American Journal of Infection Control xxx (2015) 1-3

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American Journal of Infection Control

American Journal of
Infection Control

journal homepage: www.ajicjournal.org

Brief report

Knowledge, attitudes, and practices of health care personnel

concerning hand hygiene in Shiraz University of Medical Sciences
hospitals, 2013-2014
Milad Hosseinialhashemi a, Fatemeh Sadeghipour Kermani MD b,
Charles John Palenik PhD, DDS, MS, MBA c, Hamid Pourasghari MD d,
Mehrdad Askarian MD, MPH e, *
a

Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran

Community Medicine Department, Shiraz Medical School, Shiraz University of Medical Sciences, Shiraz, Iran
c
Indiana University School of Dentistry, Indianapolis, IN
d
Department of Health Service Management, School of Health Management and Information Sciences, Tehran, Iran
e
Department of Community Medicine, Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
b

Key Words:
Hand hygiene
Health care personnel
Health careeassociated infections
Infection prevention

This study evaluated knowledge and self-reported attitudes and practices concerning hand hygiene
among hospital workers in Shiraz, Iran, using a 68-question survey divided into 4 sections:
demographics, knowledge, attitudes, and practices. Work experience had a correlation with practices and
knowledge (P < .05), and knowledge and practices scores were positively correlated (P < .05). Participants appear to have sufcient knowledge and proper attitudes regarding hand hygiene; however,
compliance practices were suboptimal.
Copyright 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.

Health careeacquired infections (HAIs) can occur anywhere

health care is provided. HAIs are among the most common preventable medical complications among hospitalized patients.1,2
HAIs occur in approximately 5% of hospitalized patients causing
signicant increases in morbidity and mortality.2 The Centers for
Disease Control and Prevention estimated that in 2002, >1.7 million
HAIs and 99,000 HAI-associated deaths occurred in hospitals.3,4
In addition to the human toll, HAIs place signicant nancial
burdens on health care systems. However, recent studies suggest
that proper and consistent application of existing infection
prevention and control practices can lead to up to a 70% reduction
in certain HAIs. The nancial benet of using these preventive
practices is estimated to be $25-$31.5 billion in medical cost savings
per year.4,5
* Address correspondence to Mehrdad Askarian, MD, MPH, Department of
Community Medicine, Shiraz University of Medical Sciences, PO Box 71345-1737,
Shiraz, Iran.
E-mail address: askariam@sums.ac.ir (M. Askarian).
Funding/Support: Supported by the Vice-Chancellor for Research, Shiraz
University of Medical Sciences (grant no. 5852).
Additional information: This study was performed by Milad Hosseinialhashemi
in partial fulllment of the requirements for certication as a general practitioner at
Shiraz University of Medical Sciences, Shiraz, Iran.
Conicts of interest: None to report.

Elimination of HAIs requires culture change among all members

of a health care personnel (HCP) team plus the support of facility
leadership. Success is based on a combined effort of personal
commitment, implementation of evidence-based practices, and
proper resource allocation.4,6
One of the key elements in the control of HAIs is universal hand
hygiene (HH) among HCP. Raising awareness, signicant training,
incentives, and behavior modication have improved HH; however,
the overall rate remains a concern. HCPs hands readily become
contaminated with transient bacteria posing a risk for transmission
and possible HAI. Proper HH is one of the simplest and most
effective measures for preventing HAIs.7-9 Other studies indicate
that HCP with better knowledge of and attitudes toward standard
precautions have better HH compliance.9-11
Our study aimed to assess knowledge levels, attitudes, and selfreported practices of HCP toward HH in several Shiraz hospitals.
METHODS
Study design
This cross-sectional study was conducted among HCP afliated
with 5 Shiraz University of Medical Sciences hospitals using

0196-6553/$36.00 - Copyright 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2015.05.002

M. Hosseinialhashemi et al. / American Journal of Infection Control xxx (2015) 1-3

Table 1
Demographic data from study respondents
Ward-unit
Demographics
Position
Physician
Medical-nursing student
Nurse-midwife-technician-therapist
Degree
Associates
Bachelors
Masters
General practitioner
Specialist
Subspecialist
Total

Internal medicine

Surgery

4 (9.5)
6 (14.3)
32 (76.2)

9 (7.3)
3 (2.4)
111 (90.2)

8 (13.8)
6 (10.3)
44 (75.9)

17
19
5
1
0
0
42

55
51
10
5
0
2
123

21
29
3
3
1
1
58

(40.5)
(45.2)
(11.9)
(2.4)
(0.0)
(0.0)
(100.0)

Obstetrics-delivery assistant

(44.7)
(41.5)
(8.1)
(4.1)
(0.0)
(1.6)
(100.0)

(36.2)
(50.0)
(5.2)
(5.2)
(1.7)
(1.7)
(100.0)

