Knowledge, Attitude and Practices of Hand Hygiene among Students and Nurses Staff in Mwanza Tanzania: A Cross-Sectional Hospital-Based Study during Global COVID-19 Pandemic

Background: Hand hygiene (HH) is a critical component of infection prevention and control (IPC) which aims at preventing microbial transmission during patient care hence reducing the burden of healthcare associated infections (HCAIs). Information on the level of HH knowledge, attitudes and practices among healthcare workers (HCWs) from low-and middle-income countries is scarce. This study determined knowledge, attitude and practices of HH among students and staff nurses in Mwanza, Tanzania. Methods: This cross-sectional hospital-based study was conducted between August and October 2020 among student and staff nurses from 2health centres, 2district hospitals, 1regional referral hospital and 1zonal referral hospital. Self-administered pretested structured questionnaires were used for data collection. All data was transferred to Microsoft excel spreadsheet for cleaning and coding, then to STATA software version 13.0 for analysis. Results: A total of 726 nurses aged 18 to 59 years with median (IQR) age of 29(24-38) years were enrolled. About 3 quarters 76.4% (555/726) of nurses had good level of knowledge on HH as most of them 88.3% (641/726) had received rigorous IPC trainings during COVID-19 pandemic. About 42.0% (305/726) of the participants reported that, the action of HH was effortless. Majority of the participants, 81.1% (589/726) practiced hand washing more than hand rubbing routinely. Being a student nurse [OR: 0.30, 95%CI: 0.21-1.44, p<.001], working in inpatient department [OR: 0.38, 95%CI: 0.27-0.55, p<.001], high level of education i


INTRODUCTION
Hospital Acquired Infections (HAIs), also known as nosocomial infections or health care-associated infection (HAIs) are defined by the World Health Organization (WHO) as infections occurring in a patient during the process of care in a hospital or other health care facility, which were not present or incubating at the time of admission. This includes infections acquired in the health care facility, but appearing after discharge, and also occupational infections among Health Care Workers (HCWs) of the facility. 1,2 The acquisition of an infectious agent causing HAI is aided by 3 factors, namely; 1) source of the organism e.g., contaminated hospital environment, 2) presence of a susceptible host e.g., patient with impaired anatomical barriers and 3) aseptic procedure, 3. after body fluid exposure/risk; 4. after touching a patient; and 5. after touching patient surroundings. 4 These moments of HH aims at preventing the transmission of pathogens between patients, from patients to HCWs and vice versa, from patients to hospital environment and from contaminated hospital environment to patients. 4 In most low-and middle-income countries, the level of knowledge as well as attitude and practice of HH among HCWs is reportedly poor. Inadequate HH facilities and lack of adequate and appropriate training are the major factors contributing to poor knowledge, attitude and practice of HH among HCWs. 5 In Nigeria, about 55.8% and 68.8% of HCWs washed their hands before patients' palpations and giving injections, respectively. 6 In Ethiopia, about 65.9% of HCWs are reported to be knowledgeable about HH and 56% have poor practices of HH. 7 In Tanzania, Wieden mayer et al., reported a compliance of 56.1% and 30.5% to HH practices among healthcare workers in healthcare facilities with and without HH interventions, respectively. 8 Wieden mayer et al., proved that whenever IPC trainings i.e., HH is offered among HCWs, there is always a room for improvement, definitely reducing the burden of HAIs. 8 We therefore hypothesised that, the level of HH knowledge, attitudes and practices among HCWs improved dramatically during the global COVID-19 pandemic. This is because, during the COVID-19 pandemic, HH was among employed strategies for preventing the spreading of the virus known to cause COVID-19. Therefore, this study determined the knowledge, attitude, and practices of hand hygiene among students and nurses in 6 healthcare facilities in Mwanza, Tanzania.

