Khaled M. Abd Elaziz and Iman M.

Bakr

Assessment of knowledge, Attitude

Assessment of knowledge, attitude and practice of hand washing

among health care workers in Ain Shams University hospitals in
Cairo.
Khaled M. Abd Elaziz, Iman M. Bakr
Community, Environmental and occupational department, Faculty of medicine, Ain
Shams University, Cairo

Abstract
Background: Most nosocomial infections are thought to be transmitted by the hands
of health care workers. The aims of this work were to assess the knowledge, attitude
and practice of hand washing among health care workers (HCW) in Ain-Shams
University hospitals and to assess its different wards for facilities required for hand
washing (HW). Methods: A cross-sectional descriptive and observational study was
conducted for six months from June till November 2006. It included preparatory
phase, observational phase for practice and assessment of knowledge & attitude
through self-administered questionnaire to HCW in 10 different departments. 2189
opportunities among HCW were observed. Results: Doctors showed a significantly
higher compliance (37.5%) than other groups of HCW (P=0.000), however only
11.6% of them had done the HW in an appropriate way. The most common type of
HW practiced among HCW was the routine HW (64.2%) and the least was the
antiseptic HW (3.9%). Having a short contact time and improper drying (23.2%) was
the most common form of inappropriate HW. Most of the wards had available sinks
(80%) but none of them had available paper towels. The mean score knowledge was
higher in nurses than in doctors (42.611.7 versus 39.110.5). 97.3% of the nurses
believe that administrative orders and continuous observation can improve hand
washing practices. Conclusion: Compliance to hand washing was low.
Implementation of multifaceted interventional behavioral hand hygiene program with
continuous monitoring and performance feedback, increase supplies necessary for
HW and institutional support is important for improving the compliance of hand
hygiene guidelines.
Keywords: hand washing, medical health care workers, knowledge, attitude, practice

Introduction
Most nosocomial infections are
thought to be transmitted by the hands
of health care workers. It has long been
known that hand hygiene among health
care workers plays a central role in
preventing the transmission of
infectious agents. Hand-washing is the
most effective way of preventing the
spread of infectious diseases.(1) But
despite
a
Joint
Commission
requirement that Centers for Disease
Control and Prevention hand hygiene
guidelines
be
implemented
in

The Egyptian Journal of Community Medicine

hospitals, compliance among health

care workers remains low. (2)
The reasons of lack of compliance to
hand washing include: lack of
appropriate equipment, low staff to
patient ratios, allergies to hand
washing
products,
insufficient
knowledge among staff about risks and
procedures, the time required and
casual attitudes among staff towards
biosafety. (3)
Improved compliance with hand
washing was associated with a
significant decrease in overall rates of

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Khaled M. Abd Elaziz and Iman M. Bakr

Assessment of knowledge, Attitude

nosocomial infection and respiratory

infections in particular. (4)
Hand hygiene technique is seldom
incorporated into research studies and
audits
designed
to
increase
compliance. As a result, numerous
unanswered
questions
remain
concerning this aspect of hand
hygiene.(5) In order to be effective,
efforts to improve compliance with
hand washing guidelines must be
multifaceted (6) and should include
increasing
the
availability
and
accessibility of hand washing sinks and
alcohol-based hand rubs. (7)
Aim of the work
1- Assessment of knowledge,
attitude and practice of hand
washing among health care
workers (HCW) in Ain- Shams
University hospitals
2- Assessment of different wards
in Ain- Shams University
hospitals for facilities required
for hand washing

Subjects and methods

A cross sectional descriptive &
observational study was conducted in
Ain Shams University hospitals. The
practical part extended for six months
(from June till November 2006) was
implemented in three phases:
Phase one: Preparatory phase, Two
infection control nurses from 10
departments were selected and trained
on
observing
hand
washing
opportunities and filling out the forms
needed. Training included lectures on
the importance of hand washing and its
impact on nosocomial infection rate
and the correct practice of hand
washing.
Phase two: Observational phase, a) for
HCW, Observational forms to record
the events in each opportunity