ICU

Burn

Oncology

8 (26.7)
3 (10.0)
19 (63.3)

10 (20.4)
4 (8.2)
35 (71.4)

12 (16.0)
5 (6.7)
58 (77.3)

51 (13.5)
27 (7.2)
299 (79.3)

5
17
5
2
1
0
30

9
27
3
9
1
0
49

14
45
10
1
4
1
75

121
188
36
21
7
4
377

(16.7)
(56.7)
(16.7)
(6.7)
(3.2)
(0.0)
(100.0)

(18.4)
(55.1)
(6.1)
(18.4)
(2.0)
(0.0)
(100.0)

(18.7)
(60.0)
(13.2)
(1.4)
(5.3)
(1.4)
(100.0)

Total

(32.1)
(49.9)
(9.5)
(5.6)
(1.8)
(1.1)
(100.0)

NOTE. Data are shown as n (%) within each ward-unit.

ICU, intensive care unit.

convenience sampling from July 2013-July 2014. Approval for the

study was obtained from Shiraz University of Medical Sciences
Committee of Ethics. Verbal consent was obtained, and participation was voluntary.
Participants
Included were physicians, medical residents and students,
nurses, midwives, nursing-midwifery students, and therapiststechnicians working in internal medicine; surgical, burn,
oncology, and obstetrics wards; and intensive care units. Sex, work
experience, and type of work contract did not affect inclusion.
Sampling
A minimum sample size of 322 was needed to obtain a condence level of 95% with a condence interval of 5%. Sample size
calculations came from the scientic literature and other Shiraz
studies.
Trained interviewers distributed self-report questionnaires with
instructions during all working shifts and collected them immediately after completion. The interviewers answered any participant questions. Respondents were assured that all responses would
be kept condential and used for research purposes only.

Table 2
Scores of knowledge, attitudes, and practices of health care workers in each
ward-unit
Ward/Unit
Knowledge (no. of enrolled people)
Internal medicine (42)
Surgery (123)
Obstetrics-delivery assistant (58)
ICU (30)
Burn (49)
Oncology (75)
Total (377)
Attitude (no. of enrolled people)
Internal medicine (42)
Surgery (123)
Obstetrics-delivery assistant (58)
ICU (30)
Burn (49)
Oncology (75)
Total (377)
Practice (no. of enrolled people)
Internal medicine (42)
Surgery (123)
Obstetrics-delivery assistant (58)
ICU (30)
Burn (49)
Oncology (75)
Total (377)

Mean

SD

P value

12.64
13.10
12.86
14.86
13.93
16.08
13.85

2.46
2.62
1.81
2.96
2.64
2.14
2.72

<.001

32.45
32.97
35.48
31.96
32.28
33.74
33.28

2.78
2.90
2.98
3.35
2.90
3.04
3.14

<.001

14.33
12.50
20.98
12.43
15.08
16.48
15.13

5.95
4.02
5.97
4.80
6.09
4.41
5.78

<.001

ICU, intensive care unit.

Questionnaire design and scoring

An infection control expert developed the questionnaire. It
included the following 4 sections: demographics (5 items),
knowledge (24 items), attitudes (8 items), and practices (31 items).
It was pretested on a random sample of HCP. Reliability was
assessed using a Cronbach a internal consistency coefcient
(r 0.77).
Correct knowledge answers received 1 point. Attitudes were
assessed on a 5-point, Likert-type scale. Practice items had 5
possible choices: always, often, sometimes, seldom, and never.
Always and often responses received 1 point, whereas the other 3
received zero points. When respondents achieved 0%-25%, 26%50%, 51%-75%, and 76%-100% of their total possible score, they
were assessed as being very poor, poor, moderate, and good,
respectively.
Statistical analysis
Data were examined for frequencies, means, and SDs. Analysis
involved SPSS Statistics Version 21 (SPSS, Chicago, IL).

Independent-samples t test and 1-way analysis of variance were

used to determine intergroup differences. Correlation coefcients
were calculated between age and knowledge, age and attitude, age
and practice, work experience and knowledge, work experience
and attitude, work experience and practice, knowledge and practice, knowledge and attitude, and attitude and practice. Also, a
correlation coefcient was calculated by age and experience.
P values of .05 were considered signicant. Correlation was
signicant at the .05 level (2-tailed).

RESULTS
Of the 500 HCP (out of a possible 2,756) approached, 377 (75.4%)
returned completed questionnaires. Respondents were 20-52 years
old (29.98  6.24). Work experience ranged from 0-30 years
(5.34  5.25). Most respondents were women (80.6%, P < .001). The
distribution of education levels was not balanced (1-sample c2 test,
P < .001). Detailed demographic data of the respondents are shown
in Table 1.