Study Design, Duration, and Settings
This was a cross-sectional, hospital-based study conducted from August to October 2020 in primary, secondary, and tertiary healthcare settings in Mwanza, Tanzania. Primary healthcare facilities included 2 health centres; secondary healthcare facilities included 2 District Hospitals; and tertiary healthcare facilities included 1 Regional Referral Hospital and 1 Zonal Referral Hospital. The estimated number of nurses(employees) in each Health Centre was 20 and 14 in the 2 health centres; 125 and 87 in the 2 District Hospitals; 163 in Regional Referral Hospital, and 513 in Zonal Referral Hospital respectively. Student nurses pursuing bachelor's degree in Nursing practice their clinical subjects in tertiary healthcare facilities (Regional Referral and Zonal Referral Hospitals).

Study Population, Sample Size Estimation and Selection Criteria
The population of this study comprised mainly nurses (staffs and students in clinical rotations) because it's the nurses that mostly provide medical care services (e.g., samples collection, giving injections and cleaning of wards/clinics) to patients both in wards and clinics. Therefore, they possess the major risk of transmitting pathogens between patients, and patients and contaminated hospital environment resulting to patients' acquisition of HAIs. The minimum sample size for this study was 384, obtained by using Kish Leslie formula (1965) and a prevalence of 50%. We used a prevalence of of 50% to calculate the sample size because there was no similar study conducted in Tanzania before. All nurses (staffs and students in clinical rotation) in the selected healthcare facilities who were on practice and consented to participate in this study were enrolled. A total of 750 nurses were enrolled in the study but 24 were excluded due to incompleteness of their data collection tool. Therefore, only 726 participants were considered for final data analysis.

Sampling Procedure and Data Collection
Simple random sampling method was used, whereas participants in the respective healthcare facilities under this study were enrolled consecutively until overall sample size was met. Due to unequal staffing levels of the selected study sites, the distribution of enrolled participants is not equal.
Data Collection, Management, and Analysis Self-administered pretested structured questionnaire was used for data collection. The questionnaire was sectioned into 4 parts namely; PART A: socio-demographic questions, PART B: comprised with 15 knowledge-based questions, PART C: comprised with 7 attitude based questions, and PART D: comprised with 10 practice-based questions. For knowledge based questions, scores were expressed in percentages and for each correct answer one point was awarded. To get percentages, points earned from correct answers by participant were dived by total points the participant was supposed to earn and then multiplied by 100%. Thus, the level of knowledge on HH among participants was categorised into good knowledge (>75%), moderate knowledge (50%-74%) and poor knowledge (<50%) as reported in previous studies. 9 All data were transferred to Microsoft excel spreadsheet for cleaning and coding and then to STATA software version 13.0 for analysis. Percentages and fractions were used to present categorical data while median (interquartile range: IQR) were used to present continuous data. Chi square and logistic regression analysis were simultaneously performed to determine the association between categorical outcome i.e., knowledge level on HH and categorical predictors i.e., socio-demographic data. To facilitate analysis of association between categorical outcome and categorical predictors, 2 levels of knowledge (poor and moderate) were categorised to "not knowledgeable" while good knowledge was categorised to "knowledgeable". A p-value of less than .05 at 95% Confidence Interval (CI) was considered statistically significant.

Ethical Considerations
This study was approved by the joint CUHAS/BMC Research Ethics and Review Committee (CREC) with certificate number: 1590/2020. Permission to conduct this study was sought for from the administrations of the respective healthcare facilities. All participants were requested to sign informed written consent forms before being enrolled into the study. To ensure that confidentiality is observed throughout the study, unique identification codes were used to identify participants as opposed to use of participants' names. During data collection, physical distancing, wearing of face masks and use of alcohol-based sanitisers were observed to prevent the possible spreading of COVID-19.

