INTRODUCTION

Ignac Semmelweis, known as the "Father of Hand Hygiene," created hand hygiene for the first time in Europe in the nineteenth century to stop healthcare-associated infections (HAIs) [1]. Hand hygiene is a broad term that refers to washing hands with ordinary or antimicrobial soap and water or utilising alcohol-based hand rubs to get rid of dirt and other unwanted substances that have become attached to the hands as well as viruses, bacteria, and other microbes [2].

The World Health Organisation recommends doing hand hygiene five times during patient care: prior to contact with a patient, before administering an aseptic therapy, following contact with a patient, following contact with body fluids, and following contact with a patient's surroundings [2]. Since the implementation of the "5 Moments" programme, the compliance rate in some nations, including Saudi Arabia, has grown from 51% to 67% [3].

The most effective and easiest strategy to reduce the occurrence of healthcare-associated infections is to practise proper hand hygiene. Improving hand hygiene, on the other hand, is a critical intervention for achieving one of the patient safety goals in a healthcare setting. A very important issue when it comes to patients' health and safety is nosocomial infections also known as hospital-acquired infections (HAIs) [4]. Nosocomial infection occurs when the infection is not manifested at the time of admission to the hospital but develops after 48 hours of hospitalization [5].

According to estimates, the prevalence of HAI in the United States is between 1.7 and 23.6 per 100 admitted patients, costing hospitals between 28.4 and 33.8 billion dollars annually in direct hospital expenses and causing around 80,000 fatalities [5].

Nosocomial infections affect 5-10% of hospitalised patients in wealthy nations, but 20% of patients in impoverished countries [3]. HAIs are a huge illness burden that has a considerable cost impact on people and healthcare systems globally. Monitoring and preventing such infections should be a top priority of each hospital and every health care system [3].

In high-income countries, hand hygiene compliance rarely exceeds 70%, while in low-income countries, only around 9% of hand hygiene practices are followed when caring for critically ill patients, indicating that improvements are needed everywhere [6].

Hand hygiene compliance is estimated to be 40% and is lower in intensive care units compared to the other settings. Most nurses have better compliance compared to physicians. When compared to after handling a patient, less hand hygiene is performed beforehand. Workplace factors such as a heavy workload, the lack of alcohol-based hand rubs or sinks at the point of care, and a lack of organisational support all have an impact on how well people practise hand hygiene [7].

Many previous studies have reported several barriers to appropriate hand hygiene, there are many reasons healthcare workers fail to adhere to hand hygiene best practices. Among them are skin rashes, difficult access to supplies, disruptions in worker-patient relationships, the need to prioritise patients, forgetfulness, disregard for policies, a lack of time, a heavy workload, a lack of staff, and a dearth of data demonstrating the effect of better hand hygiene on hospital infection rates [7].

As stated by Wisniewski et al., the main reason why healthcare personnel don't comply with hand hygiene regulations, in addition to the obstacles previously discussed, is that they are unaware of the need for hand washing. Practises for hand hygiene among healthcare workers are significantly influenced by their level of knowledge, attitude, practise, and compliance [8]. A cross-sectional study revealed that there are gaps in knowledge among healthcare workers in Saudi Arabia [3]. In the healthcare sector, healthcare providers are mostly responsible for spreading germs if they do not wash their hands properly. Especially Nurses and physicians have the greatest physical contact with patients; therefore, they are the primary vectors of transmission within hospitals [9].

HCWs regularly come into contact with sick patients and contaminated surfaces because they are on the front lines of the COVID-19 outbreak. During this crisis, hand hygiene has gotten a lot of attention, not just because it is important but also because healthcare workers are worried about their exposure. HCWs are also worried about bringing the virus back into their homes, where they have elderly family members and babies who are more susceptible to the illness. Hospitals had trouble with hand hygiene before the COVID-19 pandemic. According to research, in March and April 2020, during the COVID-19 crisis, the demand for and use of hand sanitizers among healthcare workers soared by four times. Infection preventionists' routine hand hygiene audits and covert observations made by undercover shoppers both revealed greater than 90% compliance with hand hygiene practises at the same time [10].  

Due to a lack of observation and research in developing nations, the causes of low hand hygiene levels among healthcare workers have not yet been determined. In order to increase hand hygiene compliance and enhance patient quality of care by lowering hospital-acquired infections, the goal of this study is to evaluate the level of knowledge, attitudes, and practise of hand hygiene among HCWs (doctors and nurses) at King Salman Bin Abdul-Aziz Medical City (KSAMC) in Madinah City.

