Assessing Hand Hygiene Practices Among Nurses in the Kingdom of Saudi Arabia

300 nurses were approached to enroll 243 participants so the response rate was 81%. The study found that 65.4% (159) of the participants followed a good hand hygiene practice while 10.3% (25) showed inadequate hand hygiene practice. Good hand hygiene practice was found to be significantly higher among female participants (88%) than the male participants (44%). The participants from the department of internal medicine (43.5%) showed the highest percentage of inadequate hand hygiene practice while participants from the department of pediatrics reported a 100% good hand hygiene practice.


INTRODUCTION
Hand hygiene is a simple and important procedure that prevents the spread of healthcare-associated infections within hospital settings. As a cost-effective intervention, hand hygiene plays a vital role in infection control and ensures the safety of patients in health care organizations [1]. It is estimated that more than 1.4 million people across the globe are affected due to hospital acquired infections [2].
The World Health Organization projects that the prevalence of hospital acquired infections is about 5-10% in the developed countries and roughly 40% in the developing countries [3]. The previous literature declares that the burden of hospital acquired infection among underdeveloped nations is predominantly high [4]. The previously published literature substantiates that washing hands with soap and water or using alcohol-based hand rub are the most effective methods for preventing the transmission of infectious diseases [5].
There is sufficient evidence from the previously published literature mentioning that infections can cause severe adverse effects on patients and can result in prolonged hospital stays, pneumonia and even death [6]. Furthermore, the presence of hospital acquired infections also increases the economic burden within households and raises the cost of the health care delivery system in the country [7]. Hands of the health care professionals are usually contaminated with pathogenic microbial organisms, which play a significant role in the transmission of infections from one person to another person within the hospital setting [8].
Among health care professionals, nurses constitute the majority of health care professionals and are considered to be the nucleus of the health care delivery system given as they are in direct contact with patients and spend more time with them [9,10]. Health care associated infections are also a major public health problem in the Kingdom of Saudi Arabia. A study carried out by Abdel-Fattah et al. [11] in the Taif Al-Hada Armed Forces Hospital found that 668 out of 1382 hospitalized patients developed hospital acquired infections during their stay in the hospital. Similarly, a study conducted by Sabra et al. in Taif [12] between the years of 2010 to 2011 indicated that 48.3% of patients had developed hospital acquired infections.
There is considerable evidence from the previous literature indicating that strict hand hygiene practices among health care professionals can significantly reduce the incidence of hospital acquired infections [13 -15]. However, several studies show that the compliance of hand hygiene among health care professionals is generally low [16,17]. Also, the study by Kalata et al. [18] in hospitals in Malawi found that only 23% of the health care professionals adhered to hand hygiene practices.
The low adherence to hand hygiene practices acts as a major barrier to implementing infection control programs in hospitals. Moreover, there are no ideal methods available for monitoring the compliance of hand hygiene practices among health care professionals [19]. Therefore, the objective of this study is to assess the practices of hand hygiene among nurses in the Kingdom of Saudi Arabia and to find the association between the hand hygiene practices and the general demographic characteristics of nurses.

Study Setting & Participants
A cross-sectional survey was administered to nurses in six selected hospitals in the Asir region of the Kingdom of Saudi Arabia from November 2017 to May 2018. The study used cluster sampling to select hospitals. The first 6 out of about 12 government-owned hospitals in the Asir region whose managers were available and facilitated the process of data collection were included in the study. Opportunistic sampling technique was used to recruit the study participants. From the selected hospitals, the nurses who had direct contact with patients were invited to participate in the study.

Sample Size Calculation
The sample size was calculated by using the Raosoft sample size calculator. The margin of error was kept 5% with a confidence interval of 95%, and a response distribution of good hand hygiene practice as 29.8% from a previous study from Saudi Arabia [20] with an anticipated frequency of nursing population of 1000. The minimum sample size calculated was 243.

Data Collection
The research team visited the selected hospitals and had a face to face discussion with the nurses specific to individual departments of the hospital during their break time. The nurses were briefed about the research and informed that their participation in this research is completely voluntary. The researchers also explained to nurses that the data collected would be used only for research purposes with utmost confidentiality. A written informed consent was obtained from each nurse at the time of enrollment.
Data was collected using the standard questions related to the practice of hand hygiene based on the WHO Guidelines on Hand Hygiene for Health care professionals [21]. Additional questions were included for collecting the general demographic information of participants such as age, gender, departments and years of experience.
The questionnaire was developed in English language and then translated into Arabic language for the purpose of research. All the nurses from the selected hospitals were provided with the online link where they can find the electronic version of the questionnaire in the Arabic language. The nurses were asked to complete and submit the questionnaire electronically.