Levels of knowledge on HH among Nurses
More than 3 quarters (76.4%; 555/726) of the study participants had good knowledge on HH and had received training on HH(88.3%; 641/726) during the COVI-19 pandemic from March to May 2020 prior to the study. Two thirds (68.5%;497/726) of the participants reported patient exposure to colonised surface and another two thirds (66.7%; 484/726) of respondents reported germs already present on patient body as the main route of cross-transmission and infections. The majority of participants acknowledged that, HH actions prevent transmission of germs to patients if well practiced: before touching the patient (96.1%; n=698); immediately after a risk of body fluid exposure (91.2%; n=662); after exposure to immediate surroundings of a patient (87.2%; n=638); and immediately before a clean/aseptic procedure (90.4%; n=656). The majority of respondents reported that HH protects HCW from pathogens when it is practiced: after touching a patient (93.8%; n=681); immediately after a risk of bodily fluid exposure (92.1%; n=668); immediately after a clean/aseptic procedure (100%; n=726); and after exposure to the immediate surroundings of a patient (89.7%; n=651). Most of the participants (79.9%; n=580) admitted that, if you touch the patient's environment you have essentially touched the patient.

The Attitudes of Nurses (Staffs and Students in Clinical Practices) towards Hand Hygiene
More than one-third (42.0%; n=305) of the participants said it requires no effort to practice good HH while more than a quarter (29.2%; n=212) said it requires big efforts to practice good HH. More than half (56.6% 411/726) of the participants said that they require no reminders so as to practice HH. The rest (43.4%; 315/726) who requires a reminder, the majority of them (63.5%; 200/315) said the availability of posters is enough to remind them to practice good HH. On the other hand, more than half of the nurses believed that; hand rubbing is more rapid for hand cleansing than hand washing (53.4%; n=388), hand rubbing causes skin dryness more than hand washing (50.3%; n=365), hand washing is more effective against germs than hand rubbing (54.4%; n=395), and that hand washing and hand rubbing should not be performed in sequence (53.2%; n=386). Furthermore, more than half (53.2%; 386/726) and nearly three quarters (74.2%; 539/726) of the respondents reported that, the use of gloves damages the skin and that the purpose of HH is to prevent transmission of infections from patients to HCWs, respectively ( Table 3).

The Practices of Nurses (Staffs and Students in Clinical
Practices) on Hand Hygiene. More than three quarters (81.1%; 589/726) of the respondents routinely practiced hand washing than hand rubbing. Further, majority of the respondents (97.5%;-

