Knowledge, Attitude and Practice regarding hand hygiene among Medical Students and Nurses-A questionnaire based survey in tertiary care hospital

Hand hygiene is a milestone to control infectious diseases and prevent cross transmission of microorganism and reduces the incidence of healthcare associated infections, improved hand hygiene practice has been recognized as an important public health measure. The study was carried out in a Tertiary care teaching hospital over a period of three months. A total two seventy six (276) students were included in this study. A descriptive approach was adopted, including collection of information through questionnaire based survey. Structured knowledge questionnaires were prepared according toW.H.O. criteria. The present study concluded that the knowledge regarding hand hygiene was found to be average, 186 (67.4%) of the medical students and nurses attending tertiary care hospital, whereas 190 (68.8%) had average score for attitude of handhygiene and173 (62.7%)had average score for practice of hand hygiene. So frequent orientation, regular training, workshops, seminars and hand hygiene education should be given mandatory for all the students and staffs for understanding the importance of hand hygiene were improved hand hygiene practice should reduce the healthcare cost which help in preventing hospital acquired infections.


INTRODUCTION
According to the World Health Organization, Hand hygiene is a common term which is applicable to hand washing, antiseptic hand rub, antiseptic hand wash or surgical hand antisepsis. (Mohesh and Dandapani, 2014) Hand Hygiene helps in preventing cross-transmission of microorganism and controlling the prevalence of healthcare associated infections. The most appropriate hand hygiene behaviour is considered as the keystone for preventing health care associated infections. (Kamble et al., 2016;Allegranzi and Pittet, 2009) The World Health Organization (W.H.O.) has introduced the concept of "My ive moments for Hand hygiene" for Global Patients Safety Challenges, it includes:-1. Moments before touching a patient 2. Before performing aseptic and clean procedures 3. After being at risk of exposure to body luids 4. After touching a patient

After touching patient and surrounding
So the application and adherence to hand hygiene practices can prevent Healthcare Acquired Infections (HAI). (Shinde and Mohite, 2014) This concept of hand hygiene is used to improve, training, understanding, monitoring and reporting hand hygiene among the Health Care Workers. It is recommended in all National and International Infection Control Guidelines. (Ansari et al., 2015) The major cause of mortality and morbidity in admitted patients is due to Health care associated infections (HAI) contributing to 7-10% of the total hospital infections. (Arthi et al., 2016) The signi icance of hand hygiene irst identi ied in 1840s by Dr. Oliver Wendell Holmer to prevent Childbed fever. (Nawab et al., 2015) Later Ignaz Semmelweis introduced the concept of Hand hygiene and antisepsis by demonstration that the contaminated hand cleansing with an antiseptic agents into patient contact reduces the transmission of infectious diseases effectively than just washing hands with plain soap and water. (Paudel et al., 2017)  The recommended duration for hand washing is between 30 seconds to one minute. It is noted that Alcohol based hand antiseptics are used in most of the countries for rapid antimicrobial effects, broad spectrum coverage, better patient tolerability and also ease of application. (Al-Naggar and Jashamy, 2013) The maximum of health care workers are composed by the nurses which are appraised as "nucleus of the healthcare system", it is very crucial in preventing the diseases among the hospitalized patients.
Hand hygiene is also used in the prevention of Hospital Acquired Infections or Nosocomial infections; these are obtained during patient hospitalization within 48-72 hours. (D'souza. and Urnarani, 2014) For preventing cross infections and Healthcare associated infections, several countries worldwide started their national campaigns to improve hand hygiene as a part of the World Health Organization's 'Clean Care is Safer Care' Campaign. (Allegranzi et al., 2013;Reichardt et al., 2013) Two types of micro-organism are found over the human skin:-1. Resident's lora (organisms that normally inhabited in skin).

Transient's lora (Contaminates).
Transient's lora causes most hospital acquired infections by cross-transmission, but it can be comfortably removed by hand cleaning. So regular hand washing by doctors and nurses decreases the colonization of skin with transient lora and render safe for next patient's contact. (Pittet, 2001) According to the W.H.O., prevalence of nosocomial infections is 19% in developing countries, so the personal hygiene and standard universal safety precautions should be included. W.H.O. estimated that washing hands with soap and water reduces the death caused by diarrhea up to 50%. Hand washing prevents acute respiratory infections by 16%. (Chakraborty et al., 2018) As per our knowledge, very few community studies have been conducted regarding the awareness of hand hygiene in India. The staff has exposed to a variety of infectious throughout the process of day to day nursing activities and they are at higher risk in contacting infections. Hand hygiene education should be mandatory for all clinical courses. Hence, present study has undertaken to determine the "Knowledge, Attitude and Practices about hand hygiene among medical students and nurses.

Research methodology
The methodology adapted for the study including research settings,

Research approach
A descriptive cross sectional study approach had approach.