Scoring System for Practice
There were a total of 11 questions in the questionnaire that were given score 1 and 0 for right and wrong answers, respectively. If the participant answered "sometimes", it was considered as a wrong answer to reduce the effect of social desirability. The total score ranged from 0 to 11. The total score was divided into three categories: 'inadequate practice' (less than 6), 'adequate practice' (6 to 8) and 'good practice' (9 to 11).
Good Practice: The study participants who responded to the practice questions >75% in line with the suggested hand washing practice.
Adequate Practice: The study participants who responded to the practice questions up to 50-75% in line with the suggested hand washing practice.
Poor Practice: The study participants who responded to the practice questions <50% in line with the suggested hand washing practice.

Data Analysis
The data analysis was carried out by using SPSS (Version 16.0, SPSS Inc. Chicago, IL, USA). A frequency table was used to describe the self-reported practice of hand hygiene among nurses. Chi-square test/Fischer exact test was applied to nominal scales as applicable. The p-value <0.05 was considered to be statistically significant.

Ethical Approval
Ethical approval was obtained from the research ethics committee, College of Medicine, King Khalid University, Abha, Asir region, (HA-06-B-001) Kingdom of Saudi Arabia. Official permission was obtained from the Ministry of Health-Asir region to conduct this study in the selected hospitals of the Asir region.

RESULTS
Three hundred nurses from the six hospitals were approached to recruit 243 nurses into the study, thus yielding a response rate of 81%. Table 1 shows the general demographic characteristics of the study participants. Among the 243 participants, 50.6% (123) belonged to the age group of 25-34 years, 38.3% (93) had clinical experience of about 6 to 10 years. Majority of the participants 77.8% (189) had undergone a training course on hand washing.
Participants' responses to the practice questionnaire are described in Table 2. Nearly 69% (167) of the participants claimed to routinely wash their hands and 69.1% (168) claimed to use alcohol-based hand rubs. The highest percentages of hand wash practice reported by the participants were 91.4% (222) after exposure to body fluids, followed by 88.5% (215) when their hands look dirty and 87.2% (212) after exiting an isolation room. The lowest percentages of hand wash practice reported by the participants were 70.8% (172) after physical contact with patients, followed by 72.4% (176) before any medical procedures and 73.3% (178) before entering an isolation room.  Table 3 shows the distribution of participants according to hand hygiene performances. The self-reported responses to the hand hygiene questionnaire in the study found that 65.4% (159) of the participants followed a good hand hygiene practice (>75% responses are in line with the suggested hand washing practice) while 10.3% (25) showed inadequate hand hygiene practice (<50% responses are in line with the suggested hand washing practice).
The association between participants self-reported practices on hand hygiene and the general demographic variables is indicated in Table 4. In the study, good hand hygiene practice was found to be significantly higher among female participants (88%) than male participants (44%) when compared with inadequate (3.4% vs 16.7%) and adequate practice (38.9% vs 8.6%)(p<0.0001). The participants in the age group 25-34 years showed a significantly lower percentage of good hand hygiene practice (56.1%) than 45-54 years (84.6%) when compared with adequate practice (33.3% vs 15.4%) (p=0.038). The participants with 11-15 years of experience showed a significantly lower percentage of good hand wash practice (58.6%) than above 15 years of experience (77.8%) when compared with inadequate (25.9% vs 0%) and adequate practice (15.5% vs 22.2%) (p=0.003 & 0.0006 respectively). The participants following good hand hygiene practice (67.2%) had significantly higher exposure to training course than participants with adequate practice (22.2%) (p=0.002) The participants from the department of pediatrics showed 100% good hand hygiene practice followed by obstetrics (92.3%) and mixed medicine & surgery (77.8%). The participants from the department of internal medicine (43.5%) showed the highest percentage of inadequate hand hygiene practice.

