Hand Hygiene Awareness and Knowledge Among Healthcare Personnel in The Dawadmi Region of Saudi Arabia: A Cross-Sectional Survey Study

Introduction: The outcome of patient care in healthcare settings is influenced predominantly by healthcare-associated infections (HAIs). Hand hygiene is the single most essential component in avoiding HAIs. Objectives: The aim of the study is to evaluate the awareness and knowledge about hand hygiene among the healthcare personnel in the Dawadmi Region of Saudi Arabia. Materials and Methods: This cross-sectional survey study was carried out between May till September 2021. The tool (Questionnaire) was adopted from World Health Organization's Hand Hygiene Knowledge and awareness Questionnaire (revised in 2009), validated according to CROSS (Checklist for Reporting of Survey Studies) check list. Results: A total of 300 participants were randomly enrolled, 60 were nursing assistants, 140 nurses, and 100 residents, were enrolled in this study. With respect to years of experience in hand washing, 123 participants had 1–5 years (41%), 6–10 years (80%), 11–20 years (77%), and greater than 30 years of participation (6.67%). Concerning the education of hand washing and hygiene, training programs were attended by 230 participants (76.67%), and 70 participants (23.33%) did not attend the latest training program conducted by each institution. Most of them (83.33%) were using alcohol for hand hygiene. Conclusions: This study has clearly shown the requirement of an in-depth appraisal of important issues of compliance and patient safety. Educational interventions to recognize the hand hygiene opportunities, improved availability of hand hygiene facilities and multifaceted approach to tackle various barriers (poor attitude, workload, etc) of adherence are needed to be accorded priority.


INTRODUCTION
The global burden of infections acquired by patients during therapy in healthcare settings is enormous. The most common mode of germ transmission during treatment is through contaminated hands. Proteus mirabilis, Staphylococcus aureus, Clostridium difficile, Acinetobacter spp., enterococci, or Klebsiella spp. were the most common pathogens associated with healthcare-associated infections (HAIs). 1 The source of infection was colonized areas of the patient's skin, infected or draining wounds, the patient's bed linen, gowns, bedside furniture, and other objects in the patient's immediate vicinity. 2 Hand hygiene (HH) is an efficient approach to avoid infections. It involves either utilizing an alcohol-based hand rub or washing hands with water and soap. It is the responsibility of the healthcare employees, indirectly or directly taking part in patient care to carry out HH in an effective manner. 3 The challenging part in the implementation of the effective methods of HH is securing compliance among healthcare workers, although the procedures are relatively simple. 2 Lack of persuasion, working status, insufficient awareness, increased workload, and lack of awareness in implementation guidelines are all obstacles to the application of appropriate hand hygiene practices. [4][5][6][7][8] In spite of the high occurrence of HAIs, a less number of researches in Asia examined this topic in this region of the world. 9 Given that the first and most crucial step in decreasing nosocomial infections caused by inadequate HH is increasing healthcare worker awareness, and also on account of the lack of recognition paid to this problem in our locality, identifying information about HH routine can be beneficial. 10 The purpose of this analytical study was to assess the healthcare staff 's knowledge of HH practices and to recognize areas of knowledge gaps.

Research design and setting
This was a cross-sectional survey study, carried out in various private healthcare settings and general hospitals in the Dawadmi region between May 2021 and September 2021. The hospitals have specialized infection control measures as well as hand hygiene training sessions for workers.

Sample size estimation
The sample size for this cross-sectional investigation was estimated using the following formula:1.962 X P (1-P) d2 where P = 50 (50%-conservative estimate of the anticipated knowledge score of 50% that was extracted from literature of similar researches) and d = 0.05. The estimated sample size is 3.84 x 0.5 (1-0.5) 0.0025 = 384.
Exclusion: Non-medical workers in the hospitals (Receptionists, Cashier, House-keeping workers, Cafeteria workers) are NOT included in the study.

Sampling method
A simple random selection procedure was used to choose around 300 healthcare staff based on the projected sample size. The three vital wards in these two hospitals were general internal medicine wards, emergency wards, and intensive care units (ICUs). Personnel were asked to participate in the study based on the list of staff. If they did not comply with filling out the questionnaire, the next person on the list was invited. Sampling was carried out until the required sample size was reached.

Data collection
"WHO (The World Health Organization) Hand Hygiene Knowledge Questionnaire" (updated 2009 version) was utilized to acquire data in this study. "Hand Hygiene Knowledge Questionnaire" included the participants' gender, age, occupation, course year, formal HH training, and 27 multiple-choice and "yes" or "no" questions to measure their HH knowledge. Each right answer was given one point, while incorrect answers were given zero. Overall results were reported in percentages, with a score of more than 75% considered good, 50-74% considered moderate, and 50% regarded poor knowledge. An occupational medical professional translated the questionnaire into Persian. Following that, six more specialists (including two an internist, two emergency medicine specialists, an epidemiologist, and occupational medicine specialists) remarked on the accuracy of the questionnaire. Each question was examined by the expert group and labelled as beneficial, required, or not necessary. For each query, CVR (content validity ratios) were computed. The questionnaire's content validity index was 0.8, and the tool's validity was accepted.

Statistical analysis
The data was analysed using descriptive statistics (mean, standard deviation) using SPSS version 21.0 and Microsoft Excel spreadsheet.

