh S, Rahimi M, Mohammadi MS. Investigating of Knowledge, Attitude and Practice of Sabzevar Families in Relation to the Prevention of Covid 19 and the Factors Affecting it in 1400. 2021.
Pollak Y, Dayan H, Shoham R, Berger I. Predictors of adherence to public health instructions during the COVID-19 pandemic. MedRxiv. 2020.
Hosseinialhashemi M, Sadeghipour Kermani F, Palenik CJ, Pourasghari H, Askarian M. Knowledge, attitudes, and practices of health care personnel concerning hand hygiene in Shiraz University of Medical Sciences hospitals, 2013-2014. American Journal of Infection Control. 2015;43(9):1009-11.
Alp E, Ozturk A, Guven M, Celik I, Doganay M, Voss A. Importance of structured training programs and good role models in hand hygiene in developing countries. Journal of infection and public health. 2011;4(2):80-90.
Esfandiari A, Salari H, Rashidian A, Asl HM, Foroushani AR, Sari AA. Eliminating healthcare-associated infections in Iran: a qualitative study to explore stakeholders’ views. International journal of health policy and management. 2018 Jan; 7(1):27.

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

Knowledge, Attitude, and Practice of Hand Hygiene among Healthcare Workers during the COVID-19 Pandemic in referral hospitals: A case study from Southern Iran

Status:

Version 1

Abstract

Background

Methods

Ethics:

Results

Discussion

Strengths and limitations of the research

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1