Research Question

1. 1. What are the levels of knowledge regarding hand hygiene among HCWs (physicians and nurses) at King Salman Bin Abdul-Aziz Medical City (KSAMC) in Madinah City in KSA.?
   2. What are the levels of attitudes regarding hand hygiene among HCWs (physicians and nurses) at King Salman Bin Abdul-Aziz Medical City (KSAMC) in Madinah City in KSA.?
   3. What are the levels of practices regarding hand hygiene among HCWs (physicians and nurses) in King Salman Bin Abdul-Aziz Medical City (KSAMC) in Madinah City in KSA?

Hypothesis of Study

Null

There is no statistically significant association between healthcare workers' Knowledge, Attitudes, and Practices with hand hygiene compliance

Alternate Hypothesis

There is a statistically significant association between healthcare workers' Knowledge, Attitudes, and Practices with hand hygiene compliance.

Aim of Study

To assess the knowledge, attitudes, and practices of HCWs (physicians and nurses) on hand hygiene measures in KSAMC in Madinah City.

Objective of Study

• To assess the knowledge of hand hygiene among HCWs (physicians and nurses) in King Salman bin Abdul-Aziz Medical City (KSAMC) in Madinah City in KSA.
  • To assess the attitudes of HCWs (physicians and nurses) in King Salman bin Abdul-Aziz Medical City (KSAMC) in Madinah City in KSA towards hand hygiene
  • To assess the practices of hand hygiene among HCWs (physicians and nurses) in King Salman bin Abdul-Aziz Medical City (KSAMC) in Madinah City in KSA.

MATERIALS AND METHODS

Study Design

A descriptive, cross-sectional design was used to carry out this investigation. Using self-reported surveys, KSAMC in Madinah City HCWs (doctors and nurses) were asked about their knowledge, attitudes, and hand hygiene practises.

Study Setting

The study was conducted at King Salman bin Abdul-Aziz Medical City (KSAMC) in Madinah, a tertiary care hospital with over 1200 beds. In the medical city, there are three dedicated services: general health care, maternity and pediatric health care, and mental health care.

Study Population

In this study, the sample will only include physicians and nurses who provide direct patient care.

Sample Size

To choose the participants, a convenience sampling method was used. 1955 nurses and 550 doctors make up the whole staff of the KSAMC. To determine the sample size with a 95% confidence level, a response distribution of 50%, and a margin of error of 5% Using Raosoft Software's sample size calculator ("Sample Size Calculator by Raosoft, Inc.," 2019), the target sample size for doctors is 227 and for nurses is 322, based on the proportion of doctors and nurses in the population.

Inclusion Criteria

All physicians and nurses who provide direct contact with patients.

Exclusion Criteria

Physicians and nurses who do not provide direct contact with patients for example work in administrative positions.

Physicians and nurses who are on vacation at the time of study.

Other HCWs like lab technicians, radiologists, pharmacists, and IT.

Data Collection

Self-reported questionnaires were sent to physicians and nurses included in this study according to the inclusion criteria. The data was collected through an electronic survey created by Google Forms. The study questionnaire will upload to Google Forms once ethical approvals have been received. A questionnaire link was sent from the medical director and nursing education department to physicians and nurse managers, to be distributed to physicians and nurses to send their responses within the survey period. The questionnaire was distributed among physicians and nurses working at KSAMC, from November to February 2023. All collected data was securely stored and deidentified, with access only made available to the principal investigator.

Study Instrument

In this study, we used Self –reported questionnaires adopted from a previous Publication by Gupta (2020), with written permission from the author through personal communication via email. This questionnaire tool was designed to assess physicians' and nurses’ knowledge, attitudes, and practices about hand hygiene. The questionnaire consists of four sections: demographics (7 questions), knowledge (8 questions), attitudes (11 questions), and practice (19 questions) with a total of 45 questions.

The Scoring System

The survey instrument for hand hygiene contained three scales: knowledge, attitude, and practise. The survey contained a demographic component to gather data on the respondents' age, gender, job title, years of experience, department of employment, and whether or not they had formal hand hygiene training. More than 75% were deemed good, 50–74% were deemed moderate, and less than 50% were deemed low.

Hand Hygiene Knowledge Scale

A scoring system was used, with one point given for each accurate response about knowledge and a score of 0 for each incorrect response, for the first scale, hand hygiene knowledge, which was examined using eight questions, comprising multiple choice and "yes" or "no" questions on general hygiene knowledge.

Hand Hygiene Attitude Scale

Attitudes were examined using 11 questions in which respondents were asked to choose between strongly agreeing and strongly disagreeing on a 1-to-5 scale. The score was calculated by aggregating the summed-up items; the higher the score, the better the attitudes towards hand cleanliness.