The Egyptian Journal of Community Medicine

observed as regard the hand washing

compliance (done or not done) and
hand washing technique and practices
(if done). The observation was done
unobtrusively. The opportunities of
hand
washing
included
those
opportunities where the HCW could do
invasive procedures, come into
personal contact with the patient, do
non-invasive procedures as blood
pressure or temperature measurement,
body fluid contact, waste disposal or
come in contact with contaminated
inanimate
objects.
Multiple
opportunities could be observed for a
single health care worker. b) Ward
inspection forms were filled throw
inspection of the availability of
facilities needed for hand washing in
each department, as hand hygiene
guidelines, posters, sinks, towels, soap,
alcohol-based hand rubs and gloves.
Phase three: assessment of knowledge
and attitude of hand washing through a
self-administered questionnaire. It
targeted different aspects, indications
and types of hand washing for doctors
and nurses (20 questions) and workers
(10 questions). Questions about
knowledge were answered as True,
False or Unsure. They included: Is HW
indicated even if sterile gloves were
used? The most common mode of
transmission of infection is through
hands of HCW? Four questions on
different techniques of hand washing
whether routine, antiseptic or alcohol
hand rub and the difference between
them. Two questions on the minimum
time needed for routine and antiseptic
HW. Also question on hand drying
after antiseptic HW and turning the tap
off,. Whether routine HW is done after
doing invasive procedure or not, and if
the hands are contaminated with blood,
is it a must to use antiseptic HW. Also
questions on the action of soap and
alcohol on the flora of the skin,
bacteria and viruses, the type of the
antimicrobial used in relation to the

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Assessment of knowledge, Attitude

onset and duration of action. Types of

alcohol used in alcohol hand rub.
Whether adding glycerine can reduce
skin irritation and whether rinsing
betadine scrub should be done
immediately (before iodine irritates the
skin)
Attitude questionnaire included 4
questions and were filled by nurses in
different departments. They included:
Whether HW is protective to HCW,
whether it could be improved by
administrative orders and continues
observation, whether it lowers the
nosocomial infection rate more than
any other measure and whether it could
be improved in their hospitals by good
role models by doctors.
A total score was given to the
knowledge (out of 20) and attitude
questionnaire (out of 20). Attitude
questions were four questions based on
Likart scale. Totally agree and agree
answers were considered as positive
attitude and a percentage was
calculated.
Forms were revised for completeness
and consistency. Data entry, data
checking and data analysis were done
with the program SPSS (Statistical
package for social science) version
11.0.5.
Ethical consideration: approval of the
design and steps of the study were
conducted with members of the
infection control unit in Ain Shams
University hospitals. A consent was
taken from the participants of the study
before answering the questionnaires.
Also the observation of the hand
washing practices was among the
routine work of the infection control
nurse responsible for all the activities
of infection control in the studied units.
Results
2189 opportunities among health care
workers in Ain Shams University

The Egyptian Journal of Community Medicine

hospital were observed for compliance

to hand Hygiene.
Most of the observed opportunities for
hand washing were done by nurses
(1180) followed by doctors (465).
Collectively doctors (37.5%) showed a
significantly higher compliance to
hand washing than the other groups of
health care workers (P=0.000),
however only 11.6% of them had done
the hand hygiene in an appropriate way
(Table 1).
Departments
included
in
the
observations were the Orthopedic,
neurosurgery, plastic and general
surgery (722 observations), pediatric,
gynecology and chest intensive care
units (1193 observations) and the
hematology departments.(Table 2)
The most practiced type of hand
washing among the health care
workers was the routine hand washing
(64.2%) and the least was the
antiseptic hand wash (3.9%). (Table 2)
Hand washing was observed during
different intervention. Hand washing
was performed at a higher rate after
doing the different intervention than
before doing them, however hand
washing was done in a more
appropriate way before doing the
different intervention than after doing
them except for the non-invasive
procedures were it was nearly similar
before and after.
A self-administered questionnaire
containing twenty different aspects,
indications and types of hand washing
was filled by 152 HCW. Workers were
allowed to answer only 10 of these
items. The mean score knowledge was
higher in nurses than in doctors
(42.611.7 versus 39.110.5).
The assessment of the knowledge of
HCWs in different departments
showed that the highest mean scores
was in the NICU pediatric department.
Doctors had high mean score in
knowledge in General surgery
department 7 (47.58.6), nurses