Research design
The collection of information and data directly from the study through a predesigned and pretested questionnaire scheduled.

Population
The population for this study included the medical students and nurses working in Tertiary teaching hospital of Jawaharlal Nehru Medical College.

Sample size
Sample size of the study is two hundred and seventy six (276), health care workers.

Construction of tool
The tool was a predesigned and pretested questionnaire schedule constructed using review of literature from books, journals and published research studies.

Description of tool
The structured questionnaire had three sections as follows

Section 1
It consists of items related with selected demographic variables such as age, gender, quali ication and profession.

Section 2
A structured questionnaire was used to access the awareness. It consists of items related to assess the awareness regarding hand hygiene practice among medical students and nurses in hospital.

Section 3
It consists of items related to source of awareness for students about hand hygiene.

Data collection process
Step-I =The investigator procured permission from respective authority to conduct the study.
Step-II = Investigator introduced herself to the participants and noti ies about his\her aim, objectives and obtains written informed consent from all the study subjects.
Step-III = Conducted survey using structured Performa.

Data analysis technique
Variables were tested using chi-square tests and Data analyses were conducted using MS excel and SPSS version 20, p<0.05 was considered statistically signi icant. Table 3 showed that 25 (9.1%) subjects had poor knowledge, 186 (67.4%) subjects had average knowledge and 65 (23.6%) subjects had good knowledge regarding hand hygiene.

DISCUSSION
The discussion includes 1. Socio-demographic variables of medical students and nurses.
2. Findings related the knowledge, Attitude and Practice of hand hygiene among young medical undergraduates' students and nurses.
The inding is similar to the study is done in Mangalore, in 2014. Hundred (100) nursing students were included in the study, yielding a response rate 94%. About (95%) of the respondents were between the ages of 20-22 years. Majority (95%) were females and (5%) were males. About (6%) of the respondents had attended seminars and workshop. (Table 1).
Findings related the knowledge of hand hygiene among medical undergraduates students and nurses.  What is the reason for healthcare workers to practice good hand hygiene? A.
To prevent transfer of bacteria from hospital to home. 76 27.5 B.
To prevent transfer of bacteria from home to hospital. 58 21.0 C.
To remove visible soiling from hands. 16 5.8 D.
To prevent infections that patients acquire in the hospital.    In the present study, majority of participants i.e. 186 (67.4%) had average level of knowledge (5-7) regarding hand hygiene, 25 (9.1%) participants had poor level of knowledge (0-4) and 65 (23.6%) had good level of knowledge (>7). The reason could be that more than half of the respondents had attended the seminars. The mean knowledge score among 276 students, mean was 6.32, median 6, and mode 6, range 6 and standard deviation was 1.40, out of 10 questions.
The inding is similar to the study done at Aligarh, in 2015. About 130 students were included in study 71 (80%) had average knowledge only (7%) had good knowledge regarding hand hygiene. (Table 2).

Findings related to the Attitude of hand hygiene among medical undergraduates and nurses
The present study majority of participants i.e. 33 (12.0%) had poor level of attitude (0-3) regarding HH, 190 (68.8%) participants had average attitude (4-5) and 53(19.2%) had good attitude (>6). The reason could be that more than half of respondents had attended workshops and had good education about it. The mean attitude score among 276 students, mean was 4.66, median 5, mode 5, range 4 and standard deviation 0.944, Out of 6 questions.
The inding is similar to the study done at Raichur, Karnataka, in 2013. About 144 students were included in the study (52.1%) had average attitude only (20%) had good attitude regarding hand hygiene where they had received a formal training. (Table 4) Findings relate the Practice of hand hygiene among medical undergraduates' and nurses.
In the present study majority of participants 173 (62.7%) had a through aware about the practices (5-6), 43 (15.6%) had good practice regarding hand hygiene (>6) and 60 (21.7%) had poor practice (0-4). More of the participants daily practiced the hand hygiene moments and monthly they got the training from the hospital. The mean practice score among 276 participants mean 5.39, median 6, mode 6, range 5 and standard deviation 1.101. Out of given 7 questions. The inding is similar to the study done in Sri Lanka, in 2013. About 289 students were included in the study where (5.53%) had good practice, (26.9%) had average practice and two-third (67%) has low HH practice. (Table 6)

CONCLUSIONS
The present study concludes, in the current study overall level of knowledge in medical students and nurses was average 186 (67.4%), attitude was average 190 (68.8%) and practice was average 173 (62.7%). The knowledge scoring for hand hygiene was found to be average (score 5-7), for attitude the average score was (4-5) and for practice score was average (5-6). The present study concluded that knowledge, attitude and hand hygiene practice among medical students and nurses was found to be adequate among the study group was satisfactory. There is need to continue training program for nurses and medical students on major concept of hand hygiene. Continuous vigilance, assessment and supervision regarding hand hygiene can be a logical solution to improve the KAP among medical students and nurses for awareness.