M. Hosseinialhashemi et al. / American Journal of Infection Control xxx (2015) 1-3

Table 3
Status of knowledge, attitudes, and practices of health care workers in different wards-units
Status of knowledge
Wards-units
Internal medicine
Surgery
Obstetrics-delivery assistant
ICU
Burn
Oncology
Total

Very poor
1
0
0
0
0
0
1

(2.4)
(0.0)
(0.0)
(0.0)
(0.0)
(0.0)
(0.3)

Poor
23
57
29
8
14
4
135

(54.8)
(46.3)
(50.0)
(26.7)
(28.6)
(5.3)
(35.8)

Moderate
18
61
29
19
32
63
222

(42.9)
(49.6)
(50.0)
(63.3)
(65.3)
(84.0)
(58.9)

Status of attitude
Good
0
5
0
3
3
8
19

(0.0)
(4.1)
(0.0)
(10.0)
(6.1)
(10.7)
(5.0)

Moderate
10
21
5
7
12
14
69

(23.8)
(17.1)
(8.6)
(23.3)
(24.5)
(18.7)
(18.3)

Good
32
102
53
23
37
61
308

(76.2)
(82.9)
(91.4)
(76.7)
(75.5)
(81.3)
(81.7)

Status of practice
Very poor
5
15
0
6
5
2
33

(11.9)
(12.2)
(0.0)
(20.0)
(10.2)
(2.7)
(8.8)

Poor
23
93
18
19
32
38
223

(54.8)
(75.6)
(31.0)
(63.3)
(65.3)
(50.7)
(59.2)

Moderate
11
14
23
4
6
32
90

(26.2)
(11.4)
(39.7)
(13.3)
(12.2)
(42.7)
(23.9)

Good
3
1
17
1
6
3
31

(7.1)
(0.8)
(29.3)
(3.3)
(12.2)
(4.0)
(8.2)

NOTE. Data are shown as n (%) within each ward/unit.

ICU, intensive care unit.

Of the respondents, 87% reported completing an HH educational

course within the last 3 years. Total respondent mean scores for
knowledge, attitude, and practice were 13.85  2.72, 33.28  3.14,
and 15.13  5.78, respectively. HCP in oncology wards achieved the
highest mean knowledge scores of 16.08  2.14, whereas HCP in the
obstetrics wards-delivery assistant units had the highest mean
attitude and practice scores (35.48  2.98 and 20.98  5.97,
respectively) (Table 2). Most (64.9%) participants had moderategood level of knowledge, all had moderate-good attitude, but
only 32.1% reported moderate-good compliance (Table 3).
There were no signicant statistical differences in the total
knowledge, attitude, and practice scores between male and female
HCP. Also, means of scores of HCP who had HH courses in the last 3
years did not differ from those who had not. One-way analysis of
variance indicated that knowledge, attitude, and practice means of
scores signicantly differed among wards and care units (P < .001).
A positive linear correlation existed between total knowledge
(Pearson correlation 0.214, P < .001) and practice (Pearson
correlation 0.224, P .001) scores with work experience. Work
experience did not have a signicant correlation with attitude
(P .21). When considering work experience as a control variable,
age did not have any signicant correlation with knowledge, attitude, or practice scores (P .28, P .63, and P .07, respectively).
When considering experience and age as control variables, total
knowledge scores (correlation 0.178, P .001) and total attitude
scores (correlation 0.376, P < .001) have a positive linear correlation with total practice scores. Total knowledge had no signicant
correlation with total attitude scores (P .32).
DISCUSSION
HH guidelines and infection prevention courses are designed to
reduce and prevent HAIs. Most (87.0%) of this studys participants
had passed an HH course in the last 3 years. The result was that
their HH knowledge scores were rated as moderate or good. These
results are similar to those of a previous Shiraz study.12 In an Indian
study, Nair et al reported lower knowledge levels after training.13
In our study, all HCP attitude scores toward HH were moderate to
good. These results are similar to previous studies.14,15 An Egyptian
study reported HCP had positive attitudes toward HH.16 However,
only one-third of HCP surveyed in this study had moderate to good
self-reported HH compliance. Poor HH compliance has been reported in other HCP in Iranian,11,12 Egyptian,16 and Greek17 studies.
Results indicate Shiraz HCP had proper HH knowledge and attitudes; however, compliance was rated as being poor. There were
study limitations involved considering the study contained selfreported information, and human and statistical analyses resources were quite modest. Therefore, we believe the Iranian health
system should consider revising its infection prevention and

control training and monitoring, especially concerning HH policies

to improve actual practices among its HCP. This could include
several forms of HH surveillance.

Acknowledgments
We thank Dr. Saman Farahangiz, Dr. Behnam Dalfardi, and Dr.
Zahra Shayan for their valuable advice.

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