Ethics
The study protocol was in conduct to the ethical guidelines of the 1975 declaration of Helsinki. All the healthcare workers were informed about the procedures of the study, and verbal informed consent was acquired from all the participants included in the study. The study was approved by the Institutional Ethics Committee.
Most of the healthcare workers recognized a lack of resources as a factor that prevented them from executing hand hygiene, with 223 (77.67 percent) choosing gloves as the contributory factor, 183 (61 percent) citing forgetfulness, 183 (61 percent) citing a lack of alcohol hand rub, 185 (61.67 percent) citing a lack of towels to wipe hands, and 191 (63.67 percent) citing a lack of time. In our survey, we discovered that the majority of 210 (70%) of participants believed they could enhance individual adherence with hand hygiene practices.

Hand hygiene indications -hand washing or hand rub
In our study, the majority of the healthcare workers recognized the following indications for HH achieved either by utilizing hand rubs that are alcohol-based or hand washing, with 82% (246) reporting the necessity for HH after exposure to the proximate environment of a patient, 77.67% (233) instantly after the exposure to body fluid, 77.67% (233) promptly before a aseptic/clean procedure, and 71.67% (215) before direct skin-to-skin contact with a patient. Each of the recommended hand hygiene techniques was thought to be effective by one-half of the healthcare professionals. (Table 3)

Hand hygiene improvement measures
As shown in table 4, most often indicated method for ensuring effective HH was institutional and senior management promotion and support of HH practice, 233 (77.67 percent).

DISCUSSION
HH is a reasonably easy and economical strategy that has been implemented in diverse establishments to avert HAIs. The demographic details of the participants involved in our study reveals that there is uniform distribution of the various categories of healthcare personnel. This is in contrast to a study conducted in ICU settings of tertiary care hospitals in Turkey in which it was observed that the majority (41.3%) participation was by the nurses employed in ICU settings. 11 The assessment of knowledge and awareness regarding the HH among the participants revealed that Alcohol-based hand rubs are ideal for HH. This is in concordance with the recommendations according to the WHO (World Health Organization). Pittet et al. found that despite the fact that the pharmacy had adequate stock, it was not dispersed to the various units, thus causing unavailability of alcohol-based hand rub in various units. 10 Most of the participants in this study practiced HH as per the recommendation for different indications of patient care. In contrast to our study, a study conducted among tertiary care institutions in U.S, the healthcare workers favoured washing hands with soap and water over alcohol-based rubs. 12 In a research of healthcare workers in the United States, the mean selfreported adherence rate was 84 percent, but when omitting out on occasions was taken into consideration, the total compliance percentage was only 38.4 percent. 13 Among the various factors affecting the compliance of HH, availability of hand rub, training of the healthcare personnel on HH plays a significant role. This is evident from the review which reveals that the majority of the situations that were associated with a higher compliance rate were training of healthcare personnel, the introduction of alcohol-based hand rub or gel, performance feedback, and accessibility of materials. 14 The noncompliance variables recognized in our study also correspond to those found in a review of impediments to effective hand hygiene. 15

Limitations of this study
There are a few drawbacks to this research. To prove that the findings in this study are statistically significant, the statistical data in this study must be validated on a large sample size. The study needs to be modified by an assessment of the HH awareness before and after the execution of effective training methods for healthcare workers on hand hygiene.   MOH (Ministry of Health) and in the private sector has made an obvious observation about the mandatory requirement for a dedicated infection control team, which will emphasize the eminence of hand hygiene.
In this questionnaire-based study, response bias may have led to overestimation of compliance. A triangulation with observation of HCWs was not done because if it is done with their knowledge then Hawthorne effect comes into play and if done without their knowledge then ethical considerations need to be discussed.

RECOMMENDATION
The recommendations from the above study are as follows: The training of all healthcare workers on the significance of hand hygiene is the key process in achieving a phenomenal change in the attitude of healthcare workers towards the prevention of HAIs. All categories of healthcare workers need to be aware of hand hygiene before they are inducted into inpatient care. There is an absolute need for a dedicated infection control team in every healthcare setting, irrespective of their in-patient bed strength and out-patient volume. Periodic assessment of compliance with hand hygiene among healthcare workers has to be made by the infection control team. Interventions based on the periodic assessment of hand hygiene compliance will be planned and executed by the infection control team. Adequate budgeting has to be planned by the management of the healthcare facilities for the consumables, training of the new healthcare workers, assessment process, and implementation based on an assessment to provide a hundred percent safe environment for the patients.

CONCLUSION
To conclude, this study has clearly shown the requirement of an in-depth appraisal of important issues of compliance and patient safety. Educational interventions to recognize the hand hygiene opportunities, improved availability of hand hygiene facilities and multifaceted approach to tackle various barriers (poor attitude, workload, etc) of adherence are needed to be accorded priority. This has to be a part of the overall strategy of improving the adherence to universal precautions in tertiary care hospitals.

ADDITIONAL INFORMATION
Human subjects: Verbal consent was obtained from all the participants of this study.
Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissues.

CONFLICTS OF INTEREST
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the above submitted work.
Financial relationships: All authors have declared that they have no financial relationships at present or within previous three years with any organizations that might have interest in the submitted work.
Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.