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Assessment of knowledge, Attitude

(482.7) and workers (63.31105) in

the NICU pediatric department. (Table
4)
Although the highest mean knowledge
of hand washing was among nurses in
the NICU pediatric 48.02.7 yet the
lowest attitude scores were found
among nurses in the same department
68.0 7.5 (results not shown in tables).
As regards the attitude of nurses
towards hand hygiene, it was found
that 96% of nurses believe that hand
washing is protective health care
personnel from infection. Also it is
noted that 97.3% of the nurses believe
that
administrative
orders
and
continuous observation can improve
hand washing practices. As regards
lowering of nosocomial infection rates
92% of the nurses believe that this
method (Hand washing) can lower
nosocomial infection rates more than
any other method of infection control
Only 70.7% of the nurses had positive
attitude towards the improvement of
hand washing by watching role models
do hand washing. (Table 5)
The
most
common
form
of
inappropriate hand washing was in the
improper drying and having short
contact time(23.2%).(Figure 1).
As regards the ward assessment, most
of the wards had available sinks (80%)
and none of them had available paper
towels. (Table 6)
Discussion
Hand hygiene prevents cross infection
in hospitals, however adherence to
guidelines is commonly poor. (8) While
the techniques involved in hand
hygiene are simple, the complex
interdependence of factors that
determine hand hygiene behavior
makes the study of hand hygiene
complex. (9)
In our study the overall hand hygiene
compliance among Health care
workers is 34%, this agrees with
Patarakul et al., (2005) who had found

The Egyptian Journal of Community Medicine

from their observational study that

hand hygiene among HCWs before
patient contact was less than 50%.(10)
Also it agrees with Pittet et al., (2000)
who had observed 20000 opportunities
for hand hygiene before implementing
a hand hygiene campaign during
routine patient care in a teaching
hospital in Geneva to be 48%.(11)This
gives an idea for our need to such
programs in order to raise our
compliance to hand hygiene. Our result
was much better than Kim et al.,
(2003) study who had found the
overall compliance of hand washing to
be 22.1%.(12)
As regard compliance to hand hygiene
in ICU. Our results in the chest
ICU=33.4%, NICU ped.= 62.5%
&NICU gyn.39.4%, were much better
than Rosenthal et al., (2003) who had
found a rate of 23.1% before
implementing
a
hand
hygiene
education, training and performance
feedback program in one medical
surgical ICU and one coronary ICU of
one hospital in Argentina.(13) Also our
results lie within the range of Lipsett &
Swoboda (2001) which is 28%74%.(14)Our results were comparable
with Won et al., (2004) who had
conducted their study in NICU in a
level III teaching hospital where they
found compliance to hand hygiene to
be 43%.(4)
As regard the variation in compliance
to hand washing hygiene among
different health care workers. Doctors
showed the highest compliance
(37.5%) in comparison to nurses
(36.4%) and housekeepers (22.6%) and
this disagree with Lipsett and Swoboda
(2001) who had found that nurses
showed higher compliance (50%) than
doctors (15%) and nursing supporting
personnel (37%).(14) Minimizing the
gap found between the knowledge and
attitude in nurses as found in Pediatric

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Khaled M. Abd Elaziz and Iman M. Bakr