DISCUSSION
The current study was conducted to investigate the selfreported practices of hand hygiene among nurses in the Asir region in the Kingdom of Saudi Arabia. The World Health Organization (WHO) has compiled a questionnaire for increasing the compliance of hand hygiene and also to reduce the prevalence of hospital-acquired infections [22]. In the present study, it was found that 65.4% nurses followed good hand hygiene practice and 24.3% followed adequate hand hygiene practice while the study conducted in the central region of Saudi Arabia on nursing students reported a higher percentage of moderate hand hygiene practice (68.7%) and a lower percentage of good hand hygiene practice (29.8%) [20]. However the rate of inadequate or poor hand hygiene practice in the present study (10.8%) was similar to the study conducted on nursing students of the central region of Saudi Arabia (13.1%). The differences in the hand hygiene practice may be due to the difference in subjects enrolled in the studies. A review article by Kendall et al., 2012 reported that the compliance of hand hygiene among health care professionals in Canada is low [23]. Similarly, two other studies pointed out that compliance of hand hygiene among nurses is poor and highly influenced by the heavy workload, a high number of clinical procedures and skin conditions [24,25]. Furthermore, several studies that were carried out in Saudi Arabia, SriLanka, Ethiopia, and other countries showed that a hand hygiene compliance rate among the health care professionals varies between 5.53% to 87.5% [20, 26 -31].
Regarding the relation between gender and self-reported hand hygiene practices, the results of the present study showed female nurses as having a significantly higher good hand hygiene practice than male nurses. These results are in accordance with other studies, which also showed similar significant differences in the performance of hand hygiene between males and females [32 -35]. Similarly, the study by Cruz et al., 2015 recognized that the mean score for hand hygiene practice varies between males and females [36]. However, the higher compliance rate of hand hygiene among females may also be associated with their propensity to practice socially acceptable behaviors [37,38].
In the present study, it was found that the nurses working in the Pediatric and Obstetric department followed good hand hygiene practice; this may be due to their regular involvement with the most vulnerable population to hospital-associated infection. The nurses in the department of Internal Medicine showed inadequate hand hygiene practice which may be due to the workload. Frequent hand hygiene training sessions to nurses are needed in the department of internal medicine to encourage them to observe and follow up correct hand hygiene practices.
In the present study, 77.8% of nurses self-reported to have attended training courses for hand hygiene practices, which was reflected in the higher percentage of good hand wash practice by 65.4%. The study done by Mazi et al., 2013 [39] on 1,975 health care professionals in Taif, Saudi Arabia asserted that there was an increase in hand hygiene compliance from 51% to 67% between May to June 2010 after an intervention campaign. A study by Cruz et al., 2015 mentioned that there is a need for gender-specific educational intervention in order to address gender disparity [36].
A study by Randle et al., 2006 [40] has confirmed that the practice of hand hygiene among health care workers can be enhanced significantly through regular hand hygiene training using different educational materials to remind health care workers of hand hygiene. Shinde et al., 2014 [41] advocated the need for training programs on hand hygiene at regular intervals by using the materials provided by the World Health Organization and also the need for active participation of infection control team in order to create awareness about hand hygiene and to build the supportive environment for improving the practice of hand hygiene within hospitals.

LIMITATIONS
The main limitation of the current study is that the results are based on self-reported questionnaire.There may be an exaggeration of hand hygiene compliance among nurses especially those who have attended the training course for hand washing. Moreover, there is a possibility of social desirability bias [42] as the study was conducted in hospital setting among nursing professionals. Therefore, to reduce the effect of social desirability to some extent, the participants' response "sometimes" was considered as a negative response. Another limitation of the study is that no proxy measures like hospitalacquired infection rates of different departments, and access to hand hygiene facilities of nurses in different departments were not assessed in the study to validate the self-reported hand hygiene practice. However, a previous study [43] reported that the self-reported hand hygiene compliance rate can be considered as an acceptable substitute when there exist cost and time constraints. Lastly, the participants in the study were enrolled using the opportunistic sampling technique, which limits the generalizability of results.

CONCLUSION
This study was conducted to assess the self-reported practices of hand hygiene among nurses. 65.4% of nurses in this study followed good hand hygiene practices. The male nurses and nurses working in the department of internal medicine need in-service educational intervention regarding hand hygiene to increase their compliance with hand hygiene practices. Posters and other visual aids highlighting the significance of hand hygiene need to be displayed in all the departments to sensitize the importance of hand hygiene among nurses.

ETHICS APPROVAL AND CONSENT TO PARTI-CIPATE
Ethical approval was obtained from the research ethics committee, College of Medicine, King Khalid University, Abha, Asir region, (HA-06-B-001) Kingdom of Saudi Arabia.

HUMAN AND ANIMAL RIGHTS
Not applicable.

CONSENT FOR PUBLICATION
All participants participated on a voluntary basis and gave their informed consent.

AVAILABILITY OF DATA AND MATERIALS
The original data collected using questionnaires used to support the findings of this study shall be available from the corresponding author [M. A] upon request.

FUNDING
None.

CONFLICT OF INTEREST
The author declares no conflict of interest, financial or otherwise.