Hand hygiene knowledge and perception among the healthcare workers during the COVID-19 pandemic in Qassim, Saudi Ara- bia: A cross-sectional survey

Hand hygiene is among the most important factors of infection control in healthcare settings. Healthcare workers are considered the primary source of hospital acquired infection. We assessed the current state of hand hygiene knowledge, perception and practice among the healthcare workers in Qassim, Saudi Arabia. In this cross-sectional study we used the hand hygiene knowledge and perception questionnaire developed by the World Health Organization. Knowledge and perceptions were classified into good (80 – 100%), moderate (60 – 79%) and poor (<60% score). Majority of the healthcare workers had moderate knowledge (57.8%) and perception (73.4%) of hand hygiene. Males were less likely to have moderate/good knowledge compared to females (OR: 0.52, p<.05). Private healthcare workers were less likely (OR: 0.33, p<0.01) to have moderate/good perception compared to the government healthcare workers. Healthcare workers who received training on hand hygiene were 3.2 times likely (p<.05) to have good/moderate perception and 3.8 times likely (p<0.05) to routinely use alcohol-based hand-rub than the ones without such training. Physicians were 4.9 times likely (p<0.05) to routinely use alcohol-based hand-rub than the technicians. Our research highlighted gaps on hand hygiene knowledge and perception and practice among healthcare workers in Qassim and importance of training in this regard.


Introduction
Hand hygiene is among the most important factors of infection control in a healthcare setting. Healthcare workers are considered the primary source of transmission of pathogens from one patient to the other through their contaminated hands [1]. Health care associated infections are a serious burden to the health care settings and a recent meta-analysis by US researchers reported that $9.8 billion was spent yearly by the hospitals to combat with different types of hospital acquired infections [2]. Reduced hand hygiene compliance is considered to be a global problem and the compliance also differs among different health care professionals [3].
Hand hygiene is defined as the primary measure known to be effective in preventing healthcare-associated infections and preventing the spread of antimicrobial resistance [4]. Washing hands either with water and soap or using alcohol-based hand rub is the most cost-effective public health measure that can prevent health care-associated infections [1,5]. In 2009, WHO issued guidelines concerning hand hygiene procedures to reduce the prevalence of hospital-associated infections [6]. Though hand washing is a simple procedure, some healthcare workers are reluctant to adopt the recommended hand hygiene practices. Poor compliance of the healthcare workers in following recommended hand hygiene procedures is associated with lack of adequate knowledge, awareness and attitude towards hand hygiene [6,7].
Healthcare workers have the responsibility to prevent cross-contamination, especially the nurses. Nurses are more likely to be responsible for transmission of infection causing microorganisms in the hospitals since they are higher in number and are the people who mostly come in contact with patients and contaminated objects [8,9]. Nursing interventions require the direct contact with patients, hence becoming an avenue for pathogen transfer if hand hygiene is not followed correctly [8,10].
According to the WHO, an estimated 1.4 million people globally are affected by healthcare-associated infections at any time [6]. There are many consequences associated with healthcare-associated infections-prolonged stay in the hospital, disability, higher healthcare cost for patients and families, increased morbidity and mortality and increased resistance to antibiotics. All these in turn increase financial burden on the health system [11]. Similar to the rest of the world, Saudi Arabia has a great concern about healthcare-associated infections. According to a study conducted in Saudi Arabian military hospital in the year 2004 about nosocomial infections, among 1382 patients who developed infection following hospital admission 48.3% had nosocomial infections [12]. Furthermore, a similar study conducted in KSA from 2010-2011 states that among the patients who developed infection following hospital admission, 48.3% of patients developed healthcare-associated infections; of all the healthcare-associated infections reported, there were respiratory tract infections (32.3%), urinary tract infections (25.3%), blood infections(18.2%) and surgical site infections (12.9%) [13]. Therefore, healthcare-associated infections are considered a significant public health concern for patients, healthcare workers and the health system [6]. In this context, they aim of this study was to evaluate the hand hygiene knowledge, perception and practices of the healthcare workers in Qassim, Saudi Arabia.

Study design, settings and sampling
We did a cross-sectional online survey of healthcare workers between October 2020 -March 2021 in Buraidah and Ar-ras cities of the Qassim region, KSA. An online structured survey form which was developed on the Google platform was disseminated to the healthcare workers in these two cities through our professional and social networks using emails and the WhatsApp. Study purpose and title was clearly indicated in the front page of the online page and the participants were requested to avoid multi-registration. A total of 301 healthcare workers completed the online survey.