Assessment of knowledge, Attitude

NICU could improve the compliance

rates to HW in nurses.
The mean score knowledge on hand
washing was higher among nurses than
among doctors (42.6 11.7 versus
39.110.5 resp.), however Zakzouk et
al., (2004) had found a slight
difference between them (94.77.0,
95.27.4 resp.) and showed a
collectively higher means compared to
our results in their study conducted in a
burn unit in Ain Shams University
hospital including 9 physicians and 19
nurses.(15) Mohamed, (1999) had found
the level of correct knowledge about
HW among health care workers in
Elgalaa governmental hospital was
73.1% and in Cleopatra private
hospital was72.7%.(16)
Good hand washing technique,
ensuring that all surfaces of the hands
receive
contact
with
the
decontaminating agent, has been
accepted for many years and is
acknowledged in current guidelines .(5)
23.2% of the observed opportunities
showed inappropriate hand washing.
This appeared most in both having a
short contact time less than 30 sec. and
improper drying. Basurrah and Madam
(2006) who had studied hand washing
in medical and surgical wards in a
tertiary center in Riyadh found that the
duration of hand washing was
suboptimal for all HCWs.(7) 14.5% of
our opportunities showed improper
drying of hands, Kuzu et al., (2005) in
a university hospital in Turkey found
that 79.8% of HCWs didn't dry their
hands.(17) Mohamed, (1999) had found
that HW was done correctly in 14.4%
of HCW (doctors and nurses) in
Elgalaa hospital and 44.7% in
Cleopatra hospital.(16) Talaat, (1998)
had reported that 90 % of the nurses in
his study were performing hand
washing inadequately.(18) Appropriate
health education programs should be

The Egyptian Journal of Community Medicine

implemented to raise the compliance in

this issue.
A complex interplay of cognitive,
socioeconomic and technical factors
may determine hand washing practice
among hospital based health workers
especially doctors, regardless of the
location of the country or hospital they
work in. (19) Administrative support (13)
and improved availability of resources
(20)
provides a positive influence in
efforts to improve HW adherence to
improve infection control in hospitals.
In our study ward assessment had
marked deficiency in supplies and
resources necessary for performing
hand washing as only 10% of the
wards had available automatic sinks
and hand drying material. Only 40% of
the wards had sinks where soap was
available. Ji et al., (2005) had found
that being short of water accounted for
22% of reasons of non compliance to
hand washing.(21) In our study 20% of
the observed wards had no available
sinks. Improving the availability of
materials and supplies essential for
hand hygiene is a basic step in
improving the compliance with hand
washing.
Alcohol- based rubbing reduces the
mean bacterial counts on hands more
effectively than hand washing with
antimicrobial soaps (22,23). In our study
64.2% of the observed opportunities in
this study used routine hand washing
with soap, in comparison to 99.3% in
Kuzu et al., (2005) study and only
31.7% used alcohol hand rub in
comparison to Wendt et al., (2004)
(52.2%) who had conducted his study
in a university hospital in Heidelberg,
Germany.(17,24) Hand hygiene through
alcohol hand rub need to be increased
through
increase
supply
and
continuous education. Whitby et al.,
(2008) had found that introduction of
Alcohol based hand rub without an

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Khaled M. Abd Elaziz and Iman M. Bakr

associated
program

Assessment of knowledge, Attitude

behavioral modification
proved
ineffective.(25)

As regard washing hands before and

after doing different procedures, 20.6%
and 7.9% of HCW wash their hands
before and after invasive procedures in
comparison to 13.8% and 35.6% in
Arenas et al., (2005) study who had
conducted their study among HCW in
haemodialysis units in Spain.(26) HCW
should be keen not to transmit
infection to their patients and raising
the awareness of HCW in this issue is
very important. Kim et al., (2003) had
found a positive association between
glove use and subsequent hand
disinfection.(12) 22.5%, 38.6% and
70.4% of the nurses in Hassan and
Aboul-Asm, (2007) study performed
hand washing after removing gloves,
patient contact and after body fluid
contact in comparison to 61.4%, 43.9%
and
39.8%
of
the
observed
opportunities among HCW in our
study.(27) Differences in the health team
covered and the method of the
assessment might have created the
discrepancy in the results.
Our results showed a higher positive
attitude among nurses (96.0%) towards
HW protection of health care personnel
in comparison to 86.2% in Nobile et
al., (2002) study in Italy among HCWS
in ICUs.(28)
97.3% of the nurses in our study
believe HW practices can be improved
by administrative orders and this
contradicts Harris et al.,(2000) who
found that healthcare workers are not
in favor of interventions involving
rewards and punishments, but are more
attracted to interventions that make
hand-washing easier.(29)
Using hand hygiene as a sole measure
to reduce infection is unlikely to be
successful when other factors in