Hand Hygiene Practices Scale

A total of 19 questions with four response options—very low, low, high, or very high—were used to evaluate respondents' self-reported hand hygiene practises. For all questions, the "very high" response received three points, "high" received two points, "low" received one point, and "very low" received none.

Data Analysis

The questionnaires were reviewed for accuracy and completeness after they have been returned. For easy analysis, the questions were coded.  Then, all data items were entered in the Statistical Package for Social Sciences (IBM SPSS-ver22). Descriptive statistics (percent and number) and a p-value <0.05.

Ethical Consideration

Ethical approval was obtained from physicians, nurses, and Al-Faisal University. Ethical approval from the Ministry of health hospitals was obtained. After approval from hospitals, we will obtain it. The nurses and physicians will declare that participation is voluntary. Participant names will not be written on the questionnaire. Also, confidentiality and privacy were maintained. Ethical approval and tool approval was obtained. 

RESULTS AND DISCUSSION

Among the 604 participants in the study, 65.9% were female and 34.1 percent were male. A total of 26.2% of the sample under study was between the ages of 31 and 40, making up 62.7% of the sample's age range. 39.4% of the group under study were doctors, compared to 60.6% of nurses. Less than one year of experience was held by 28.3% of participants, two years by 12.9%, and more than three years by 41.6% of participants. 60.4% of the studied sample were from Madinah general hospital, 30.1% from Maternity and children hospital, and 9.4% from Al- Amal Hospital. As for the department, 20.5% work in the emergency department, 12.7% in ICU, and 12.6% in the surgery department as in Table 1.

Table 2 shows that 88.9% of individuals had formal training in hand hygiene within the previous three years. 89.7% of people regularly wash their hands with an alcohol-based hand rub. 11.3% of respondents identified hospital air circulation as the primary method of potentially harmful germs spreading between patients in a healthcare facility, while 57% pointed to healthcare workers' dirty hands, 17.5% to patients' contact with colonised surfaces, and 14.2% to sharing non-invasive objects.

As shown in Table 3, hand hygiene is practised by 90.4% of participants prior to patient contact, 80% immediately following the risk of body fluid exposure, 81.6% immediately following exposure to a patient's immediate surroundings, 84.8% prior to a clean/aseptic procedure, 90.2% following patient contact, 89.7% following the risk of body fluid exposure, 86.3% following patient exposure to immediate surroundings, and 73.5% prior to patient contact.

According to Table 4, the minimum amount of time needed for an alcohol-based hand rub to kill the majority of germs, according to 59.8% of participants, is 20 seconds. According to 64.9% of respondents, rubbing is necessary as a kind of hand hygiene before palpating the abdomen. Before administering an injection, 56.3% of respondents stated that rubbing as a form of hand cleaning approach is essential. After emptying a bedpan, 62.3% of people said they need to wash their hands. After removing examination gloves, 52.5% said that rubbing is required as a form of hand cleansing treatment. A healthcare-associated infection had a high impact on a patient's clinical outcome, according to 52% of participants. Hand hygiene was assessed to be extremely useful in preventing healthcare-associated infection by 45.5% of respondents. 49% of respondents said hand hygiene was extremely important at their workplace.

According to Table 5, 6.6% of the respondents strongly concur that there are times when they have more important tasks to complete than practising good hand hygiene. 7.8% firmly concur that using gloves lessens the requirement for hand hygiene. 4.6% firmly concur that they are reluctant to request that others adopt good hand hygiene.

In Table 6, 42.5% strongly agree that the importance of performing appropriate hand hygiene is highly valued by the head department. 44.7% strongly agree that performing proper hand hygiene is important to colleagues. 52% strongly agree that using an alcohol-based hand massage makes practising hand hygiene easier in the workplace. Knowing the findings of hand hygiene observation inward helps to enhance hand hygiene practises, according to 51.5% of respondents.

In Table 6, 63.4% of participants had good knowledge of hand hygiene, 32.5% had moderate knowledge and 4.1% had poor knowledge. Regarding attitude, 59.8% of participants had a positive attitude toward hand hygiene, 39.1% had a neutral attitude and 1.2% had a negative attitude.  As for practice, only 7.5% of participants had good practice scores, 82.9% had neutral practice and 9.6% had poor practice. Overall KAP score was found to be 1.8% poor, 33.3% moderate and 64.9% good.

As illustrated in Table 7, a significant association was found between knowledge, attitude, and practice scores with participants’ age, job title, and years of experience (P <0.05). Figures 4-7 shows Pearson correlation for KAP scores.