The instrument
Our structured questionnaire had three parts. First part collected healthcare workers' socio-demographic information. The second and third parts collected information on healthcare workers' knowledge and perception of hand hygiene, respectively. To assess healthcare workers knowledge and perceptions on the essential aspects of hand hygiene we used the hand hygiene knowledge questionnaire [6] and the perception survey [14] for healthcare workers developed by the WHO.

Variables
To assess hand hygiene knowledge, for each correct response participants were given 1 point and 0 point for each wrong response. The overall knowledge was categorized into poor, moderate and good (80 -100% score), moderate (60 -79%), and poor if the score was less than 60%. We assessed perceptions of the healthcare workers on essential aspects of hand hygiene using 10 questions. Participants' response on each of these 10 questions were assessed with a five-point (0 -4) Likert type scale-higher the score better the perceptions. We computed the total perceptions score and the overall perceptions was categorized into good (80 -100% score), moderate (60 -79%), and poor if the score was less than 60%. For the multivariable logistic regression analyses we categorized knowledge and perceptions as moderate or good (60 -100% score) and poor (<60% score). We assessed hand hygiene practice of the healthcare workers using a single item-whether or not the healthcare worker routinely used alcohol-based hand-rub while working.

Analysis
We did descriptive analysis of the knowledge, perceptions and practice questions. We reported frequency and percentages for each of the knowledge, perceptions and practice items. We classified healthcare workers' knowledge and perceptions into good, moderate and poor. We reported number and proportions of the healthcare workers in each of these categories.
We did multivariable logistic regression analysis to investigate the factors associated with moderate to good knowledge, moderate to good perceptions and routinely using alcohol-based hand-rub. For multivariable logistic regression analyses we reported odds ratio (OR) with 95% confidence interval (CI). In addition, we reported corresponding p values. A p value of <0.05 was considered statistically significant.  Table 1 shows the background characteristics of the health care workers in Qassim, Saudi Arabia. The background characteristics of the participants reveal that around 69.8% of health care workers are from government health facility whereas only 30.2% are from private health facility. Among all the health care workers, majority of them are males (55.8%) when compared to females (44.2%). Approximately, 57.5% of health care workers are under the age group of 20-34 years, followed by 35 or over age group (42.5%). According to the nationality, about 70.1% are from Saudi and the remaining 29.9% are non-Saudi. The health care workers with graduate level of qualification were 86.7% and only 13.3% were having postgraduate level of qualification. When participants were asked about their knowledge on hand hygiene issue, about 64.5% participants revealed that the main routes of cross-transmission between patients when their hands are not clean. Approximately 28.2% health care workers reported that germs already present on or within the patient are the main source of germs responsible for health care associated infections. About 94.4 % health care workers shared that hand hygiene action prevents transmission of germs before touching a patient. Also, a vast majority of the participants 90.4% and 88% respectively said that damaged skin and artificial fingernails should be avoided as associated with a likelihood of colonization of hand with harmful germs. Overall, about 57.8% health care workers have provided 60 to 79% correct responses.  Table 3 shows the perception of health care workers about hand hygiene. According to the health care workers perception, about 63.5% reported that the impact of health care associated infection on patient's clinical outcome is very high whereas only 0.3% reported as very low. Around 67.8% of their perception is very high about the effectiveness of hand hygiene in preventing health care associated infection whereas 0.7% of low perception. Among all patient safety issues, 65.4% of health care workers consider that hand hygiene should be of very high priority within management priorities at the institution, however 1.7% of them consider it as very low priority. To increase hand hygiene permanently in health facility, few actions should be taken such as leaders and senior manager support and openly promote hand hygiene which health care workers reported as very effective (55.8%), whereas there are few who felt it as not effective (1.7%). While coming to alcoholbased hand rub availability at each point of care in health care facility, around 51.5% of health care workers opined it as a very effective action in contrast 1.7% of them opined as a not effective measure. About 0.7% of health care workers opinion about hand hygiene posters displayed as reminders at point of care is ineffective whereas approximately 50.8% of their opinion was very effective. According to the health care workers opinion about receiving education on hand hygiene to increase hand hygiene permanently in their health facility is not effective for 1% of health care workers however majority of their opinion was very effective (55.8%). Similarly, the opinion of health care workers is very effective about clear and simple instructions for hand hygiene making visible for every health care worker (55.8%) and health care workers regularly receiving the results of their hand hygiene performance (41.5%). Another measure to increase hand hygiene was patients are invited to remind health care worker to perform hand hygiene, only 28.6% of health care workers opinion was very effective for this measure whereas 4% of their perception for this measure was ineffective. We found no evidence of statistically significant association between hand hygiene knowledge and demographic and professional variables apart from gender. After adjusting for the effect of all demographic and professional variables included in the model, we found that males were 48% less likely to have moderate to good knowledge compared to females (OR: 0.52; 95% CI: 0.28 -0.98; p<.05).