The Egyptian Journal of Community Medicine

infection
control,
such
as
environmental hygiene, crowding, stuff
levels and education are inadequate (9).
Only 70% of the 10 wards observed in
our study, their stuff received formal
education on hand washing hygiene.
All HCW should have continuous
education to raise their awareness and
compliance towards hand washing
hygiene. Also only 30% of the
observed wards had written hand
hygiene guidelines. These guidelines
should be generalized to all wards of
the hospital.
Recommendations
Implementation
of
multifaceted
interventional behavioral hand hygiene
program is important for improving the
compliance
to
hand
hygiene
guidelines.
Implementation of hand washing
training programs for undergraduate
doctors, house officers and nurses.
Those training programs should be
done at intervals and assessed for the
improvement of hand washing
practices
Continuous
monitoring
and
performance feedback is beneficial
beside increase in supplies necessary
for hand washing and institutional
support.
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Assessment of knowledge, Attitude

Practical guidelines for infection

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Assessment of knowledge, Attitude

(A) Observation of hand- washing (HW)opportunities

Table 1: Compliance to hand hygiene among different groups of health care
workers in Ain Shams University
Health care
workers
Doctors
Nurses
Housekeepers
Others*
Total

Opportunities
Observed
Total
465
1180
296
248
2189

No.
174
429
67
75
745

Done
(%)
37.5
36.4
22.6
30.2
34.0

Hand Washing
Appropriate
No.
(%)
54
11.6
44
3.7
1
0.3
12
4.8
111
5.1

X2=23.9
P=0.000

X2=52.5
P=0.000

*Others include waste disposal workers and janitors

Table 2: Compliance to hand hygiene among different departments and in
different procedures in Ain Shams university hospitals
Opportunities
Observed
Departments:
Orthopedic
Neurosurgery
Plastic surgery
General surgery 7
NICU Pediatric
NICU Gynecology
Hematology
Chest ICU
Procedures:
Invasive procedures
Non-invasive procedures
Personal contact
Body fluids contact
Contaminated inanimate objects
Waste handling
After using gloves
Total

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No.

Hand Washing
Appropriate
%
No.
%

115
157
294
156
480
345
274
368

16
2
32
63
300
136
73
123

13.9
1.3
10.9
40.4
62.5
39.4
26.6
33.4

8
0
4
0
67
29
3
0

6.9
0
1.3
0
13.9
8.4
1.1
0

753
501
157
191
249
224
114
2189

258
160
69
76
52
60
70
745

34.3
31.9
43.9
39.8
20.9
26.8
61.4
34.0

34
39
7
22
3
3
3
111

4.5
7.7
4.4
11.5
1.2
1.3
2.6
5.1

Vol. 26

Done

No. 2

April 2008

Khaled M. Abd Elaziz and Iman M. Bakr

Assessment of knowledge, Attitude

Table 3: Appropriateness of hand washing in different types of hand washing

and before and after different procedures among HCW in Ain Shams University
hospitals
HW done
Appropriate
HW
No
%
Types of hand washing (HW):
No
%
17
3.5
480
64.2
Routine HW
8
27.6
29
3.9
Antiseptic HW
86
36.4
236
31.7
Alcohol hand rub
111
14.9
745
100
Total
Appropriate HW before &after interventions
No. of H.W. done
1- Invasive Procedure
22
20.6
107
Before
12
7.9
151
After
34
13.1
258
Total
2- Non invasive Procedure
16
23.9
67
Before
23
24.7
93
After
39
24.4
160
Total
3- Personal contact
4
18.2
22
Before
3
6.4
47
After
7
10.2
69
Total
4- Body fluids contact
12
63.2
19
Before
10
17.5
57
After
22
28.9
76
Total
5- Contaminated inanimate objects
2
14.3
14
Before
1
2.6
38
After
3
5.8
52
Total
6- Wastes handling
1
25.0
4
Before
2
3.6
56
After
3
5.0
60
Total
7- Using gloves
1
50
2
Before
2
2.9
68
After
3
4.3
70
Total