DISCUSSION
This is the first study on HH knowledge level, attitude and practices among nurse (staffs and students in clinical practices) during the global COVID-19 pandemic in this region. This study found out that majority of the participants were female nurses with working experience of more than 5 years, working in inpatient departments and enrolled from tertiary healthcare settings. These findings are similar to studies conducted in Tanzania 8 and Nigeria, 6 before the global COVID-19 pandemic. Majority of the participants were females because of the nature of the profession (nursing) being preferred mostly by females. Majority of the participants were staff nurses because few students are enrolled to pursue Bachelor of Nursing in the few Medical Universities available in the country and only senior students were eligible for clinical rotations. Furthermore, majority of the nurses were working in inpatient departments, this may be because the department requires significantly a higher number of work force (HCWs) to take care of hospitalised patients. As student nurses were excluded from working experience, majority of staff nurses had experience of more than 5 years. Lastly, majority of the nurses were HCWs is proportion to their improved knowledge, practices and attitude. Therefore, IPC trainings i.e., may bring positive impact in minimising the emergence and spreading of HAIs as reported previously in a study conducted in Taiwan. 10 The good level of knowledge on HH among nurses in this study was evidenced through the results from a basic knowledge-based questionnaire administered to the participants. The questionnaire included questions such as; types of HH actions which  10 Furthermore, at least one in two nurses believed that the presence of reminders viz., posters at their work stations will make them recall good HH practices. Multimodal interventional studies by Lam et al., 11 and Alp et al., 12 found that the use of reminders including posters increase compliance to HH among HCWs. In this study, more than half of the nurses believed hand rubbing using alcohol based agents is more rapid but it is not as effective as hand washing. Although, an experimental study by Ehrenkranz and colleague found that, alcohol-based hand rubbing is superior to hand washing in prevention of transfer of Gram-negative bacteria to catheters by the hands of HCWs. 13 However, WHO recommends hand washing whenever hands are visibly soiled with blood or other body fluids. 4 In this study, nurses believed that, hand rubbing causes skin dryness. This may happen when plain alcohol-based hand rub is used. Therefore, the use of glycerol (humectant for skin care) supplemented alcohol-based hand rubs is recommended as reported by the WHO. 14 Moreover, more than half of nurses reported that, the use of gloves damage their skin. This happens when latex-examination powdered gloves are worn for a long duration, resulting into skin dryness and roughness. Also, hypersensitivity to natural rubber latex (NRL) have been reported. 15,16,17 The use of powder-free gloves (if possible) and the presence of petroleum jelly at all hand washing stations is recommended in cases of hypersensitivity to NRL or skin dryness and roughness, respectively. 16,17 Lastly, about 3quarters of nurses think that HH aims at preventing transmission of infections from patients to HCWs. Therefore, they need to be updated on the risk of their hands acting as vehicles in cross-transmission of infectious agents (e.g., bacteria, fungi and viruses) between patients, and patients and their immediate environments as previous reported in "my five moments of HH" by the WHO. 4 Majority of nurses in this study practiced hand washing than hand rubbing. A similar observation was reported elsewhere. 18 This may be because hand washing facilities are always readily available as reported by nurses in this study. However, participants' attitude that hand washing is more effective against harmful germs than hand rubbing may also explain why the majority of nurses prefer hand washing. Moreover, most of the nurses change gloves in between when attending to different patients and before put on gloves for the next patient, nurses practice hand cleaning. Nurses in this study may be knowledgeable that long duration of gloves wearing facilitates re-colonisation of hands as reported by Grasso s et al., 19 and Wistrand et al., 20 . Therefore, hand cleaning is recommended whenever gloves are removed. Further, during situations like palpation of the abdomen, giving an injection, emptying a bedpan, making of patient's bed, and visible exposure to blood, most nurses prefer to practice hand washing over hand rubbing as recommended by WHO. 21 This may be because facilities for hand washing are always available or due to the participants' attitude that hand washing is more effective than hand rubbing. Despite the fact that, the majority of nurses reported that HH standards are discussed during shift handovers, nearly a half and about one third of the participants practiced hand rubbing and hand washing in less than the recommended minimum time, respectively. Thus, frequent trainings and retraining on IPC measures i.e., HH are recommended to make sure the majority if not all nurses practice hand cleaning (rubbing and washing) correctly.
Finally, in this study we observed that, being a nurse student, working in the inpatient department, increased level of formal education i.e., degree and above, and being a staff nurse with working experience of >5 years was associated with being knowledgeable on HH among student and staff nurses. Similar observations were reported in previous studies. 22,23 Student nurses had received training on IPC measures recently during their lectures as a part of strategy to prevent transmission of COVID-19 among University community and during clinical practices in wards or clinics. They were also more likely to adhere to clinical guidelines including HH as they are at all times under supervisions during their respective clinical rotations. Nurses working in the inpatient departments may have evidenced critical cases and outcomes of infectious diseases such as COVID-19 than those from outpatient departments. From this phenomenon, their alertness to seeking for more information on IPC measures including HH may have increased and definitely increasing their level of knowledge. Increasing level of formal education among nurses is proportional to having sufficient knowledge on infectious diseases, therefore increasing the likelihood of seeking further knowledge of infection prevention and control i.e., HH. 22 Lastly, as reported by Asadollahi et al., 23 our study also observed that working experience of 5 years and above is associated with increased level of HH knowledge among the nurses which may be explained as they have received more trainings on IPC measures notably HH.

CONCLUSION
Majority of the nurses exhibited good level of knowledge about hand hygiene. This could have been enhanced through the extensive and frequent trainings on IPC notably HH during the global COVID-19 pandemic between March and May 2020.
We recommend that, HCWs are reminded on the correct duration required for effective HH because only two thirds and a third practiced hand washing and hand rubbing within recommended duration respectively. We also recommend further studies focusing on the compliance of HCWs on HH.

Study Limitations
Recall bias among study participants maybe a limitation of this study.