Results
Regarding the perception of hand hygiene we found evidence of statistically significant association with education, types of health-care facility and training. We found that health care worker with post graduate level education were less likely to have moderate or good perception (OR: 0.27; 95% CI: 0.09 -0.80; p<.05). We also found that health-care workers from the private facilities were 67% less likely (OR: 0.33; 95% CI: 0.15 -0.73; p<0.01) to have moderate/good perception compared to the health-care workers from the government facilities. Regarding training on hand hygiene, we found that health-care workers who received training on hand hygiene were 3.2 times likely (95% CI: 1.24 -8.21, p<.05) to have good/moderate perception about hand hygiene compared to the ones who did not receive training.
Our multi-variable logistic regression analysis results suggest evidence of statistically significant association (p<0.05) between routinely using alcohol-based hand-rub and type of profession, level of education, and training. Physicians were 4.9 times likely (95% CI: 1.06 -22.75; p<0.05) to routinely use alcohol-based hand-rub than the technicians, after adjusting for the effect of other variables. In addition, we found that health-care workers who received training on hand hygiene were 3.8 times likely (95% CI: 1.2 -11.67; p<0.05) to routinely use alcohol-based hand-rub than the ones who did not receive such training.

Discussion
Our study aimed to assess the hand hygiene knowledge, perception and practice among the healthcare workers in Qassim, KSA. The study findings revealed that about 58% of the healthcare workers have moderate knowledge of recommended hand hygiene, while 41% have poor knowledge. Moderate knowledge among health care workers in hospital settings are also reported in studies conducted in North Central Nigeria, Iran, India and Pakistan [15][16][17][18]. This could be a reason for concern as some studies found that hand hygiene practice remains low despite a good amount of knowledge [19].
The study participants also implied that wearing artificial jewelry, fingernails and damaged skins could be the sources of spreading germs in the hospital settings. A similar result was reported by Suen et al (2020) in Hong Kong [20], Rajcevic et al in Serbia (2012) and Maheshwari et al in Bhopal city, India(2014) [7].
Our multivariate regression analysis revealed an association between knowledge on hand hygiene and the gender of the healthcare worker. Our study has shown that a woman healthcare worker has comparatively better knowledge of hand hygiene than a man healthcare worker. This finding agreed with a cross-sectional study in Hong Kong, where female healthcare workers demonstrated significantly higher knowledge than male healthcare workers [20]. The study findings also reported that healthcare workers with post-graduation education are less likely to have moderate or good hand hygiene perception. Research has shown educational intervention is a significant predictor of good hand hygiene compliance and hand hygiene education courses are needed to improve the competency infection control issues among health care workers [21]. A qualitative study conducted in Iran among the healthcare workers found that the appropriate education positively affects hand hygiene behaviour and attitude [22]. We found that the healthcare workers who attended training activities on hand hygiene are more likely to have a better perception of the issue. This is consistent with other qualitative and quantitative research findings conducted in Turkey and Uttarakhand, India [19,23] Ay et al 2019). The importance of repeated hand hygiene training for the healthcare workers has already been emphasized to reduce hospital-acquired infections [7].
Previously it has been reported that physicians' perceptions and perceived effectiveness of hand hygiene to some extent vary from other health care professionals [24]. The physicians of this study also have shown similar characteristics. They are more regularly using alcohol-based hand rubs to protect themselves from germs compared to other professional health care workers. This is also congruent with research done in Pakistan by Ahmed et al. in 2020 [15]. Rajcevic et al (2012) found that the health care workers have a low level of knowledge pertaining to alcohol-based formulations. However, evidence from a teaching hospital in India shared that understanding the importance of hand hygiene is an essential driving factor among the health care professionals to regularly maintain the practice [25].
In this study, it is evident that moderate knowledge among the health care workers is the main barrier to maintain good hand hygiene practice at workplace. More repeated training courses and a culture of promoting good hand hygiene practice should be promoted frequently. The main limitation of the study is that the data has been gathered from only one hospital setting and due to the cross-section nature of the study, the findings of the cannot replicated for a similar larger population group. However, the findings of the study would be useful for the hospital authorities to take extra precautions and should make necessary arrangements to provide extra support on a regular format to the health care professionals who are working at the front line to deal with any emergency arises.