The Egyptian Journal of Community Medicine

Vol. 26

No. 2

April 2008

Khaled M. Abd Elaziz and Iman M. Bakr

Assessment of knowledge, Attitude

B) Knowledge assessment of hand washing practices

Table 4: Comparison between the mean knowledge scores of HCWS, doctors,
nurses and workers in different departments in Ain Shams University
Department
HCWS
Doctors
Nurses
N=152
N=42
N=75
Mean+ SD
Orthopedic
36.715.2
25.8 8.0
44.215.3
Neurosurgery
42.910.1
44.010.4
33.3 2.8
Plastic surgery
41.811.9
40.0 7.0
37.711.9
General Surgery 7
42.29.5
47.5 8.6
41.49.8
NICU Pediatric
51.89.5
46.6 5.7
48.02.7
ICU Pediatric
41.28.5
41.2 8.5
NICU gynecology
41.710.4
43.311.7
42.5 9.5
ICU gynecology
44.114.8
45.010.0
45.0 17.7
Hematology
44.713.4
42.716.6
42.0
2.7
Chest ICU
36.012.8
41.510.8
35.0 9.3
Collective mean knowledge score of doctors, nurses and workers= 39.110.5,
42.611.7 and 44.215.0 respectively

Table (5): Assessment of attitude towards hand washing of Nurses in Ain shams
university
Attitude of nurses
1-HW is protective to health
care personnel
2-HW can be improved by
administrative orders and
continuous observation
3-HW lowers nosocomial
infections more than any
other methods of IC
4-HW can be improved by
role models

No.

72

96.0

73

97.3

69

92.0

53

70.7

The Egyptian Journal of Community Medicine

Vol. 26

No. 2

April 2008

Workers
N=35
50.00
47.59.5
55.05.7
40.010.0
63.311.5
37.59.5
40.028.2
52.010.9
26.015.1

Khaled M. Abd Elaziz and Iman M. Bakr

Assessment of knowledge, Attitude

Table 6: Ward assessment in different departments in Ain Shams University

hospitals (n=10)
Items
No. (%)
Number of available sinks
8 (80)
Number of sinks where soap is available
4 (40)
Availability of hand drying material
1 (10)
Availability of paper towel
0 (0)
Availability of cloth towel
1 (10)
Availability of alcohol hand rub
4 (40)
Availability of automatic sinks
1 (10)
Availability of gloves at point of care
7 (70)
Written hand hygiene guidelines
3 (30)
Availability of communication material for hand hygiene(HH)
5 (50)
Staff formally educated on HH
7 (70)
A product selection process has been implemented
1 (10)
Feedback performance provided to staff
1 (10)

25

23.2

20

18.8
15.7

15

14.5

9.9

10

7.9
5.6
4.3

5
0

A+

B+

A+

B+

d
B
ne
A+
ea
cl
rs
es
c
he
rfa
Ot
su
e
ll
im
ta
tt
No
ac
Cnt
o
tc
ng
or
yi
Sh
dr
Ber
op
pr

Im
A-

Figure 1: Forms of inappropriate hand hygiene among observed opportunities

(Total 605)
A- Improper drying is any method of dying other than dying in fresh clean towel
B- Short contact time is below 30 seconds in routine hand washing and alcohol hand
rub, or less than 2 minutes in hygiene wash.
C-Not all surfaces cleaned
D-Others

The Egyptian Journal of Community Medicine

Vol. 26

No. 2

April 2008